Nursing Home Care Plans

Care plans are a collection of problem, intervention (approach), and goal statements that direct the care of your loved one in the nursing home and are based on a comprehensive assessment of physical, social, emotional, and spiritual needs. The comprehensive assessment describes the resident’s capability to perform life functions and significant impairments of those abilities.

The comprehensive assessment includes the following information:

  • Complaints and symptoms
  • Level of consciousness
  • Vital signs
  • Sensory needs (hearing, sight, smell, touch, taste)
  • Condition of skin
  • Weight and height
  • Mood/Affect
  • Mobility level
  • Eating/nutritional habits
  • Bowel and bladder patterns
  • Sleeping habits
  • Activity of daily living status
  • Teaching needs
  • Communication
  • Risk for falls
  • Pain
  • Risk for pressure sores

Do I have the opportunity to be involved in developing my loved one’s nursing home care plan?

Yes, care plan meetings are completed within a few weeks of admission, quarterly, or more often if necessary. Residents and families are encouraged to be involved in the care plan process. You should be invited to your loved one’s care plan meeting by nursing home staff, but can request a care plan meeting at any time; staff should oblige your request. At care plan meetings, all disciplines (including dietary, social services, nursing, and activities) discuss residents’ progress toward current care plan goals.

Do medical providers (nurse practitioners or physicians) ever attend care plan meetings?

At some facilities they do. It is a good idea to have a medical perspective in the care plan. Ask the nursing home or your loved one’s physician about how the physician is involved in the care plan process. It is the responsibility of the physician to understand the nursing plan of care in order to provide appropriate medical care. Sadly enough, many physicians do not know the nursing care plan as they are providing medical care, which can result in dangerous outcomes.

What information is included in the care plan?

  • All physician orders should be addressed.
  • Any long term and most acute problems need to be addressed.
  • Care plan goals are listed and should be attainable. These goals should be assessed and modified as needed at each care plan meeting.
  • Interventions are noted to help the resident attain the goals that are set. All departments should assist with interventions.

How often should care plans be completed or modified?

A basic care plan should be completed to care for immediate health problems within 24 hours of admission. A full care plan that encompasses all of your loved one’s health problems and is used to direct care should be completed within 21 days of admission.
After the initial plan is completed, updates are completed quarterly, with significant changes in condition, and with new orders.


National Citizen's Coalition for Nursing Home Reform