Case Studies

Case Study

Admitting Diagnosis: Displaced Intertrochanteric Fracture of the Left Femur
Discharge Location: Home

A 91-year-old gentleman who was admitted to The North End Rehabilitation and Healthcare Center from Spaulding Rehabilitation Hospital for skilled nursing and therapy following a left femur fracture. Upon admission, Mr. C. was evaluated by and participated in skilled occupational and physical therapy where he was noted to require stand by assistance with upper body dressing and maximum assistance with lower body dressing. He required moderate assistance for toileting and bathing and contact guard assistance with hygiene and grooming. Additionally, he required minimum assistance with bed mobility, moderate assistance with transfers and contact guard assistance to ambulate 5 feet with a rolling walker. Mr. C. was determined to return home and he consistently participated in therapy. Upon discharge, Mr. C. was able to do 13 steps with contact guard assistance and was able to transfer and ambulate 300 feet with a rolling walker and supervision. He was also able to perform upper body dressing with supervision, lower body dressing with minimum assistance, and was able to perform bed mobility with modified independence. He made great gains toward his therapy goals and was able to return home at an increased level of independence with strong family support and VNA services. Great job, Mr. C.!

10.0 – Complete Independent – No assist, no equipment
9.0 – Modified Independent – No Assist, but equipment or extra time
8.0 – S/u – No physical assist other than set-up; supervision for safety/technique; and/or single cue to initiate
7.0 – Supervision-No physical assist; supervision for safety/technique; and/or single cue to initiate
6.0 – SBA-Pt. performs task with close supervision and or visual/verbal cues for task completion
5.0 – CGA – Contact Guard Assist
4.0 – Min – Occasional assist (25% or less time or effort to complete)
3.0 – Mod – Frequent assist (40-50% of the time or effort involved to complete task
2.0 – Max – Constant assist (75-90% of the time or effort involved to complete task
1.0 – CD – Complete Dependence: No contribution from pt; task done by others or not assessed


Case Study

Admitting Diagnosis: Cerebral Infarction
Discharge Location: Home

A 76-year-old female who was admitted to the North End Rehabilitation and Healthcare Center from Mass General Hospital for skilled nursing and therapy services to safely return home following a cerebral infarction. Upon admission, Ms. K. was evaluated by and participated in skilled occupational, physical and speech therapy where she was found to require maximum assistance for lower body dressing, minimum assistance for bed mobility and contact guard assistance for transfers, gait, toileting, upper body dressing, and hygiene. Additionally, she was put on a mechanical soft texture diet to reduce risk of aspiration and required moderate cueing for problem solving. She was determined to return home and worked hard with the therapists to return to a more functional level. Upon discharge, Ms. K. was able to transfer and ambulate 350 feet independently, was able to perform all self-care tasks without assistance and was able to be upgraded to a regular diet, showing vast improvement with her safety during swallowing activities. She made great gains toward her therapy goals and was able to return home with home health services. Great work, Ms. K.!

10.0 – Complete Independent – No assist, no equipment
9.0 – Modified Independent – No Assist, but equipment or extra time
8.0 – S/u – No physical assist other than set-up; supervision for safety/technique; and/or single cue to initiate
7.0 – Supervision-No physical assist; supervision for safety/technique; and/or single cue to initiate
6.0 – SBA-Pt. performs task with close supervision and or visual/verbal cues for task completion
5.0 – CGA – Contact Guard Assist
4.0 – Min – Occasional assist (25% or less time or effort to complete)
3.0 – Mod – Frequent assist (40-50% of the time or effort involved to complete task
2.0 – Max – Constant assist (75-90% of the time or effort involved to complete task
1.0 – CD – Complete Dependence: No contribution from pt; task done by others or not assessed


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