Doris Mabry Service Plan Notes

Service Initiation Date: September 29, 2017

NO DNR ON FILE

Last Date Reviewed: 01/15/2020

Location Notes: Apartment # 4203.

During the week, the facility entrances will be locked at 9PM, on the weekends they will be locked at 8PM. After these times, the front doors are locked and you may not enter through them, you must enter through one of the 3 side doors which are found at each side of the building. At the side entrances, there will be a keypad; On that keypad you will press and hold the # key. The directory will come up, you will keep pressing the # key until Doris’ apartment number shows (4203). When you see her apartment number, stop pressing # and it will give you a 4 digit code. Enter that code and it will call your supervisor on duty who can then let you into the building. Once you are let in, you will have 3 seconds to open the door before it is locked again. In order to leave after hours, you must exit through one of the side entrances.

Summary: Mrs. Mabry lives alone at Watercrest.  Her daughter, Barbara, visits her frequently.  We are there for Mrs. Mabry to assist her with getting dressed, making breakfast and keeping the apartment clean and organized.  We are only there four hours per day but that allows her daughter the ability to not be there every morning and evening and still make sure her mom is taken care of.

Allergies:  Unknown

Stated Medical Condition

• Macular degeneration (affects vision)

• Hearing loss

• Hip replacement

• Knee replacements

• Breast Cancer

• Pancreatic Cancer

Is the client on hospice?: Yes. Omnix Hospice

Is the client on home health?: Yes. Omnix Home Health

Date of Birth: 4-2-1922

Height and Weight:

Pets: No

Smoker: No

Dress Code: Blue scrubs with name tag in pocket.

Is Cell Phone Use Allowed?: No

Is Sleeping Allowed?: No

Personal Care

• See Service Plan and detailed list of ADL’s in the blue folder.

• Her biggest need is helping her get dressed and put her stockings and shoes on. She cannot bend over.

• Help with makeup.

Personal Services

• See detailed list of cleaning tasks on Page 2 and 3 of Service Plan in the blue folder.

• Keep the apartment clean and organized

• Complete laundry and do not leave for the next day.

Likes and Dislikes

• See Getting to Know You document in the blue folder.

• Enjoys conversation but also appreciates her time alone

• Does not want to be asked what to do next. Caregivers should assist her in the morning and clean and organize her apartment for the remaining time.

Notes

• Emergency Contact Information found in the blue folder.

• Knock on the door loud enough for her to hear you.

• Room 4203 on 2nd Floor

• MEDICATION IS TAKEN ONLY IN THE MORNINGS.

  • The pill organizer is set up for two weeks. Please ignore morning and evening. Meds are only taken in the morning.

Updates:

• 06/22/2018

  • Doris likes to take showers on Monday, Wednesday and Fridays.

  • Don't leave wet clothes in the laundry.

  • Don't ask Doris what needs to be done. We need to stay busy and know we are also there so her daughter can have respite and not be there every morning.

• 07/04/2018 - UPDATED TASKS FOR CAREGIVERS

  • Every day:

    • Assist with shower on Mon, Wed and Friday

    • Home exercise program/stretching. (See image at bottom of this page)

  • Occasionally

    • Assist with shopping list

    • Review calendar and facility activities.

• 07/04/2018 - It was reported that Doris' skin was very dry on her back. Please apply lotion after bathing.

• 10/25/2018 - Daily routine notes were written up by the regular caregiver and placed in the blue folder.

• 11/7/2018 - Update from caregiver:

  • Mrs. Doris is dropping items in her closet and she’s concerned about the fall risk. She also noticed that Mrs. Doris is having trouble with toileting as there is stool on the toilet seat, toilet handle and sink.

• 11/8/2018 - April from Omnix Home Health informed us that Doris’ took the wrong day’s pill and asked if we could help reminder her of the correct one to take each day. I spoke with the caregiver, Michelle, who said she reminds Doris every day but Mrs. Doris can forget she’s already taken medication and take more before she is supposed to.

• 11/13/2018 - Abuse, Neglect and Exploitation complaint submitted to Adult Protective Services and Texas Department of Health and Human Services for alleged exploitation (theft by former caregiver).

• 1/1/2019 - Mrs. Mabry returned from an long trip to San Diego for the holidays and has been incoherent and confused. She had a fall last night and has a large bruise on her right shoulder.

• 1/2/2019 - Mrs. Mabry had a bladder infection.

• 1/6/2018 - Doris thought her black Vera Bradley purse was taken. She had to be reminded that her daughter took the bag to their home for safe keeping.

• 2/8/2019 - Reported by caregiver, Michelle Tehas, that Doris has been weak, confused with a dazed look at times. Doris reported that she thought she had a heart attack the night of 2/5/2019. This was reported to daughter, Barbara Hagen. I also called to advise Doris to call 911 if she believes she’s having a heart attack.

