Care Plans in Long-Term Care

This chapter discusses some common areas of concern while living in long-term care:

• care plans;
• use of antipsychotics or sedatives for behaviour management;
• use of restraints; and
• temporary absences from the residence.

Care Plans in Long-Term Care

A care plan is a document that records the care to be provided to an individual in a long-term care facility that considers the person’s unique abilities, physical, social and emotional needs, and cultural and spiritual preferences. Care plans provide guidance to caregivers so they can effectively care for and meet the unique needs of the person in care.(1)

Facility operators are expected to conduct an initial assessment of the resident within 24 hours of admission. They must then develop a short-term care plan which identifies immediate care needs, risk factors, personal preferences, and a contact person.(2)

Operators are also required to develop a comprehensive care plan within 30 days of the adult’s admission. This is created with the adult, their supporters, and the care team in a care conference. The older adult has a right to take part in developing the care plan. The facility is required to monitor the resident’s needs regularly and to review and adjust care plans at least annually and whenever there is a substantial change in health or circumstances. The facility must make reasonable efforts to involve the resident and their family member or representative in care planning and in any changes to a care plan. The planning team will gather information about the individual’s abilities and needs and determine how best to provide care.(3)

Care plans vary because they are tailored to the individual. Elements of a care plan may address:

• medication;
• oral health;
• nutrition;
• recreation and leisure;
• fall prevention;
• considerations about wandering and behavioural interventions;
• emotional and social needs;
• cultural and spiritual preferences; and
• other factors involved in ensuring the health, safety, and dignity of the resident.(4)

The care plan will be shared with the individual’s health care team to ensure consistency in care.

A care plan may identify circumstances in which restraints may be used. In order for restraints to be used, the resident or their substitute decision-maker must provide prior written consent to the use of restraints. There is an exception when it is an emergency and necessary to protect a person from harm.(5)

Ongoing care planning and the involvement and consent of the resident or their substitute decision-maker is a general issue that arises in care facilities, not just with respect to medications.

If there is an issue regarding the resident’s type or quality of care, or if a family member or representative notices a significant change in the resident, they can request a care planning conference. Facility operators are required to hold care conferences at least annually, but also whenever there is a significant change in the resident’s condition or circumstances. Operators must make every effort possible to include the residents, their family members, or their substitute decision-maker in care planning.(6)

For more information about care plans, see regional health authority websites.

If language is a barrier, an interpreter should be present at the assessment and care conference. An interpreter can be requested in advance through a provincial online booking system. For more information see the Provincial Health Services Authority’s website. If someone is unable to book online, interpretation service can also be booked through the Provincial Health Service Authority phone line: 604-297-8400; Toll-free: 1-877-BCTalks (228-2557). Unfortunately, onsite interpreters are currently only available for Lower Mainland health authorities (Fraser Health, Vancouver Coastal Health). Individuals outside the Lower Mainland will have to rely on virtual or telephone interpretation.

MOST Forms and Advance Directives

The care plan may also include advance directives and end of life planning if these have been discussed with the resident and their family or authorized representative.

Care facility operators may suggest or cite a MOST document as a care planning tool. This refers to a “Medical Order for Scope of Treatment” which is normally completed by a doctor in consultation with a patient and kept with the patient’s medical information. It outlines the level of care that a person would like if they were unable to speak for themselves in a medical emergency. It is essentially a form of advance care directive. Some facilities may insist on such a document at admission, but this is not a legally required condition for admission.(7)

A MOST document can be a useful tool for patients to communicate their wishes to health care workers providing emergency care. However, there are other forms of advance care planning that individuals may want to consider, including making a representation agreement. For more information about advance directives and representation agreements, see Nidus’ website and People’s Law School website.

References

1. Residential Care Regulation, BC Reg 96/2009, s 81, online: <canlii.ca/t/89ln>; British Columbia, Ministry of Health, Home and Community Care Policy Manual, (6 February 2023) at ch 2.A, online: <www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/accountability/policy-and-standards/home-and-community-care-policy-manual>.
2. Residential Care Regulation, BC Reg 96/2009, s 80, online: <canlii.ca/t/89ln>.
3. Residential Care Regulation, BC Reg 96/2009, s 81, online: <canlii.ca/t/89ln>.
4. Residential Care Regulation, BC Reg 96/2009, s 81, online: <canlii.ca/t/89ln>.
5. Residential Care Regulation, BC Reg 96/2009, s 84, online: <canlii.ca/t/89ln>.
6. British Columbia, Ministry of Health, Home and Community Care Policy Manual, (6 February 2023) at ch 2.D, online: <www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/accountability/policy-and-standards/home-and-community-care-policy-manual>.
7. People’s Law School, ”MOST (medical orders for scope of treatment) forms” (June 2019), online: <www.peopleslawschool.ca/understand-most-forms/>.

This information applies to British Columbia, Canada. Last reviewed for legal accuracy by Seniors First BC, February 2024.