Sample Care Area Assessment (CAA) for Dental Care

Resident Information:

• Name: Barbara Jensen
• ID: 456321
• Date of Assessment: YYYY-MM-DD
• Room Number: 122

Assessment Team:

• Primary Nurse: Karen Walters
• MDS Coordinator: Timothy Grant
• Dentist: Dr. Rachel Nguyen
• Registered Dietitian (RD): Marcus Lee
• Speech-Language Pathologist (SLP): Elena Rodriguez

Care Area Assessed:           

• Specify the care area: Dental Care

Step 1: Triggered Care Areas

• Triggered by Barbara's reports of discomfort while eating, observed difficulty in maintaining oral hygiene, and a recent incident of oral discomfort leading to refusal of meals.

Step 2: Review of MDS 3.0 Findings

• Barbara has a history of partial dentures, chronic dry mouth, and previous dental caries. Her current oral health status presents challenges to her nutrition intake, speech, and overall quality of life.

Step 3: Detailed Assessment

• Clinical findings: Inspection reveals poor denture fit, signs of gingivitis, and potential new dental caries.
• Review of medical records: Documents ongoing dental issues, including the last dental visit over a year ago and a lack of comprehensive dental care since admission.
• Consultations with interdisciplinary team members: Highlight the need for a dental evaluation, potential denture adjustment or replacement, and strategies to manage chronic dry mouth.
• Resident and family interviews: Indicate Barbara's growing frustration with her oral health issues and their impact on her enjoyment of food and social interactions.

Step 4: Problem Identification

• Identified risks include malnutrition due to oral discomfort, potential for dental and gum infections, and negative impacts on social well-being and speech clarity.

Step 5: Care Planning

• Goal: To address and manage Barbara's dental care needs, ensuring optimal oral health that supports her nutritional status, speech function, and quality of life.
• Interventions:

• • Schedule a comprehensive dental examination with Dr. Nguyen to assess needs for denture adjustment, treatment of gingivitis, and caries management.
  • Implement a daily oral hygiene protocol tailored to Barbara's needs, including special attention to denture care and dry mouth management.
  • Collaborate with the RD to adjust Barbara's diet to softer, more nutritious foods that are easier to chew and swallow, pending dental treatment.
  • The SLP to assess and provide interventions for any speech difficulties related to Barbara's oral health status.
  • Educate nursing staff and Barbara on the importance of oral health in relation to overall well-being and specific care techniques for denture wearers.

• Responsible Staff: Dentist, Nursing Staff, RD, SLP
• Timelines: Immediate dental consultation with ongoing monitoring and care adjustments based on treatment outcomes and Barbara's feedback.

Step 6: Interdisciplinary Team Review

• The team collaborates on the dental care plan, ensuring a holistic approach to Barbara's health that includes addressing her oral health concerns as a priority.

Step 7: Resident and Family Engagement

• Engaging Barbara and her family in the care planning process ensures they are informed and supportive of the dental care strategies, facilitating Barbara's cooperation and participation in her oral health management.

Step 8: Monitoring and Reassessment

• Short-Term: Follow-up within one month post-dental treatment to assess healing and adaptation to any denture adjustments or new oral hygiene protocols.
• Long-Term: Biannual dental assessments to monitor oral health status, with adjustments to care plans as necessary to maintain optimal oral health.

Documentation and Signatures:

• Signature of MDS Coordinator: Timothy Grant, Date: YYYY-MM-DD
• Signature of Primary Nurse: Karen Walters, Date: YYYY-MM-DD
• Signatures of other interdisciplinary team members involved.

IDT Meeting Follow-Up:

• Scheduled Date: YYYY-MM-DD to review Barbara's oral health progress, discuss any new challenges, and refine the dental care plan to continue supporting her health and well-being effectively.