Karen H. Service Plan Notes

Service Initiation Date: November 28, 2017

NO DNR ON FILE

Last Date Reviewed: 03/02/2020

Location Notes: Enter through the garage. The keypad code is 0317.

Summary: Karen lives at home alone and uses us to do housekeeping tasks and run errands.  As her needs increase, she will use us for personal care, as well.

Allergies:  Unknown

Stated Medical Condition

  • Congestive Heart Failure

  • Diabetes

  • Kidney Disease (dialysis)

  • Hypertension

Dress Code: Blue scrubs with name tag

Is Cell Phone Use Allowed?: No

Is Sleeping Allowed?: No

Allergies:

Is the client on hospice?:

Is the client on home health?:

Date of Birth: 12/12/1942

Height and Weight:

Pets:

Smoker: No

Personal Care

  • See Service Plan and detailed list of ADL’s in the blue folder.

Personal Services

  • See detailed list of cleaning tasks on Page 2 and 3 of Service Plan in the blue folder.

  • Help her do the things she can't do.

Likes and Dislikes

  • See Getting to Know You document in the blue folder.

  • Very easy going

  • Prefers not to be asked “what to do next.” Keep busy cleaning, organizing and running errands. Check the care notes completed by the other caregivers to see what they do. Karen doesn’t like to continue to train caregivers.

Notes

  • Emergency Contact Information found in the blue folder.

  • Trash goes out on Mondays

Updates:

  • 06/27/2018 - After a two-and-a-half-month visit in a rehabilitation facility, she is home again. She needs help 3 hours a day to help her with personal care, bathing, meal prep, housekeeping and errands. This will take place for a few weeks until she gains more strength.

  • 07/06/2018 - You are reimbursed for using your vehicle for errands. Please add notes in the shift in TSheets with the number of miles.

  • 07/06/2018 - It was advised for caregivers to not bring in personal bags or purses due to presence of pests.

  • 08/08/2018 - Karen is back from the hospital but is noticeably weaker. She still needs help with running errands and honey-do's around the house. She will also need help transferring, walking and using the toilet.

  • 08/20/2018 - Message from caregiver: Please make sure water is poured out of her cooler daily and refilled with ice * breakfast sandwich in a bowl placed in cooler daily prior to leaving her. * plastic organizer was purchased today to eliminate all the folding tables and clutter. Most drawers are labeled. If she needs more labeled the labels and markers are in top drawer to left.

  • 08/26/2018 - Reported that Karen was incoherent and flush in the face the last two days when she arrived. Her home health nurse is aware and a visit is planned for Monday. Karen did not want to go to the ER. Caregiver asked to monitor her closely and all 911 if necessary.

  • 09/04/2018 - Reminders

    • Please check water level in oxygen concentrater. Distilled water bottles are near the tank.

    • Please check the mailbox daily.

  • 09/12/2018 - Avoid asking Karen repeatedly what to do next. There is a list of cleaning tasks in the blue folder. You can also view past notes to see what is done on a daily basis. Please do all housekeeping tasks on each visit.

  • 09/13/2018 - Karen was admitted to the hospital. She will let us know when she is discharged.

  • 10/09/2018 - Karen was admitted to the hospital. She will let us know when she is discharged. Oxygen levels were low and her legs were swelling and weeping.

  • 10/23/2018 - Updates from Karen

    • Karen asked for everyone to leave clear paths for her to be able to use her motorized scooter in her house, hallways, kitchen, etc. She was held up by the scale in the kitchen.

    • She needs to weigh and log her daily results.

  • 12/5/2018 - Karen’s nurse keeps reminding her to take her medications 1st thing in the morning for her heart.

  • 1/4/2019 - Karen came home from the hospital today. She is recovering from kidney failure and must do dialysis 3 days a week.

  • 3/25/2019 - Caregiver, Amy, reported Karen was in pain during her shift and complained of left arm pain. She was advised to seek medical attention but Karen believes the pain is not her heart, but rather the implant in her arm for dialysis.

  • 9/3/2019 - Karen has been in the hospital in ICU due to low blood pressure and a small blood clot in her hand that was causing her hand to turn black at the fingers. She has been released now but she is continuing treatment at home. Caregiver reported that she has a lot of fluid retention due to not being able to go to Dialysis. She is avoiding anything that can make her breathe harder and she is avoiding a lot of fluids to help with fluid retention.

  • 9/17/2019 - Karen has returned to the hospital due to the darkening in her hand again.

  • 10/7/2019 - Karen is at home and doing well

  • 11/5/2019 - Karen has been admitted to the hospital. Reason unknown at this time.

  • 11/11/2019 - Update from regular caregiver that Karen is supposed to be released from hospital to rehab facility in The Woodlands today. She should be there for a couple of weeks.

  • 12/3/2019 - The oxygen consentrator was not working properly. The caregiver found and cleaned calcium buildup around the water tank. It was cleaned and works now. Please be aware in case it needs cleaning again.

  • 12/8/2019 - Note from caregiver: (Karen) has a fungal infection between her thighs and her vagina area..it is pretty bad I was not made aware of it until last week she said she had it for a year but it got worse in the hospital this last time..she was prescribed a very strong antibiotic and a topical cream for it but Karen believed the antibiotic was what caused the diarrhea so she quit taking it many days ago..I would help her with the cream but it did not improve..it is many many open bloody areas in those areas she then decided to just use powder but with diareahha so much I'm sure its irritated it...I stayed a little late on Thursday (at her request not my suggestion) to speak with her nurse that comes out and nurse said to start washing with antibacterial dial soap and to apply the fungal spray used for athletes foot...we planned to start that on Tuesday. Was sent to hospital by nurse today because her vitals were not great and due to the persistant diarrhea .

  • 12/20/2019 - Update from Caregiver: Mostly normal week Karen's trying to get better. She has been to weak to get into regular bathroom lately so has been using bsc. Needs to be emptied and sanitized at every visit. Also Karen's bottom is still pretty sore and bleeding so the pillowcase she sits on needs to be washed each visit if possible