Hanging Mobile
The first type of Mobile I will describe is the standard Hanging Mobile. I will then expand the definition of a Mobile to include Flat Mobiles.

The format for the Mobile you select
for a resident is determined by…
the angle at which your resident is normally positioned.

The Hanging Mobile is, of course, similar in structure to what you would find over a child's crib. However, the objects suspended are updated for your adult residents.

Here's how the Hanging Mobile is constructed:
1. Materials: Straws, yarn, poster board, magazine pictures, and glue
2. Magazine pictures are selected that might be significant to your resident's recent past or long-term memory. Of course, if your resident is able to communicate, the Mobile can be more effective if he or she is involved in the selection of these magazine pictures to be pasted onto the Mobile. For example, a farmer may have pictures of crops, a silo, a farm house, etc. on his Mobile.
3. Paste the pictures that you and perhaps your resident have selected to both sides of the poster board. Plastic straws can be slid inside one another for added stability to form the horizontal cross supports for your Mobile.
4. Lengths of yarn suspend the pictures from the ends of the straws. I have found that staples work best for affixing the yarn to the straws, and to the poster board to which the magazine pictures have been pasted.
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5. Then, the entire assembly might be suspended from the resident's ceiling with yarn or string. Of course, assess for fire regulations and sprinkler head distance compliance, etc. However, as you can tell from the bed-bound residents on the DVD, if the Mobile is hanging from the ceiling, it may be too far away for your resident to notice. Also, a Mobile hanging from the ceiling might get in the way of the CAN caring for that resident.
6. Instead of hanging the Hanging Mobile from the ceiling, actually, I found many Activity Directors who implemented this idea had these Mobiles on their One-to-One Individual Activity Carts. Thus, when they went room-to-room, they would hold the Hanging Mobile in the line of vision of an appropriate room-bound resident. Or the Mobile could be left in a bag in the resident’s room. See “Activity Project Bag Labels” page at the beginning of this Manual. Next, I am going to provide you with a few sample Care Plan Goals and Approaches for the Mobile. However, before I do that, I would like to make a few comments regarding Care Plans.

Care Plan Goals
I realize that many of you may not be attending the Care Plan Conference at your facility and, therefore, are perhaps not overly concerned about getting Care Plan Goal ideas. However, I have found that the concept of asking yourself…
"What resident problem am I addressing with this activity?"
"What is the goal I am trying to have the resident accomplish?"
"What approach is the best one to use to help the resident accomplish the goal?"
… is essential for implementing any program with a resident whether you attend the Care Plan C 13b

onference or not. With that said you might have asked yourself at one time or another…

What is a "Measurable" Goal? Your corporate consultant probably has provided your department with information regarding writing Care Plans, Progress Notes, etc. If my information contradicts your corporate policy, your Corporate Policy of course takes precedence. Since interpretations of CMS regulations vary from state to state regarding what is a measurable goal, only the starter phrases for sample Care Plan Goals and Approaches are given to you in this Manual. Your surveyor’s interpretation of exactly what is a "measurable" goal and corporate software package will determine exactly how detailed the goal needs to be in order to be considered "measurable." One way to make the goal starter phrases and approaches provided to you in this and other Manuals in the series more measurable, is to add specific numbers related to that specific resident’s capabilities and limitations. Some examples of adding specific numbers to a goal starter phrase in order to make it measurable are as follows:
1. For how long will the resident respond or be involved in the activity? For 10 seconds. Revised Goal: For 5 minutes.
2. For what distance? For 3 inches. Revised Goal: To reach 5 inches.
3. How many times per week? To do (name activity) xx times a week, for xx minutes…etc.
4. With what level of assistance? With total physical assistance, with partial physical assistance, with elbow prompt, upon verbal request, independently once started, independently…etc.
Obviously, the number of ways in which you can weave numbers into goals is infinite, and these are just a few.

Sample starter phrases for Care Plan Goals regarding a Mobile might be:

Additional time frames might be added to the above, for example, within three months, or three times a week, if needed.
Residents with whom to try a Hanging Mobile

Culture Change Implementation: Place Hanging Mobile in labeled Activity Project Bag left in resident’s room for CNA, volunteer, etc. use.

