Objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident's medical record. Diagnoses include CVA with right hemiplegia, Expressive and Receptive Dysarthia, and Cataract of the right eye. R3 was receiving Total Parenteral Nutrition in the acute care setting. 1045 documented Z1 had examined R3 and that R3's family were in the process of obtaining a healthcare power of attorney. Oral care only.
Resident is awake and alert.
Oral care given, res sucked H20 out of swab. Fed per spoon and showed no difficulties with swallowing. Did become slightly choked when she held the cup herself and took a drink herself. R3 was observed to consume 10 spoonfuls of pureed foods and 50cc Enlive supplement without any signs of choking. R3 would swallow upon cuing from staff.