22nd Case of the Week Due 3/14/19, by 1pm EST

Medicaid/SNF. CCR4. 51 yo male w/ CVA, Dysarthria, & Dysphagia. Target LOS 22 days provided to facility based on DRG 065. TGD: 2/08/2019. Expected DCP: To return to living w/ family/friends. Tentative rehab completion date: 2/25/19. SW exploring w/ member alternative living arrangement, final d/c not set. Expected DC date: 2/19/2019. Number of Skill Days used prior to current review/100 days: NA. PMH: HTN. PLOF/ Living Situation: Independent in all ADLs & IADLs shared between pt & fiancé. Ambulatory w/o DME & took public transportation. No other DMEs reported. Home Assessment: Not provided. Home Setup: Lives w/his fiancé in a 4th floor walk-up apartment w/left HR ascending. Behavioral Health: Not provided. Advanced Directive/Living Will: Not provided. Service requested for SNF.
*Skilled Medical Needs: Precautions: Fall risk, Monitor VS, Mech soft diet, thin liquids, right sided weakness. Meds: Acetaminophen 650mg Q6H, ASA 81mg QD, Plavix 75mg QD, Amlodipine Besylate 10mg QD, Lipitor 80mg QD, Losartan Potassium 100mg QD, HCTZ 25mg QD, Colace 200mg QHS, Senna 8.6mg QHS, Baclofen 10mg TID. 2/3: v/s BP 138/78, P 68 T 97.6
*Current Mental Status: AAOx3. No clinical update on Dysarthria. Dementia Score: Not Provided.
*Bed Mobility: Supervision --> Set-up (Improved). *Ambulation: 75 ft MinA w/ Hemi-walker --> 90 ft Min w/ Hemi-walker (Improved).
*Transfers: CGA --> SBA (Improved).
*Stairs: 3 steps Mod --> 6 steps Min (Improved).
*Bathing UB: Mod A --> Min A (Improved); *LB: Mod A --> Min A (Improved).
*Dressing UB: Min A --> CGA (Improved); *LB: Max A --> Min A (Improved).
*Toileting: Mod A --> Min A (Improved).
*Toilet transfers: Min A --> CGA (Improved).
*Speech Tx: Dysphagia, swallowing abilities is mild. Mechanical soft, thin liquids. Self-feeding: Supervision (unchanged).
Therapy 2-3hrs/day 5-6 days a week. Pt participates in therapy daily.


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