21st Case of the Week Due 2/14/19, by 1pm EST
Review 1/2/19
CCR1. 79 y/o F admitted 11/25/18 after being found unresponsive on the floor, pulseless. Intubated, trach and treated for HCAP and UTI. Target LOS NA days provided to facility based on NA. Treatment Goal Date: Input Start of Care. Expected DCP: Not Provided. Expected DC date: Not Provided. Number of Skill Days used prior to current review/100 days: 11 days. PMH: Dementia, DM2, Hypothyroidism. PLOF/Living Situation: Not provided. Home Setup: Not provided. Behavioral Health: Not provided. Advanced Directive/Living Will: Not provided. Service requested for: SNF. *Skilled Medical Needs: Vent dependent, vent setting PRVC 350/24%/10/5, Trach care. Attempted weaning x1 unsuccessful. Assess respiratory every 4hrs and PRN. Goal, ventilator weaning, pt stable *Current Mental Status: Awake and disorientated, responsive to tactile stimuli. Dementia Score: Not Provided. *Bed Mobility: Dependent. *Ambulation: Not tested. *Transfer: Dependent. *Stairs: Not tested. *Bathing UB: Dependent. *LB: Dependent. *Dressing UB: Dependent. *LB: Dependent. *Toileting: Dependent. *Toilet Transfers: Dependent. *Speech Tx: Not Provided.
Note: This req is for LTAC not SNF as documented above. No Functional Status provided per Initial Review.
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