12th COTW Due 11/01/18, by 1pm EST Medicare Emblem/HIP SNF

CCR1. 82 y/o F. Admitting Dx Altered Mental Status, S/p Fall w/Head Injury. R/o CVA, Ataxia, Hematuria. Elevated BP, Proteinuria. BP 215/116, P73, R18, T 98.0, Sat 98%; K 2.3-3.2, TROP 0.02, BNP 159.7, WBC 4.1, H/H 10.6/33, NEUT 71.8, UA: Blood Mod, Protein 100, WBC 1-4, RBC >20
Target LOS: 17 provided to facility based on DRG number: 088.
Expected DCP: D/c home w/ family, date TBD.
Number of Skill Days used out of 100 days: 3 eviCore days.
PMH: Dementia, CVA, HTN, DM, CHF, Asthma.
PLOF: I w/ambulation & ADL's-Initial Review Sup-Min A w/ ADLs.
Home Set Up: Lives w/son & granddaughter single family house 1 flight of STE & flight of stairs to living areas of the house.

Skilled Medical Needs: Albuterol Sulfate 2.5 mg/3mlQ 4 hr, ASA 81 mg, Enalapril 2.5 mg, Norvasc 10 mg, Solu-Medrol 40 mg/ml injection daily. Weekly weights. Ensure Enlive TID, Proform protein supplement BID. Labs ordered-HBA1C. O2 2 L/min N/C. BG Novolog TID. B/L heel pads in bed. Incontinent of B/B. Dry loose skin, black/blue discoloration to B/L UE/LE, ecchymotic area to Lt FA & discoloration to upper back. VS: 146/78, 74, 18, 97.2, BS 104mg/dl, Wt 119.6. Falls/poor safety awareness/universal precaution.

Current Mental Status: AAOx2 periods of confusion.
*Ambulation: 30 ft Mod A w/ RW. Bed mobility: CGA(Improved, 20ft Initial)
*Transfers: Min A (Unchanged, Initial)
*Stairs: 0 Steps Pt has 2 flight to stairs at home (Initial not noted)
*Bathing: Max A Hygiene/grooming: Min A (Initial not noted)
*Dressing: UB: Min A; LB: Mod A (Initial not noted)
*Toileting: Mod A (Improved, Initial Incontinent)
*Toilet Transfers: Min A (Unchanged, Initial)
*Speech: Low fat Mod-regular diet. Set-up (Initial not noted)

Participating in therapy 1.5 hrs/day, 5 days/wk. PT/OT Goals not met, prognosis good to continue therapy for increased functional gains: All Functional Skills Sup-Min A, Ambulate 75ft w/RW prior to D/c Home.


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