23rd Case of the Week Due 4/11/19, by 1pm EST

Commercial/SNF CCR2. Admitted to hospital 3/3/2019. 66 yo F w/ fall. S/p Rt Hip Cephalurnedullary Nailing for Hip Intertrochanteric Fx. Target LOS 19 days (3/30/19) provided to facility based on DRG number 466. Expected DCP: Home w/family support. D/c date TBD. Number of Skill Days used out of 100 days: 17 eviCore days. PMH: DM, Hypothyroidism. PLOF/ Living Situation: Living arrangements: Lives with family in 6th floor apartment, 5-6 steps to enter and elevator access. Prior to admission, pt ambulated with a RW outdoors with supervision and SC indoors with Mod I required assistance to negotiate stairs.
Skilled Service: SNF.
*Skilled Medical Needs: Safety, falls, 3/23/19 V/s: BP: 138/75, T: 100.6, 02 Sat: 89%, P: 105, R: 22.
WBCs 15. New onset, first incident of Rt Hip swollen, red and warm to touch-possible infection, culture completed 3/24/19 and awaiting results. Ortho appt in 1 wk- Nurse will call Ortho to see if appt can be move up. Nurse awaiting ABX order to start. Tylenol 325mg PO q4h PRN Fever, Hydrocodone 10-325mg PO q4-6h PRN Rt Hip Pain.
*Current Mental Status: AOx3
*Ambulation: 10ft 2ww Mod an improved
*Transfers: Mod an unchanged
*Stairs: 1 step Max an improved
*Bathing: CGA improved
*Dressing: CGA Mod an improved
*Toileting: Mod an improved
*Toilet transfers: Min an improved
*Speech Tx: N/a.
Pt always participates in PT/OT, 2-3 hours/day x 5 days wk except for the dates of 3/23 & 3/24 only 1hr of therapy d/t possible infection. Goals established, and therapy has been initiated to assist w/all functional mobility towards PLOF.



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