Resident Information:

• Name: Charles Anderson
• ID: 334455
• Date of Assessment: YYYY-MM-DD
• Room Number: 510

Assessment Team:

• Primary Nurse: Helen Ramirez
• MDS Coordinator: Mark Johnson
• Social Worker (SW): Emily Clark
• Psychologist: Dr. Sarah Bennett
• Hospice Care Consultant: Dr. Lisa Moreno

Care Area Assessed:

• Specify the care area: Mood State

Step 1: Triggered Care Areas

• Triggered by a PHQ-9 score of 15, indicating significant depression in the context of a terminal cancer diagnosis. Charles's transition from independence to requiring assistance with ADLs and experiencing regular urinary incontinence has contributed to his current mood state.

Step 2: Review of MDS 3.0 Findings

• Charles, a new resident, faces challenges adjusting to life in the Living Center due to his terminal illness and consequent loss of independence. His emotional well-being is further compromised by feelings of embarrassment related to urinary incontinence.

Step 3: Detailed Assessment

• Clinical findings: Depression linked to terminal illness diagnosis, significant changes in lifestyle, and physical health concerns.
• Review of medical records: Documented diagnosis of terminal cancer and depression, initiation of antidepressant medication, and discussions about hospice care.
• Consultations with interdisciplinary team members: Emphasized the need for personalized care planning, incorporating psychological support, hospice care guidance, and strategies to maintain dignity and independence.
• Resident and family interviews: Highlighted the importance of Charles's personal belongings and the comfort derived from his family's support.

Step 4: Problem Identification

• Identified risks include further mood deterioration, potential for weight loss due to depression, and increased agitation stemming from his illness and environmental changes.

Step 5: Care Planning

• Goal: To improve Charles's mood state, facilitate his adaptation to the Living Center, and ensure a dignified, comfortable environment that acknowledges his terminal condition.
• Interventions:

• • Regular 1-2 weekly visits by the SW to provide emotional support and facilitate hospice care discussions.
  • Engage a psychologist to assess and adjust antidepressant therapy as needed, ensuring optimal management of depression symptoms.
  • Implement personalized strategies to manage urinary incontinence, enhancing Charles's comfort and reducing feelings of embarrassment.
  • Involve Charles and his family in personalizing his living space with meaningful items from home to foster a sense of belonging and continuity.
  • Coordinate with hospice care services to align Charles's care with his and his family's wishes, focusing on quality of life and symptom management.

• Responsible Staff: Social Worker, Psychologist, Nursing Staff, Hospice Care Consultant
• Timelines: Immediate implementation with ongoing evaluation and adjustment based on Charles's needs and preferences.

Step 6: Interdisciplinary Team Review

• The team agrees on the comprehensive approach to address Charles's mood state and overall well-being, emphasizing the importance of coordinated care and family involvement.

Step 7: Resident and Family Engagement

• Active involvement of Charles and his family in developing the care plan ensures that interventions are aligned with his values, preferences, and comfort.

Step 8: Monitoring and Reassessment

• Short-Term: Monitor Charles's response to antidepressant adjustments and the effectiveness of incontinence management strategies.
• Long-Term: Evaluate the impact of social work and psychological interventions on Charles's mood and quality of life, adjusting the care plan as necessary.

Documentation and Signatures:

• Signature of MDS Coordinator: Mark Johnson, Date: YYYY-MM-DD
• Signature of Primary Nurse: Helen Ramirez, Date: YYYY-MM-DD
• Signatures of other interdisciplinary team members involved.

IDT Meeting Follow-Up:

• Scheduled Date: YYYY-MM-DD to review Charles's progress, discuss any new challenges, and refine the care plan to continue supporting his psycho-social and physical needs effectively.