Custodial SNF with Hospice Placement Referral Form    Today's date: 9/15/2023  Proj. D/C Date: 9/16/23   Coverage Information :  Secondary Payer Source :  Medicare Health Insurance Commission #:    Home Address :     D/C Diagnosis:   Active Hospital Problems   Diagnosis   ? (Principal) ACUTE ASPIRATION PNEUMONIA   ? THROMBOCYTOPENIA, UNSPECIFIED (UNKNOWN ETIOLOGY)   ? ACUTE HYPOXEMIC RESPIRATORY FAILURE   ? DYSPHAGIA   ? COVID-19 DISEASE   ? GLIOBLASTOMA MULTIFORME, TEMPORAL LOBE   ? POLST FORM ON FILE FOR DNR/DNI, LIMITED ADDITIONAL INTERVENTIONS   ? PRESSURE ULCER OF SACRUM STAGE 2 (PARTIAL THICKNESS SKIN LOSS)   ? PRESENCE OF FOLEY CATHETER   ? SEVERE PROTEIN CALORIE MALNUTRITION   ? URINARY RETENTION   ? CKD STAGE 3A (GFR 45-59)   ? PRESENCE OF BIVENTRICULAR AICD   ? HEART FAILURE W REDUCED LVEF <=30%, UNSPECIFIED ACUITY   ? ATRIAL FIBRILLATION, PAROXYSMAL   ? NONISCHEMIC DILATED CARDIOMYOPATHY   ? HYPOTHYROIDISM     Resolved Hospital Problems No resolved problems to display.   Gender: Female   Height:    Weight: Weight: 65 kg (143 lb 4.8 oz) Admit Date: 9/10/2023 Prior Living Status/Location: Home with friend Prior ADL Assistance :   Contact Person/DPA & Relationship:  HBS Attending: Dr. Pgr#:  Tel#:    Additional Medical Information Custodial SNF placement with Hospice COVID positive on 9/10/23    Skilled Need Additional Medical Information Custodial SNF placement with Hospice     Mental Status Confused Behav. Explanation & Meds:     Current Facility Location Current ADL Assist:  Assistance      Current Feeding Assist Bowel/Bladder NPO Bladder Incontinent and Bowel Incontinent   Check for date of last bowel movement and enter here: 9/15/23    Communication Status Non-verbal Primary Language:  Interpreter Required:NO    Special Admit Considerations/Facility Requests Patient/family prefers  Date of last PPD:  Date of last CXR: 9/10/23    Immunization History Administered Date(s) Administered ? COVID-19 PFizer-BioNtech 12yrs-adult, external administration 02/03/2021, 02/25/2021 ? COVID-19 mRNA LNP-S, bivalent PF 12yrs-adult (Pfizer), 30mcg/0.3mL 10/24/2022, 06/22/2023 ? COVID-19 mRNA, LNP-S, PF (Pfizer-BioNTech) PURPLE CAP 10/21/2021, 04/20/2022 ? INFS pres free 6mos-adult (Fluarix quadrivalent) 10/09/2018 ? INFS pres free high dose (Fluzone quadrivalent) (influenza) 09/14/2020, 10/06/2022 ? INFs (Influenza split virus ). 10/01/2014 ? INFs 4yrs and over (FLUVIRIN) (Influenza) 10/31/2016 ? INFs Pres Free High Dose (FLUZONE) (influenza) 12/09/2019 ? INFs pres free 18yrs-adult (influenza) 01/13/2014 ? INFs pres free 65yrs and over (Fluad quadrivalent IIV4) (Influenza) 10/21/2021 ? INFs pres free 9yrs-adult (AFLURIA) (Influenza) 11/11/2015 ? PNUcn13 (PREVNAR 13) (Pneumococcal conjugate, 13 valent) 11/08/2016 ? PPSV23 (Pneumococcal polysaccharide) 12/11/2009, 01/22/2018 ? Tdap (ADACEL) (Tetanus, diphtheria, acellular pertussis) 12/11/2009, 08/28/2019 ? ZOS (Herpes zoster recombinant) Shingrix 10/15/2020, 05/07/2021 ? ZOS (Zostervirus live, shingles) 11/18/2015 ? infs pres free 65yrs and over (fluad trivalent iiv3) (influenza) 10/19/2017 ? td 7yrs-adult (tetanus, diphtheria), adsorbed 11/07/1995     Dialysis Info Place:not applicable Transferring:N/A Days: not applicable Time: not applicable Transport: not applicable Tel#: not applicable    Post-skilled Plan Custodial with hospice    Current Skin Status Skin Intact    PCC/MSW:   Pgr#:          Note Details  Author (R.N.) File Time 9/15/2023  3:44 PM Author Type REGISTERED NURSE Status Signed Last Editor (R.N.) Specialty GENERAL, OTHER Hospital Acct # Admit Date 9/10/2023  Admission (Current) on 9/10/2023  Admission (Current) on 9/10/2023   Detailed Report  Note shared with patient Care Timeline  09/10   Admitted 1536  pt admitted.