Resident Information:

• Name: [Resident's Name]
• ID: [Resident ID]
• Assessment Reference Date: [Date]
• Triggered Care Area: Visual Function

1. Assessment Summary:

• MDS Findings: Triggered due to vision or loss impairment. Inability to read regular print identified.
• Clinical Observations: Relies on staff assistance for ADLs; non-ambulatory but mobile for restroom use.
• Medical History Review: Diagnosed with macular degeneration and Alzheimer's disease. Currently on eye medication.

2. In-depth Assessment:            

• Review of Symptoms: Confirmed macular degeneration affecting visual capabilities.
• Risk Factors Identified: Alzheimer’s disease contributing to cognitive impairment, affecting the ability to compensate for visual loss.
• Complications/Contributing Factors: At risk for complete blindness, increased falls, and further vision deterioration. Physical safety is a concern.

3. Interdisciplinary Team (IDT) Evaluation:

• Medical: Continuous eye medication with monitoring. Referral to an ophthalmologist for any new visual issues.
• Nursing: Assists with ADLs, monitors for signs of vision change or discomfort.
• Rehabilitation Services: Evaluates for assistive devices to aid mobility and prevent falls.
• Social Services: Encourages participation in social activities suitable for visual limitations.

4. Care Planning: Individualization

• Goal: Minimize hazards related to visual impairment, enhance social engagement, and prevent falls.
• Interventions:

• • Adapt living space for better accessibility and safety.
  • Provide visual aids and large-print materials.
  • Encourage social interaction within visually accessible environments.
  • Implement fall prevention strategies specific to visual impairment.

5. Monitoring and Reassessment:

• Short-Term: Daily monitoring for any changes in visual status or effectiveness of interventions.
• Long-Term: Monthly reassessment of visual function, fall risk, and social engagement levels.

6. Documentation and Communication:

• Documentation: Detailed entries on visual assessment outcomes, intervention plans, and progress updates.
• Communication: Regular updates to the resident's family and healthcare providers about condition changes and care plan adjustments.

7. IDT Meeting Follow-Up:

• Scheduled Date: [Date]

• • Review resident progress, adapt interventions as needed, and reassess visual function and fall risk strategies.