Doris M. Burke

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CARECONNECT — RESIDENT RECORD PACKET
Resident: Doris M. Burke
Facility: Meadow Creek Health & Rehabilitation · Room 214-B
Generated: 8/20/2026, 5:31:52 PM
This copy was released to the requester under 45 CFR §164.524 (right of access).

DAILY CARE LOG
  Repositioning:
    06:00 — Repositioned — right side: Pillow wedge placed. Skin over sacrum pink, blanchable, no breakdown. (A. Reyes, CNA #4412)
    08:05 — Up to recliner: Transferred with 2-person assist and gait belt. Tolerated 45 minutes. (A. Reyes, CNA #4412)
    10:00 — Repositioned — left side: Heels floated on pillow. Barrier cream applied. (A. Reyes, CNA #4412)
    12:15 — Repositioned — back with wedge: Head of bed 30°. Incontinence care completed. (T. Nguyen, CNA #5108)
    14:10 — Repositioned — right side: Resident requested TV on. Call light in reach. (T. Nguyen, CNA #5108)
    16:00 — Repositioned — left side: Small reddened area right heel noted, reported to charge RN. (T. Nguyen, CNA #5108)
    18:20 — Repositioned — back: Skin check by RN: stage 1 pressure area right heel, offloading boot applied. (K. Alvarez, RN, RN #2201)
  Meals:
    Breakfast 7:40: Scrambled eggs, oatmeal, peaches, 8oz milk, decaf coffee — intake 75%, fluids 360 mL (Fed self with setup assist. Enjoyed the peaches.)
    Lunch 12:05: Baked chicken (minced), mashed potatoes, green beans, pudding — intake 50%, fluids 240 mL (Refused green beans. Encouraged fluids.)
    Snack 14:45: Greek yogurt, graham crackers — intake 100%, fluids 120 mL (Dietitian-added protein snack.)
    Dinner 17:30: Salisbury steak (minced), rice, carrots, sugar-free jello — intake 80%, fluids 300 mL (Sat up in chair for full meal.)
  Vitals:
    08:00 Blood pressure: 128/74
    08:00 Heart rate: 78 bpm
    08:00 Temperature: 98.4 °F
    08:00 O₂ saturation: 96% RA
    11:30 Blood glucose: 156 mg/dL
    06:30 Weight: 148.2 lb (-0.6 lb)
    14:00 Pain: 3 / 10 hip
    All day Bowel / bladder: 1 BM, continent x3

MEDICATIONS
  Apixaban (Eliquis) 5 mg — Twice daily — 09:00, 21:00 — Given: 09:00 given by K. Alvarez, RN · 21:00 given by M. Doyle, LVN
      For: Blood thinner. Prevents clots in the legs and lungs after hip surgery. | Ordered by Dr. P. Okafor, MD — ordered 8/3/2026
  Metformin 500 mg — Twice daily with meals — Given: 08:00 and 17:45 given with food. No GI upset reported.
      For: Lowers blood sugar in type 2 diabetes. | Ordered by Dr. P. Okafor, MD
  Furosemide (Lasix) 20 mg — Daily — 09:00 — Given: Daily weight and swelling checks charted.
      For: Water pill for congestive heart failure. | Ordered by Dr. P. Okafor, MD
  Oxycodone 5 mg — Every 6 hours as needed for pain — Refused: 14:00 dose refused — 'I don't want to feel foggy for my daughter's call.' Pain reassessed at 3/10. RN notified, non-drug comfort measures used.
      For: Short-acting pain relief. | Ordered by Dr. P. Okafor, MD
  Vitamin D3 1000 IU + Calcium — Daily — 08:00 — Given: Taken with breakfast.
      For: Bone strength. | Ordered by Dr. P. Okafor, MD
  Senna-S — Nightly — Held: Held — resident had a bowel movement at 13:00. Per standing order.
      For: Stool softener / laxative. | Ordered by Dr. P. Okafor, MD

CLINICAL NOTES
  [Today 18:45] Nursing shift summary — day shift — K. Alvarez, RN RN #2201
    Resident alert and oriented x3, pleasant and cooperative. Surgical incision left hip clean, dry, intact, staples in place, no drainage or odor. New stage 1 pressure area right heel — offloading boot applied, turn schedule tightened to q2h, wound nurse consult requested. Ate 50–80% of meals, fluids encouraged. Participated fully in PT and ST. Refused 14:00 PRN oxycodone. No falls. Call light within reach at end of shift.
  [Today 11:20] Physician progress note — Dr. P. Okafor, MD Attending physician
    POD 12 s/p left hip ORIF. Weight-bearing as tolerated continued. Lungs clear, no lower-extremity edema today. A1c pending. Continue apixaban through 9/6. New heel pressure area — agree with offloading and wound consult. Anticipate discharge readiness evaluation at day 21 pending therapy progress.
  [Today 21:30] Evening medication pass — M. Doyle, LVN LVN #3390
    All scheduled evening medications administered. Blood glucose 142 at bedtime. Resident settled, denies pain. Bed in low position, alarm pad active.
  [Yesterday 15:00] Social services / discharge planning — L. Freeman, LCSW Social services
    Met with resident and daughter by phone. Discussed benefit day count (18 of 21 used) and the appeal process if Medicare coverage ends before therapy goals are met. Home assessment scheduled. Daughter requested grab bars and a bedside commode be added to the DME list.

