An 87-year-old female was admitted to Coral Harbor Healthcare & Rehabilitation Center after hospitalization at Jersey Shore University Medical Center. She presented with a syncopal episode unable to recall the event. She has an extensive history of CHF, HTN, Gout, and CKD which requires Peritoneal Dialysis.

Reviewed by IDT led by PCP Dr. Walid Abboud, Nephrologist Dr. Sushil Mehandru, PA Supreet Kaur, Cardiologist Dr. Michael Aaron, PA Arjun Swamy, Physiatrist, Dr. Michael Dambeck, and APN Jennifer Curtin, Specialty Program Nurse Coordinator along with the daily clinical care of the nursing team!

Nursing Interventions:

Medication and Pain Management – including beta-blockers, blood thinners, uric acid reducers, antibiotic therapy, supplements, and vitamins.
Peritoneal Dialysis – the nursing staff provides extensive education on the management of PD with both the patient and family.
Maintain Adequate Nutrition – including dietitian consult, fluid restriction, and weight management.
Monitor Labs and diagnostic Studies – frequent labs to monitor peritoneal fluid and care, in-house EKG, and X-ray Capabilities.

Therapy Interventions:

Upon admission, the patient was dependent on transfers, bed mobility, and self-care tasks. She was also unable to ambulate. She was determined to accomplish her goal of returning home with her family. She worked hard with both the clinical team and
therapy team to accomplish her goal. Upon discharge, she required minimal assistance with transfers, bed mobility, and self-care tasks. She was also able to ambulate 50 feet safely with a rolling walker.

She was discharged safely to home with her daughter and HMH at Home Care Services. All follow-up appointments were made before discharge, including her primary care physician Dr. Lizetta Marza, and community Nephrologist Dr. John DePalma.


Patient was admitted to Coral Harbor Rehabilitation and Healthcare Center on September 03, 2021 under the care of Dr. Brian Roper. During the course of the stay, Occupational Therapy, Physical Therapy, and Speech Therapy were initiated to efficiently and effectively identify the Patient’s unique needs and tailor specialized treatment plans to successfully transition to the next level of care.

The therapy team provided skilled interventions to address the adaptation, compensation, and restoration potential of the Patient and coordinated with the interdisciplinary team to ensure appropriate clinical care areas were addressed. On October 22, 2021, the Patient was successfully discharged to home. The rehabilitation length of stay was 50 days.

Overall Composite Score Outcomes

Rehabilitation outcomes are assessed on a 10-point rating scale. 10 is the most independent level of ability, and 1 is the most dependent level of ability. A score of 0 may represent an inability to perform the task. The Model 10 Composite Score represents the Patient’s overall outcomes.


57-year-old female admitted to Coral Harbor Healthcare and Rehabilitation Center from Monmouth Medical Center with admitting diagnosis of Respiratory Failure with COPD and a history of Pulmonary Hypertension

Nursing and Respiratory Interventions

Maintain Nocturnal Support – Trilogy AVAPS-AE at HS & as needed while awake.
Maintain Adequate Oxygenation – Oxygen at 3 lpm continuous-wean as able.
Medication Management – Prednisone taper, Combivent and Advair

Pacing and Endurance with Activity

Physician Led Pulmonary Interdisciplinary Team Rounding Chaired by Shore
Pulmonary Physician Group
Patient required Medication and Trilogy Setting Titrations.

Keen Nursing Assessment and Weekly Rounding by Our In-house Pulmonologist and Nurse Practitioners is Key to Continue Management of Patients of this Acuity at this Level of Care. #TreatInPlace


Upon admission, Patient was totally dependent making no attempt to initiate with self-care tasks and unable to ambulate. She continues to receive occupational and physical therapy 5 times a week throughout her stay. Currently, she is ambulating 10 feet with roller walker and minimal assist.

Patients discharge disposition will depend on her continued progress here in Short Term Rehab. Discharge Plan is certain to include continued use of Trilogy AVAPS-AE and low flow oxygen. More updates to follow!


77-year-old female admitted to Coral Harbor Healthcare and Rehabilitation Center after a 5 day hospitalization at Jersey Shore University Medical Center for the treatment of Two Part Displaced Fracture of the Right Humerus, Pulmonary Fibrosis, Diastolic Heart Failure and AFIB.

Nursing Interventions

Medication Management: Digoxin, Lasix, Eliquis and Aspirin
Monitor Fluid Balance: Daily weight Monitoring; Monitor for recurrent Pleural Effusion
Maintain Nocturnal Support: Trilogy AVAPS-AE at HS
Maintain Adequate Oxygenation/Titrate as tolerated: Patient O2 weaned from 4L on admission to 2L on Discharge

Reviewed weekly w Interdisciplinary Care Team in Cardiac IDT- lead by cardiologist, Dr. Aaron

Patient was followed weekly in the center by Shore Pulmonology for Pulmonary Fibrosis


Upon admission, Patient required maximum assistance with all self-care tasks and was Wheelchair Level. She was receiving occupational and physical therapy 5 times a week for 3 weeks. Upon discharge, she remained wheelchair level. Sitting tolerance 6-8 hours Daily.

Patient was followed by Dr. Odejoi both in the hospital as well as her STR stay. After a 19-day LOS in STR, she returned home with 24-hour caregivers. She has Trilogy Nocturnal Support for HS which she wore chronically prior to this hospitalization.

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