20th Case of the Week Due 1/24/19, by 1pm EST-Medicaid

Review 1/11/19

CCR1. PHI verified via Fax. Brief Clinical Course: 58 y/o F. Admitted 12/27/2018 w/ fall & HTN. Hx of recent stroke, s/p fall unwitnessed & pt does not recall the fall. In rehab, per daughter, pt is more confused than usual. Baseline L sided weakness, neglect & pain. Target LOS 18 days provided to facility based on DRG 556. TGD 01/23/2019. Expected DCP: Not Provided. Expected DC date: TBD. Number of Skill Days used prior to current review/100 days: NA. PMH: Asthma, DM, Fibromyalgia, GERD, HLD, HTN, Lupus Lupus, Peripheral Neuropathy Stroke, TIA, R LE ORIF, Former smoker. PLOF/Living Situation: Requires assistance w/ ADLs, functional transfers, ambulates w/ a cane. Lives in alone in apartment. In SNF prior to this admission, fell & readmitted to hospital. Home Setup: Not provided. Behavioral Health: Mood disorder. Advanced Directive/Living Will: Not provided. Service requested for: SNF1. *Skilled Medical Needs: Acetaminophen, Amlodipine, ASA, Clopidogrel, Divalrroex, Donepezil, Escitalopram, Heoatin, Humalog Hydralazine, Ipratropium-Albuterol Neb, Levimir, Lisinopril, Metolazone, Metoprolol, Neurontin, Oxycodone-Acetaminophen. 1/7/19 Was FOF w/ back against the w/c. 1/8/19 found on the floor face first sent to ER to R/O Internal bleed. Pt agitated, hitting staff, yelling. *Current Mental Status: AAOX1. Periods of confusion Dementia Score: Not Provided. *Bed Mobility: MaxA x 2. *Ambulation: N/A ft. *Transfer: Dependent w/hoyer lift. *Stairs: N/A steps. *Bathing UB: Dependent. LB: Not Provided. *Dressing UB: Dependent. LB: Not Provided. *Toileting: Dependent. *Toilet transfers: Not Provided. *Speech Tx: Speech and swallow evaluation performed. Diet - Mechanical soft w thin liq.

No Improvement in Functional status from Initial Review. PT/OT eval completed with pt participation & goals established. Therapy initiated to assist w/all functional mobility towards PLOF.


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