Sample Care Area Assessment (CAA) for Psycho/Social Well-Being After Loss

Resident Information:

• Name: Edward Jenkins
• ID: 852963
• Date of Assessment: YYYY-MM-DD
• Room Number: 412

Assessment Team:                         

• Primary Nurse: Patricia Wilson
• MDS Coordinator: Derek Simmons
• Social Worker (SW): Michelle Nguyen
• Bereavement Counselor: Olivia Roberts
• Psychologist: Dr. Karen Lopez

Care Area Assessed:

• Specify the care area: Psycho/Social Well-Being

Step 1: Triggered Care Areas

• Triggered following the resident expressing feelings of sadness, lack of interest in previously enjoyed activities, and a sense of hopelessness, especially significant after losing a lifelong friend and companion three months ago.

Step 2: Review of MDS 3.0 Findings

• Edward has been diagnosed with situational depression. His mood and engagement levels have notably declined since the loss, impacting his overall well-being and participation in nursing home activities.

Step 3: Detailed Assessment

• Clinical findings: Persistent symptoms of depression, including withdrawal from social interactions and expressed feelings of loneliness.
• Review of medical records: Notes on the recent loss, initiation of antidepressant medication, and referral to bereavement counseling.
• Consultations with interdisciplinary team members: Highlighted the need for a personalized approach to support Edward's emotional and social needs, incorporating his interests and available social support systems.
• Resident and family interviews: Revealed Edward's passion for gardening and painting, which he has neglected recently. His family, particularly his grandchildren, have expressed a desire to be more involved in his care and activities.

Step 4: Problem Identification

• Identified risks include prolonged depression, social withdrawal, and the neglect of personal interests and hobbies that previously provided a sense of joy and purpose.

Step 5: Care Planning

• Goal: To foster Edward's emotional healing, reconnect him with his interests, and encourage social interaction to combat isolation.
• Interventions:

• • Introduce a tailored gardening project as a therapeutic activity, allowing Edward to nurture plants in the nursing home's garden.
  • Schedule regular painting sessions to rekindle his passion for art, potentially leading group activities to inspire other residents.
  • Organize weekly visits from family, especially his grandchildren, to strengthen his social support network.
  • Continue with bereavement counseling and psychologist evaluations to monitor and support his mental health recovery.
  • Facilitate participation in spiritual services or gatherings that align with Edward's beliefs and provide additional emotional support.

• Responsible Staff: Social Worker, Bereavement Counselor, Recreational Therapist, Family Liaison
• Timelines: Begin interventions immediately, with weekly progress reviews and adjustments based on Edward's feedback and engagement levels.

Step 6: Interdisciplinary Team Review

• The team supports the comprehensive care plan, emphasizing the importance of Edward's active participation in his recovery process and the potential positive impact of reintegrating his hobbies and interests.

Step 7: Resident and Family Engagement

• Engaging Edward and his family in the care planning process has been crucial, ensuring the plan reflects his personal preferences, interests, and the support network available through his family.

Step 8: Monitoring and Reassessment

• Short-Term: Monitor Edward's engagement with the gardening and painting activities, as well as his response to family visits and counseling sessions.
• Long-Term: Evaluate the overall impact of the interventions on his psycho/social well-being, making necessary adjustments to support ongoing recovery and engagement.

Documentation and Signatures:

• Signature of MDS Coordinator: Derek Simmons, Date: YYYY-MM-DD
• Signature of Primary Nurse: Patricia Wilson, Date: YYYY-MM-DD
• Signatures of other interdisciplinary team members involved.

IDT Meeting Follow-Up:

Scheduled Date: YYYY-MM-DD to review Edward's progress and adapt the care plan as needed to ensure it continues to meet his psycho/social needs effectively.