Sample Care Area Assessment (CAA) for Communication

Resident Information:

• Name: [Resident's Name]
• ID: [Resident ID]
• Date of Assessment: [Today's Date]
• Room Number: [Room Number]

Assessment Team:      

• Primary Nurse: [Name]
• MDS Coordinator: [Name]
• Physical Therapist: [Name]
• Occupational Therapist: [Name]
• Social Worker: [Name]
• Dietary Consultant: [Name]
• Audiologist: [Name, if applicable]

Care Area Assessed:

• Specify the care area: Communication

Step 1: Triggered Care Areas

• Communication triggered due to mild hearing loss and difficulty with word finding associated with a previous cerebrovascular accident (CVA).

Step 2: Review of MDS 3.0 Findings

• The resident has mild hearing loss, requiring speakers to talk louder and more clearly. The resident's history of CVA contributes to aphasia, particularly with word-finding challenges. Despite these difficulties, the resident is attentive and enjoys participating in events. The resident benefits from bilateral hearing aids and is capable of effective communication when given sufficient time for word search.

Step 3: Detailed Assessment

• Clinical findings: Moderate hearing loss confirmed, with bilateral hearing aids in use. Aphasia noted, affecting word finding but not general comprehension.
• Review of medical records: Documented diagnosis of CVA with ensuing aphasia. Annual audiology consultations confirm stable mild to moderate hearing loss.
• Consultations with interdisciplinary team members: Input from audiologist suggests maximizing use of hearing aids and considering speech therapy for aphasia.
• Resident and family interviews: Family confirms resident's social nature and frustration with missed communications. They emphasize the importance of social interactions and express concern about potential isolation and sadness due to communication barriers.

Step 4: Problem Identification

• Communication barriers due to hearing loss and aphasia increase the risk of missed messages, social isolation, and emotional distress.

Step 5: Care Planning

• Goal: Enhance effective communication to reduce risks of isolation, loneliness, and further hearing loss.
• Interventions:

• • Regular monitoring and maintenance of hearing aids by a qualified audiologist.
  • Speech therapy consultations to develop strategies for overcoming word-finding difficulties.
  • Training for staff and family members on effective communication strategies with hearing-impaired individuals.
  • Ensure the resident's participation in social events is facilitated and supported, taking communication needs into account.

• Responsible Staff: Audiologist, Speech Therapist, Nursing Staff, Social Worker
• Timelines: Immediate implementation with monthly reviews for the first three months, then as needed based on progress and reassessment.

Step 6: Interdisciplinary Team Review

• Team agrees on the care plan, emphasizing the need for personalized communication approaches and regular reassessment of hearing and speech therapy needs.

Step 7: Resident and Family Engagement

• Discussion with the resident and family about the assessment findings and proposed care plan. Their feedback is incorporated, highlighting the resident's preferences for social engagement and communication methods.

Step 8: Monitoring and Reassessment

• Short-Term: Daily monitoring of hearing aid use and effectiveness, weekly speech therapy sessions.
• Long-Term: Monthly reassessment of communication abilities and adjustment of care plan based on progress, with annual audiology reviews.

Documentation and Signatures:

• Signature of MDS Coordinator: [Signature], Date: [Date]
• Signature of Primary Nurse: [Signature], Date: [Date]
• Signatures of other interdisciplinary team members involved: [Signatures]

IDT Meeting Follow-Up:

• Scheduled Date: [Date] to review the resident's progress, the effectiveness of interventions, and potential need for care plan adjustments.