31st COTW Due 12/5/19, by 1pm EST; HF, *Use 2019 GLs*

CCR 2. 92 y/oF. Admitting Diagnosis: Rt Hip Fx. Admitted 11/2/19, s/p fall, can’t walk c/o increased Rt hip pain/weakness. Underwent ORIF Rt Hip. Physical Findings: X-ray: Rt hip fx. TGD: 12/5/2019. Expected DCP: Home alone, no date. Number of Skill Days used prior to current review/100 days: 12. PMH: HTN, DM, GERD, PVD s/p stenting, and CAD w/MI. PLOF/ Living Situation: Lives alone, elevator apartment, HHA 7 days/wk, cane, ADL/IADLs Assistance. Behavioral Health/Advanced Directive/Living Will: Not provided. Service requested for: SNF2. *Skilled Medical Needs: Medical and Med Management Tylenol and Lidocaine patch for pain. Wound Care: Pressure Ulcer Rt heel 2x3 cm Mod serosanguineous exudate Tx Triad Hydrophilic Paste. *Current Mental Status: A&OX3 Dementia Score: Not Provided. *Bed Mobility: MaxA --> Mod/MaxA (Improved). *Ambulation: Unable ft --> 5 feet ft MaxA, 2WW (Improved). *Transfers: Max x2 --> MaxA x1 (Improved). *Stairs: 0 step --> Not tested. *Bathing UB: Only hygiene/grooming CGA/MinA. LB: Mod A (Unchanged.) *Dressing UB: Min/ModA --> MinA (Improved); *LB: Dependent --> MaxA (Improved). *Toileting: Dependent --> MaxA x2 (Improved). *Toilet transfers: Not Provided. *Speech Tx: Swallows regular textures using safe swallow strategies 60% of time increased from 30% per eval. Mechanical soft/chopped textures. Participating in 2hrs Therapy daily.

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