14th Case of the Week Due 11/08/18 by 1pm EST

Medicare SNF- Review on 10/31/18
CCR4. 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 (Tx Goal Date 10/25/18)
Expected DCP: D/c home w/ family support, 11/2/18
Number of Skill Days used out of 100 days: 17 eviCore days not including this Review
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, house safe

**Skilled Medical Needs: Albuterol Sulfate 2.5 mg Q 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. Stage 1 Rt Hip, measurement/Tx not provided. Wt 119.6. Falls/poor safety awareness/universal precaution
**Current Mental Status: AAOx2 periods of confusion

**Ambulation: 65 ft x 2 CGA w/ RW (declined 150 ft Min A RW) Rest periods SOB, decrease step/stride length, decrease cadence
**Transfers: Not noted-CCR3-Min A (unchanged Min A)
**Stairs: 8 steps CGA B/L HR (improved 4 steps Mod A)
**Bathing: UB: Sup (unchanged Sup). Bathing Transfer: Min A (unchanged Min A). Hygiene/grooming: Set up (improved Sup)
**Dressing: UB: Set up (Improved SBA); LB: Min A (improved Mod A)
**Toileting: Min A (unchanged Min A)
**Toilet Transfers: Min A-Commode (unchanged Min A)
**Speech TX: Low fat Mod-regular diet

PT/OT for therapy initiation and to maximize overall functional mobility. PT/OT Goals: All Functional Skills Sup-Min A. Ambulate at Min household distance prior to D/c Home


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