A review of the medical records indicates that the patient suffers from dysphagia-on a mechanical soft diet-great aspiration risk. He suffers from multiple medical illnesses which includes, Dementia without behavioral disturbances-he is a Fast 7D with pps 30, ADFT, chronic COPD, chronic UTI infection and chronic GERD.
At today’s visit he is found in his room, lying in bed at Tiffany hall SNF. He denies pain and discomfort. He was recently evaluated by hospice. Hospice admission is on hold due to patient having wound rehab. He has an unstageable pressure ulcer to left heal for which he is follow by a wound care specialist His appetite remains poor; he refused most meals and refused his nutritional supplements. He loss 21 lbs since February
At today’s visit he is found in his room, lying in bed at Tiffany hall SNF. He denies pain and discomfort. He was recently evaluated by hospice. Hospice admission is on hold due to patient having wound rehab. He has an unstageable pressure ulcer to left heal for which he is follow by a wound care specialist His appetite remains poor; he refused most meals and refused his nutritional supplements. He loss 21 lbs since February