Resident Information:

• Name: Elizabeth Johnson
• ID: 546372
• Date of Assessment: YYYY-MM-DD
• Room Number: 118

Assessment Team:

• Primary Nurse: Anne Carter
• MDS Coordinator: James Wilson
• Social Worker (SW): Maria Gonzalez
• Grief Counselor: Dr. Kevin Smith
• Psychiatrist: Dr. Laura Evans

Care Area Assessed:

• Specify the care area: Activities and Social Engagement

Step 1: Triggered Care Areas

• Triggered by Elizabeth's responses on the PHQ-9, indicating a lack of interest in activities and feelings of hopelessness, following the recent loss of her spouse. Elizabeth's diagnosis of situational depression has prompted a referral to a psychiatrist, social worker, and grief counselor.

Step 2: Review of MDS 3.0 Findings

• Elizabeth has been mourning the loss of her spouse of 30 years, with whom she shared a room for the last two years. Her strong religious beliefs and the proximity of supportive family members are key strengths.

Step 3: Detailed Assessment

• Clinical findings: Elizabeth is experiencing signs of situational depression, which impacts her participation in activities and social interactions within the nursing home.
• Review of medical records: Confirms the recent bereavement and initiation of a mild antidepressant regimen. Ongoing grief counseling sessions have been documented.
• Consultations with interdisciplinary team members: Emphasize the importance of integrating Elizabeth's religious practices and interests into her care plan to support emotional healing.
• Resident and family interviews: Highlight Elizabeth's historical enjoyment of group activities, especially those related to her religious community, and her love for gardening and music.

Step 4: Problem Identification

• Risks of deepening depression and increased social isolation due to the loss of her spouse and current disengagement from activities that previously brought her joy.

Step 5: Care Planning

• Goal: To re-engage Elizabeth in social and recreational activities aligned with her interests and beliefs, supporting her emotional well-being and mitigating the risk of further isolation.
• Interventions:

• • Facilitate 1-2 weekly one-on-one visits by the social worker for personalized support and to encourage participation in activities.
  • Collaborate with the pastoral care team to ensure Elizabeth can attend religious services and events that reflect her beliefs.
  • Introduce Elizabeth to gardening and music therapy groups within the nursing home to reconnect with her hobbies.
  • Continue grief counseling sessions and psychiatric evaluations to monitor and adjust antidepressant therapy as needed.
  • Organize regular family visits, incorporating them into care planning sessions to ensure Elizabeth feels supported by her loved ones.

• Responsible Staff: Social Worker, Recreational Therapist, Pastoral Care, Grief Counselor, Psychiatrist
• Timelines: Immediate start with regular evaluations at weekly interdisciplinary team meetings and adjustments based on Elizabeth's feedback.

Step 6: Interdisciplinary Team Review

• The team agrees on the personalized approach, recognizing the critical role of engaging Elizabeth in activities that resonate with her personal interests and spiritual beliefs.

Step 7: Resident and Family Engagement

• Engaging Elizabeth and her family in the care planning process ensures interventions are tailored to her preferences, promoting a sense of agency and involvement in her own care.

Step 8: Monitoring and Reassessment

• Short-Term: Monitor Elizabeth's participation in activities and response to grief counseling and antidepressant treatment.
• Long-Term: Evaluate the impact of the care plan on Elizabeth's mood and social engagement, making necessary adjustments to support her continued recovery and well-being.

Documentation and Signatures:

• Signature of MDS Coordinator: James Wilson, Date: YYYY-MM-DD
• Signature of Primary Nurse: Anne Carter, Date: YYYY-MM-DD
• Signatures of other interdisciplinary team members involved.

IDT Meeting Follow-Up:

• Scheduled Date: YYYY-MM-DD to assess Elizabeth's progress, discuss any barriers to participation in activities, and refine the care plan to further support her emotional and social needs.