40. Sample Care Area Assessment (CAA) for Addressing Activities and Social Engagement
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:
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- 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.