1.0 Problem Statement

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Lilly is a 90 year old woman living in a Memory Care Facility (MCF) in San Diego, California, USA. She routinely sees her medical doctors for routine healthcare and specialists that see her for an existing heart problem, dementia, dentalcare, etc.

Lilly is a resident of the MCF because she has debilitating dementia and is in moderate1) Moderately Severe decline They may not remember their phone number or their grandchildren's names. They may be confused about the time of day or day of the week. At this point, they’ll need assistance with some basic day-to-day functions, such as picking out clothes to wear. https://www.webmd.com/alzheimers/types-dementia#2-6 to serious decline 2) Severe Decline They'll begin to forget the name of their spouse. They’ll need help going to the restroom and eating. You may also see changes in their personality and emotions. https://www.webmd.com/alzheimers/types-dementia#2-6 and can no longer be taken care of by family and friends. She is not capable of communicating serious health issues to those around her nor remember what the medical team has told her even a few minutes before. She can not remember her insurance numbers, where she lives, her family or her current set of diagnosis.

Lilly does have a Durable Power of Attorney 3) Durable Powers of Attorney helps you plan for medical emergencies and declines in mental functioning and can ensure that your finances are taken care of. Having these documents in place helps eliminate confusion and uncertainty when family members have to make tough medical decisions. https://www.legalzoom.com/articles/what-is-a-durable-power-of-attorney who does not live in the immediate area and can not be available to provide the answers required by the medical team to provide the best healthcare for Lilly.

Lilly falls down in the MCF and hits her head. She appears confused but that is “normal” for her in her current state, however, it is also a sign of a concussion 4) A Concussion is a traumatic brain injury that affects your brain function. Effects are usually temporary but can include headaches and problems with concentration, memory, balance and coordination. https://www.mayoclinic.org/diseases-conditions/concussion/symptoms-causes/syc-20355594 . MCF policy is that when a resident hits their head, they need to be seen by a doctor. Figure outlines at a simplified, high level the course of events for Lilly and the role of medical records during the process which includes a ride in an ambulance to the emergency room, the required medical assessment of her condition. a short stay in a hospital and rehabilitation hospital. When she is able, Lilly returns to the MCF.