New delirium: an acute change from the baseline — new disorientation and lethargy with fluctuating attention and disorganized thinking (a positive CAM), different from the resident’s stable dementia — concerning for an acute medical cause. A delirium workup initiated per order (vitals, glucose, oxygen saturation, an infection and medication screen), the provider notified with the change, orders received, the responsible party notified, and safety measures put in place. Will reassess and evaluate for a Significant Change assessment; supports the Section C update. Skilled recognition of delirium versus the baseline required — a daily SNF-level need.
Model abnormal 2
Acute agitation with a suspected cause: new hyperactive delirium with agitation and a low-grade fever and reduced intake — screened for a medical trigger (infection, pain, constipation, hypoxia, medication) rather than reflexively medicating, the provider notified, a workup ordered, non-pharmacologic measures in place, and an unnecessary psychotropic avoided. Will reassess; supports the Section C update. Skilled assessment required. (Behavioral management routes to the Behavioral reference.)