• 2/8/2019 - Caregiver, Michelle Tehas, advised all caregivers to wear gloves when changing her stockings due to cellulitis that is active with blisters.

• 2/20/2019 - Doris was advised by her home health nurse to seek medical attention and go to the emergency room. Doris said they are concerned about her sudden weight gain, CFS and cellulitus, shortness of breath, high blood pressure. Doris is not going right away because she says it’s not convenient. Sabrina is the nurse that saw her today. I called Omnix and spoke with RN Netty. She is going to call Barbara on her cell.

• 2/20/2019 - Eric Gomez was called two days ago by Bridget Sloan asking if Doris takes her daily meds. Doris’ BP was high and the pill organizer looked full. Doris’ caregiver, Michelle Tehas, was questioned. She explained that Doris takes meds only one time a day. The pill organizer is day/night and the bottom row is empty because Doris prefers to start with the bottom row. That’s why the morning pills looked like they were not taken. Michelle’s confirmed Doris takes them daily.

• Doris reported to Omnix that prescription drugs were missing. Omnix nurse called pharmacist to investigate. She found that the prescription drug was filled in November 2018. All of the medicine was present in the bottle. No report to be filed for the drink as the accusation is unfounded and less than $25 value. These accusations are a repeated occurrence and likely due to her undiagnosed dementia. Her vision impairment also limits her ability to see clearly.

• 3/16/2019 - Michelle arrived today to find that Doris has a black eye. It is 3 inches long under her left eye. She reported it to her supervisor at 7:39 a.m. and her daughter, Barbara, was notified at 7:41 a.m. There was also a broken glass on the ground but does not appear to be related to the black guy. Doris does not remember how she got the injury. She was confused.

• 4/18/2019 - Client is on a antibiotic for active infection in legs, so wear gloves when dressing and have her eat or boost before she leaves so she's not sick from meds. One of the meds in the bathroom is 2X a day for constipation, she won't take that and needs a reminder. Nausea is just as needed. She needs to take the one in bathroom for 7 days. She's been having this issue for a month but the liquid is confusing for her. She either spills or takes too much on her own. Nurse is aware of her constipation issue and so is daughter.

• 9/3/2009 - We are now providing services in the evenings for 2 hours with Doris in addition to her morning services. We are there in the evenings to make sure she has eaten dinner and to make sure she is dressed for bed so that she does not sleep in her day time clothing.

• 9/24/2019 - Caregivers should make sure that Doris gets her meds in the morning after her coffee but before she gets dressed. She doesn’t take medication in the evenings but the pill box is am and pm. They fill it bi-weekly.

• 10/7/2019 - Please make sure when reminding Doris about her medication in the morning that her pill box is closed with rubber bands on to secure.

• 10/7/2019 - Doris recently had a week long visit from her son, Chuck who lives in California. She enjoyed having him here. Caregiver has reported that Doris is having more incontinence than usual.

• 10/10/2019 - Doris' daughter requested that the caregivers are aware and remember to make sure that Doris is eating dinner in the evenings. She said that she is concerned that she may just be drinking Boost in place of a dinner. She would rather her eat an actual dinner

• 10/10/2019 - Here are some special insights from Doris’ regular daytime caregiver. Doris is easy going and if she thinks you are eating, she eats. Bringing your breakfast or dinner to have a meal with her if possible is a good idea to encourage her to eat. She will pretty much eat anything you make. She's a social eater and the conversation helps that. They ask Alexa a lot of questions. Doris loves that. Conversations about her favorite singer or nature is always something to help her pass times. Her regular caregiver reads her bible group pamphlets to her. She very much enjoys that at night.

• 10/14/2019 -Caregivers should make sure that laundry is not being left in the washer or dryer. If the caregiver does laundry for her, it should be completed before the caregiver leaves. Also, please check the tags on clothing before washing and/or drying. Doris doesn’t wash her laundry everyday. When it is removed, it’s put in the washing machine and when the machine is nearing full, then it should be washed.

• 10/15/2019 - Barbara wants the caregivers to know not to wash any of Doris’ clothes, she will dry clean them. The only things that should be washed are the underwear, towels and sheets and they should be washed as needed.

• 10/22/2019 - One of Doris’ caregivers has made us aware that there could be expired food in the refrigerator as Barbara doesn’t like caregivers throwing food out. Please keep this in mind as you are preparing foods for Doris and take caution not to serve her anything that is out of date. Barbara has stated that she will be the one to clean out the refrigerator.

• 01/15/2020 - Doris was admitted to the hospital on Jan 2, 2020 and was diagnosed with breast and pancreatic cancer. Upon arriving home, we will be providing 24 hour care for her.