Flat Wall Mobile or Picture Gallery
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A second format for a Mobile is a Flat Wall Mobile. The Flat Wall Mobile (a.k.a. Picture Gallery) works well with the semi-comatose resident who mainly lies on his or her side, or sits during the day turned to one side. Oftentimes, heavy-care residents are lying on their sides rather than on their backs due to contracture positioning. If you have a resident who lies facing the wall, you might consider making a Flat Mobile on the wall or a Picture Gallery. In addition to the pictures, you might also cut out word cards with the names of the pictures, and place the word cards below the pictures. If the picture is of a relative, the name and possibly relationship of the person might be placed on a word card underneath that picture, for example, "Martha, sister." Of course, if using magazine pictures and/or family photos, try to find out from family members what magazine pictures, or perhaps personal photographs, would be the most significant to the resident and might be placed on the wall. I have found that the Flat Wall Mobile or Picture Gallery also provides an area for discussion during relative visits. Relatives oftentimes don’t know what to talk about. Office supply stores carry clay and adhesives specifically for posting papers on the wall. One word of caution: each state has different interpretations of its Residents’ Rights to Privacy, which might affect the extent to which you may display the resident’s personal photographs. If you have not been through a CMS Survey yet and are unsure, ask your Corporate Consultant.

Goals: Same as those listed above for the Hanging Mobile…
Approach: Encourage family members to discuss the pictures on the wall with the resident and to supply added
pictures to replace the generic pictures provided by the Activities Department...

Flat Ceiling Mobile or Picture Gallery
(The last track of the DVD contains a slide illustrating implementation of this activity with a resident)
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The third type of Mobile is a Flat Ceiling Mobile (a.k.a. Ceiling Picture Gallery). As you are well aware, some semi-comatose residents lie on their backs staring at the ceiling. The procedure is the same as with the Flat Wall Mobile but the pictures are mounted on the ceiling. Affixing the Ceiling Picture Gallery works especially well if you have an acoustic ceiling. Pins can easily be used to suspend the pictures. Of course, if there is a fire sprinkler head on the ceiling, fire regulations must be observed.

Implementation of the Hanging and Flat Mobiles
At this point, some readers may be thinking, "Big deal… a kid's Mobile and taping pictures on the wall or ceiling!" If you are looking for something grandiose and complicated, I have found that those kinds of elaborate activities simply don't work for the Semi-Comatose and Low-Functioning residents, as explained in detail in Volume 1 of this series.

The idea in implementing the Mobile is to get the resident to make eye contact with you or the Mobile. In order to do this, position yourself at the resident's eye level. If the resident is sitting and can look at a 45-degree angle to the floor, as many residents do, you can bend or kneel down to place yourself in the resident's line of vision. I find kneeling or sitting next to the resident to be much more effective than standing and talking a foot above the seated resident's head. Agree? Construction of a Kneeling Pad will be discussed later in this Manual.

Approach: Place myself in resident's line of vision by kneeling, bending down, sitting…etc…

Training CNAs to Introduce an Activity…
For a heavy-care, Low-Functioning resident, you might start off by saying, “Elizabeth, how are you today?” As you have observed from Elizabeth on Track 7, Lillian on Track 8, and Mary on Track 9 of the DVD, most residents at this level do not respond. Thus, as indicated in an Approach above, you or the CNA might use Scent Therapy, which will be described in detail later, as an Introductory Activity for your Mobile. By Introductory Activity, I mean that you might have the resident smell vanilla, lemon, or mint extracts before showing them the Mobile. I have achieved the most noticeable resident reactions by using these three scents. However, I do not feel that vanilla, lemon, or mint extracts are an unpleasant way to wake the resident. Clearly, something as pungent as ammonia should be avoided.

CNAs, Activity Staff, and Volunteers need to be reminded that the responsibility regarding working with your Semi-Comatose residents is to interpret their vocalizations or gestures to assess if the activity is pleasurable or unpleasant for them. Oftentimes, after smelling the extract, residents will become more alert and open their eyes or make a noise. If you feel their responses to your Scent Therapy are positive, you might use one of the following Approaches.

I have found that many surveyors seem to like the Mobile for the heavy-care residents because it serves as evidence of the activity program getting to these residents. However, in addition to conducting the Mobile activity with a resident, be sure to take credit for the use of these Mobiles in the Plan of Care Goal and Approach.

A sample Care Plan Goal would be "to have eye contact with the Mobile for 10 to 20 seconds" or whatever length of time seems to be appropriate for that resident. A revised Goal the CNA or Activity Staff member might strive for would be for the resident "to reach for the Mobile,” “to touch a picture on the Mobile,” or “to name one of the items on the Mobile." Another goal, if your resident is unable to talk, might be "to make a noise in relation to the Mobile.” Additional time frames might be added, for example, within three months or three times a week, if needed to make the Goal measurable.

An Approach would be to introduce the Mobile by using vanilla, mint, or lemon extracts to increase the resident's awareness level. Below, write the names of residents in your facility with whom a Ceiling Mobile might be appropriate. Then, designate another staff member, a volunteer, or yourself to gather the materials for construction of the Mobiles. The next step is to designate a staff member or volunteer to implement the mobile with the residents listed.

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