Resident Information:

• Name: Michael Thompson
• ID: 823456
• Date of Assessment: YYYY-MM-DD
• Room Number: 207

Assessment Team:

• Primary Nurse: Janet Smith
• MDS Coordinator: Brian Foster
• Physical Therapist (PT): Lucy Williams
• Occupational Therapist (OT): Mark Johnson
• Pharmacist: Dr. Emily Green

Care Area Assessed:               

• Specify the care area: Falls

Step 1: Triggered Care Areas

• Triggered by Michael's balance problems, necessitating human assistance for transitions and surface transfers. His prescription for antidepressant medications may contribute to mobility issues. Despite a history of falls, no incidents have been recorded during the current assessment period.

Step 2: Review of MDS 3.0 Findings

• Michael was admitted with a known history of falls. Current assessment notes stability with human assistance but identifies him as high-risk for future falls.

Step 3: Detailed Assessment

• Clinical findings: Balance and mobility limitations impacting daily activities, such as moving from seated to standing positions and transferring across surfaces.
• Review of medical records: Documentation of antidepressant medication regimen, previous fall incidents, and ongoing PT/OT services.
• Consultations with interdisciplinary team members: Highlight the importance of a tailored therapy program, medication review for potential side effects affecting balance, and environmental adaptations to reduce fall risks.
• Resident and family interviews: Express concerns over fall risks and desire for increased independence in mobility and ADLs.

Step 4: Problem Identification

• Identified risks include potential for fall-related injuries due to balance and mobility issues, compounded by the effects of antidepressant medications.

Step 5: Care Planning

• Goal: To minimize fall risks and enhance Michael's mobility and independence through targeted therapy, medication management, and environmental safety measures.
• Interventions:

• • Continue and reassess PT/OT programs focusing on balance, strength, and mobility training tailored to Michael's specific needs.
  • Conduct a comprehensive medication review with the pharmacist to identify and adjust medications that may impact balance.
  • Implement environmental modifications, such as grab bars and non-slip surfaces, in Michael's living area and bathroom.
  • Educate nursing staff on personalized support strategies during ADLs to ensure Michael's safety and encourage mobility independence.
  • Engage Michael and his family in the care planning process, incorporating their feedback and preferences to support his emotional well-being and motivation.

• Responsible Staff: PT, OT, Pharmacist, Nursing Staff
• Timelines: Immediate implementation with ongoing monitoring and adjustments based on effectiveness and Michael's feedback.

Step 6: Interdisciplinary Team Review

• The team supports the comprehensive care plan, emphasizing collaboration across disciplines to address Michael's fall risks and mobility challenges holistically.

Step 7: Resident and Family Engagement

• Engaging Michael and his family in the care planning process ensures interventions are tailored to his needs and preferences, fostering a sense of involvement and control over his care.

Step 8: Monitoring and Reassessment

• Short-Term: Daily monitoring of therapy progress and medication effects, with adjustments as needed.
• Long-Term: Monthly evaluations of the overall care strategy's impact on fall risk, mobility, and independence, with adjustments based on progress and resident feedback.

Documentation and Signatures:

• Signature of MDS Coordinator: Brian Foster, Date: YYYY-MM-DD
• Signature of Primary Nurse: Janet Smith, Date: YYYY-MM-DD
• Signatures of other interdisciplinary team members involved.

IDT Meeting Follow-Up:

Scheduled Date: YYYY-MM-DD to review Michael's progress, discuss any challenges in fall prevention strategies, and refine the care plan to continue supporting his safety and mobility needs effectively.