THERAPY & REHAB
  Physical Therapy — R. Patel, PT, DPT (Today 09:30 · 45 min)
    Goal: Ambulate 150 ft with rolling walker, supervision only
    Progress: Walked 110 ft with rolling walker and contact-guard assist (up from 80 ft Monday). Sit-to-stand x5 with minimal assist. No loss of balance.
    Plan: Continue 5x/week. Add stair training Thursday. Target discharge home with daughter by 9/8.
  Occupational Therapy — J. Whitfield, OTR/L (Today 13:15 · 30 min)
    Goal: Independent upper-body dressing and safe toilet transfer
    Progress: Dressed upper body independently using reacher. Toilet transfer with supervision and grab bar. Fatigued at 25 minutes.
    Plan: Home safety evaluation Friday. Recommend grab bars, raised toilet seat, shower chair.
  Speech Therapy — C. Mbeki, CCC-SLP (Today 15:00 · 30 min)
    Goal: Safe swallow on mechanical soft diet, no coughing with thin liquids
    Progress: No overt signs of aspiration today. Cued for small bites and chin tuck. Tolerated thin liquids well.
    Plan: Re-evaluate for diet upgrade to regular texture next week.
  Registered Dietitian — S. Kim, RD, LD (Today 10:00)
    Goal: Maintain weight, meet 1.2 g/kg protein for wound healing
    Progress: Weight down 0.6 lb this week; intake averaging 65%. Protein supplement added mid-afternoon.
    Plan: Add Greek yogurt snack daily, recheck weight in 3 days, family may bring approved favorites.
  Respiratory / Restorative — B. Oyelaran, RRT (Today 07:15)
    Goal: Incentive spirometry 10x per hour while awake
    Progress: Reaching 1250 mL. Lungs clear bilaterally.
    Plan: Continue restorative walking program with nursing on non-therapy days.

APPOINTMENTS & TRANSPORTATION
  Tomorrow, Aug 21 — Nephrology + dialysis access check @ Baylor Scott & White — Waco, TX (88 mi) (Lone Star Medical Transport (third-party, contracted), driver Marcus Hill · Van #LS-14 · wheelchair lift)
    Departs facility: 8:15 AM
    Arrives at appointment: 10:30 AM (est.)
    Leaves destination: 12:30 PM (est.)
    Back at facility: 2:45 PM (est.)
  Today, Aug 20 — Ultrasound — left lower extremity venous duplex @ Meadow Creek on-site imaging (In-house — no travel required, driver N/A)
    Departs room: 2:10 PM
    Study started: 2:22 PM
    Study completed: 2:48 PM
    Back in room: 2:58 PM
  Aug 27 — Primary care follow-up — Dr. Reed @ Ellis County Family Medicine, Waxahachie (4 mi) (Facility van, driver Assignment pending — posted 24 hrs before)
    Departs facility: 8:45 AM
    Arrives at appointment: 9:10 AM (est.)
    Leaves destination: 10:15 AM (est.)
    Back at facility: 10:45 AM (est.)

INSURANCE & APPEAL
  Payer: Medicare Part A — Skilled Nursing Facility benefit
  Policy: 1EG4-TE5-MK72
  Authorization: Auth #SNF-2026-88421 · approved through Aug 23, 2026
  Days used: 18 of 21
  Appeal status: Not filed — preparing · deadline: Noon the day after the Notice of Medicare Non-Coverage (NOMNC) is delivered
    1. You receive the NOMNC — The facility must hand you a Notice of Medicare Non-Coverage at least 2 days before coverage ends. Sign it — signing only means you received it, not that you agree.
    2. Call the BFCC-QIO immediately — Livanta is the QIO for Texas: 1-888-524-9900 (TTY 1-888-985-9295). Call by noon the day after you get the notice. This is a free, fast appeal and care continues while they review.
    3. Facility sends the Detailed Explanation of Non-Coverage (DENC) — Within one day of your call the facility must give you and the QIO a DENC explaining why they believe skilled care is ending. Ask for a copy for your records.
    4. QIO decision within 72 hours — A doctor reviewer decides. If they agree with you, Medicare keeps paying. If not, you can escalate to a Reconsideration by a Qualified Independent Contractor, then an ALJ hearing.

ADMISSION FORMS ON FILE
  · Admission agreement & facility contract (State licensing + 42 CFR §483.15)
  · Resident Rights acknowledgment (42 CFR §483.10 + state residents' bill of rights)
  · HIPAA Notice of Privacy Practices + authorization to disclose (45 CFR §164.520 / §164.508)
  · Advance directive acknowledgment (Patient Self-Determination Act, 42 U.S.C. §1395cc(f))
  · Consent for treatment, photography & wound documentation (State consent law)
  · Medicare SNF Beneficiary Notices (SNFABN / NOMNC) (42 CFR §405.1200)
  · Arbitration agreement (voluntary) (42 CFR §483.70(n))
  · Assignment of benefits & financial disclosure (Medicare/Medicaid billing rules)
  · Personal property inventory (42 CFR §483.10(f)(9))
  · Photo, media & directory listing release (HIPAA facility directory rules)
  · Influenza, COVID-19 and pneumococcal vaccine consent or refusal (42 CFR §483.80(d))
  · Preadmission Screening and Resident Review (PASRR Level I) (42 CFR §483.100–138)
  · Trust fund / personal needs allowance authorization (42 CFR §483.10(f)(10))
  · Ombudsman, survey results and grievance contact acknowledgment (42 CFR §483.10(g)(4))

Every entry above is attributed to a named staff member and cannot be deleted.
Questions about this record: ask the charge nurse in the app, or contact the facility privacy officer.

Your rights to these records

• · 45 CFR §164.524 — a copy must be provided within 30 days, in the form you ask for.
• · 42 CFR §483.10(g)(2) — residents may inspect their records within 24 hours of asking.
• · Copies must be provided within 2 working days, at no more than a reasonable, cost-based fee.
• · You may request an amendment if something is wrong; the facility must respond in writing.
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• · Requesting records is never grounds for transfer, discharge or retaliation.