Care Intake Standards Map (LTC)
A visual, step‑by‑step guide outlining what should occur during admission, assessment, care planning, and early monitoring in long‑term care settings.
The Care Intake Standards Map breaks down the required steps a facility must follow from the moment a resident is admitted. This tool helps attorneys quickly identify where breakdowns occurred and whether the facility met its obligations during the most critical phase of care.
Use this map during case intake, breach evaluation, and timeline reconstruction.
ADMISSION PROCESS (WHAT SHOULD HAPPEN)
✔ Pre‑Admission Review
• Review hospital discharge summary
• Review medication list
• Identify immediate risks
• Confirm equipment needs
• Ensure staff readiness
✔ Admission Assessment (Within Hours)
• Full head‑to‑toe assessment
• Baseline vitals
• Skin assessment
• Cognitive and functional evaluation
• Pain assessment
✔ Immediate Interventions
• Fall precautions
• Skin protection
• Hydration/nutrition support
• Medication reconciliation
• Monitoring schedule established
CARE PLAN DEVELOPMENT
✔ Interdisciplinary Team Meeting
• Nursing
• Therapy
• Dietary
• Social services
• Medical provider
✔ Individualized Care Plan Must Include
• Identified risks
• Specific interventions
• Measurable goals
• Monitoring frequency
• Resident preferences
✔ Communication to Staff
• CNAs
• Nurses
• Therapy
• Dietary
• Activities
EARLY MONITORING (FIRST 72 HOURS)
✔ Required Monitoring
• Vitals
• Pain
• Skin integrity
• Hydration/nutrition
• Behavioral changes
• Medication effect
✔ Required Documentation
• Shift‑by‑shift notes
• CNA flow sheets
• Nursing assessments
• Physician notification
COMMON BREAKDOWN POINTS
• Missed admission assessment
• Incomplete skin assessment
• Failure to identify risks
• Delayed care plan development
• Poor communication to staff
• Missed early monitoring
• Documentation gaps