Care Plan Activity Report

Kings Harbor Multicare Center

Resident: Barksdale, Clydia
Unit-Room-Bed: M1 – 114 – A
DOB: 6/15/1928 (96 y)
System/Facility ID: 19302 / 041353

Selection: Scheduled Date: 3/11/2025; With Corrections: From 3/5/2025

Notes	Status / Date
▪️ (Historical Item) Resident is a 95 y/o female with NKFA. PMH: A-fib HCVD with chronic diastolic CHF-no diuretics, OA, dementia, DM2, Pulmonary HTN, Mild dysphagia per speech 6/15/23. Appetite is variable good-eating between 50-75-5 of meals with set up/supervision. Resident eats most food groups on a liberalized diet Soft & Bite Sized Level 6 (Mechanical soft). Is PROVIDED SUGAR SUBSTITUTES/DIET CONDIMENTS. Resident will continue to benefit from HiCal/HiPro foods: 6-oz hi-cal/pro cereal @ B (253 cals, 7 g pro); 2 oz hi-cal/pro eggs @ B (287 cal, 17 g pro) to optimize nutritional needs and stabilize weight, encourage fluids to optimize hydration. Current weight is 144.6 # (3/1/23) BMI 29.4; Overweight. Goal is weight stability x 30 days. Skin intact. Resident on polypharmacy-potential effect on weight and appetite such as (Cardiac, Metformin, Antithrombotic, Tylenol). Estimated nutritional needs met with current dietary regimen to deter risk. Will continue to monitor and intervene prn. POC continue.	Entered On: 6/19/2023 Entered By: Roncev
A 95 y/o female continues on L/T care. Labs on 7/29/23: Glu 106H, GFR 38L, Na/K/Alb/BUN/H/H wnl. PO intake of fluids is good; no visible s/s fluid deficit noted. Skin: no PU/PIs. No GI complaints voiced out. Resident on meds with a potential effect on appetite/weight: DM-related, tylenol, cardiac. Resident remains at risk for altered nutrition and hydration status give the advanced age of 95 and presence of co-morbidities, including DM, HTN, dementia. Current diet and supplementation regimen provides for ≥ estimated needs to maintain weight and deter nutritional risks.	Created On: 9/16/2023 Entered On: 9/16/2023 Entered By: Ovcharova, Irina
95 y/o female with NKFA. As per MD on 11/21/23; resident has oral dysphagia 2/2 decayed teeth, Chronic atrial fibrillation, HCVD with chronic diastolic CHF, Generalized OA, Dementia, DM2, Tricuspid regurgitation, Pulmonary HTN, Mild Malnutrition / Malnutrition as per MD. Slightly weight changes noted this period, however not significant. Resident maintain adequate PO fluid acceptance with 100%, 75% as per ECNAAR and encouragements continue to maintain hydration. No visible s/s of fluid deficit noted. No edema., Skin with No PU/PI, and no GI disturbance reported. MD rx of Metformin continue for DM management, and Liberalized DM also appropriate at this time. Other meds with potential negative effect on appetite and weight are (Tylenol, Cardiac, Metformin, Antithrombotic). Resident is a risk due polypharmacy and advance age. Will continue to monitor and f/u prn.	Created On: 12/11/2023 Entered On: 12/11/2023 Entered By: Tetteh, Augustina
Consuming meals on unit where her/his intake is 50% to 100%. As per observation and CNAAR, intake is adequate to meet nutrient and fluid requirements. Appearance is obvious well-nourished resident. Weight is 141.6 lbs and represents a fairly stable weight at 141 lbs ± 2 lbs X 6 months. Per MD on 02/08/2024 indicates no edema, no PU/PI, No visible fluid deficits, and no GI discomfort. No current labs. Resident is at nutrition risk for malnutrition related to multiple co-morbidities including Dementia, DM-2, Pulmonary HTN, and Oral dysphagia.	Created On: 3/01/2024 Entered On: 3/01/2024 Entered By: Flores, Domenica
Resident is a 95-year-old female receiving a Liberalized diet approach through provision of SUGAR SUBSTITUTES AND DIET CONDIMENTS TO AID IN diabetes management with fortified foods and Soft and Bite Sized Level 6 (Mechanical soft) diet. Consuming meals on unit where her intake is variable at 25% to 75%. As per observation and CNAAR, intake is adequate to meet nutrient and fluid requirements as evidenced by weight stability. Weight is 145 lbs. and represents at 143 lbs. ± 2 lbs. X 6 months. Stable X 1/m, gain 3.4 lbs. X 3 m, and gain of 2.2 lbs. X 6 months. Weight history: 145.2 lbs. (4/03/24), 141.6 lbs. (2/03/24), 142.8 lbs. (11/03/23) BMI 28.48 is overweight status. Per MD on 5/18/2024, no edema, PU/PI., no visible fluid deficits noted, and no GI discomfort. Labs: 3/4/2024 BUN WNL, Albumin WNL	Created On: 5/21/2024 Entered On: 5/21/2024 Entered By: Flores, Domenica

▪️ = Historical Item

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