Resident Information:

• Name: John Doe
• ID: 123456
• Date of Assessment: YYYY-MM-DD
• Room Number: 101

Assessment Team:       

• Primary Nurse: Jane Smith
• MDS Coordinator: Alice Johnson
• Physical Therapist: Michael Brown
• Occupational Therapist: Lisa White
• Social Worker: Robert Green
• Dietary Consultant: Emily Taylor
• Psychiatrist/Psychologist: David Wilson
• Pain Management Specialist: Sarah Miller

Care Area Assessed:

• Specify the care area: ADL/Rehab Potential

Step 1: Triggered Care Areas

• Triggered due to significant assistance needed for ADLs post-hip fracture repair, including bed mobility, toileting, transfers, eating, dressing, and personal hygiene. The resident is non-ambulatory and exhibits signs of psychological distress affecting rehabilitation engagement.

Step 2: Review of MDS 3.0 Findings

• Post-surgical recovery from a hip fracture with extensive assistance required for all ADLs. Prior to hospitalization, the resident was independent, engaging in activities such as driving and financial management. Complications during hospital stay included an adverse reaction to anesthesia, leading to extended intubation and subsequent deconditioning.

Step 3: Detailed Assessment

• Clinical findings: Marked deconditioning, requiring extensive rehabilitation. Daily pain management is a concern, alongside a healing stage III pressure ulcer.
• Review of medical records: Hospital records indicate a challenging recovery, emphasizing the need for a comprehensive rehabilitation plan.
• Consultations with interdisciplinary team members: Emphasize rehabilitation potential with targeted physical and occupational therapy. Psychological assessment indicates a need for supportive interventions to address mood and motivation.
• Resident and family interviews: Reflects determination to regain independence but concerns about current limitations and pain. Family stresses the importance of addressing psychological well-being alongside physical recovery.

Step 4: Problem Identification

• Needs include comprehensive pain management, psychological support for mood and motivation, effective wound care, and personalized ADL rehabilitation to foster independence.

Step 5: Care Planning

• Goal: To alleviate pain, heal pressure ulcer, improve psychological well-being, and enhance ADL capabilities for eventual return to independent living.
• Interventions:

• • Customized PT/OT regimen focusing on strength, mobility, and ADL skill rebuilding.
  • Pain management strategy revision for optimal control with minimal side effects.
  • Psychological support, including counseling and potential medication adjustments, to enhance mood and rehabilitation engagement.
  • Wound care management for pressure ulcer with regular monitoring and adjustments as needed.
  • Encourage social interaction and participation in available community activities to combat isolation.

• Responsible Staff: Assigned per intervention with coordination by the primary nurse and MDS coordinator.
• Timelines: Immediate start with ongoing evaluations at weekly PT/OT sessions, daily pain assessments, and monthly psychological and wound care reviews.

Step 6: Interdisciplinary Team Review

• Comprehensive agreement on care plan with a commitment to closely monitor progress and adjust as necessary, reflecting a holistic approach to recovery.

Step 7: Resident and Family Engagement

• Active involvement in care planning, with feedback used to tailor interventions to the resident's preferences and goals, ensuring alignment with the objective of regaining independence.

Step 8: Monitoring and Reassessment

• Short-Term: Daily monitoring for pain and wound care effectiveness, weekly PT/OT progress reviews.
• Long-Term: Monthly reassessment of psychological status and ADL capabilities, with adjustments to care plans based on recovery trajectory and new health developments.

Documentation and Signatures:

• Signature of MDS Coordinator: Jane Smith, Date: YYYY-MM-DD
• Signature of Primary Nurse: Alice Johnson, Date: YYYY-MM-DD
• Signatures of other interdisciplinary team members involved.

IDT Meeting Follow-Up:

• Scheduled Date: YYYY-MM-DD to assess the resident's rehabilitation progress, discuss any challenges, and refine the care plan to ensure continued advancement toward recovery goals.