Preview
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022
EXHIBIT J-3
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022
ORANGE REGIONAL Fayo, Marion
ORANGE MEDICAL CENTER MRN; DOB; Sex; F
ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017
MEDICAL CENTER MIDDLETOWN NY 10940-
2650
Inpatient Record
Encounter Notes (continued)
Version 1 of 1 at 1/22/2017 11:33 PM
Vital Signs
Temp 97.6 "F (36.4 "C)
Temp Source Oral
Heart Rate 52
Resp 20
BP 191/81 mmHg
BP Location Right arm
BP Method Automatic
25 mg Hydralazine given. Page placed to MD
Signed by Rose, Melissa, RN on 1/22/2017 11:34 PM
Progress Notes by Rose, Melissa. RN Version 1 of 1 at 1/23/2017
1:43 AM
Author:Rose, Melissa, RN Service:
(none) Author Type:
Registered Nurse
Filed:
1/23/20171:43 AM Date of Service:
1/23/2017
1:43 AM Status:Signed
Editor:
Rose, Melissa, RN (Registered Nurse)
BP now 124/60. Will continue to monitor pt
Signed by Rose, Melissa, RN on 1/23/2017
1:43 AM
Plan of Care by Rose, Melissa, RN Version 1 of 1 at 1/23/2017
5:47 AM
Author:Rose, Melissa, RN Service:
(none) Author Type:
Registered Nurse
Filed:
1/23/20175:47 AM Date of Service:
1/23/2017 5:47 AM Status:
Signed
Editor:
Rose, Melissa, RN (Registered Nurse)
Problem: Safety
Goal: PT will be free from accidental physical injury
Outcome: Progressing
Problem: Daily Care
Goal: Daily care needs are met
Outcome: Met this Shift
Signed by Rose, Melissa, RN on 1/23/2017
5:47 AM
Progress Notes by Kaur, Narjeet, RN Version 1 of 1 at 1/23/2017
8:42 AM
Author:Kaur, Narjeet, RN Service:
(none) Author Type:
Registered Nurse
Filed:
1/23/20178:44 AM Date of Service:
1/23/2017
8:42 AM Status:Signed
Editor:
Kaur, Narjeet, RN (Registered Nurse)
Patient is alert and awake, lying comfortably in bed. Patient blood pressure is 167/70 and coreg 25
mg given. Patient denied pain/discomfort. Call bell and table in reach. Hourly rounding in progress
to address needs.
Signed by Kaur, Narjeet, RN on 1/23/2017
8:44 AM
Printed on 3/5/18 12;59 PM Page 288
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022
ORANGE REGIONAL Fayo, Marion
ORANGE MEDICAL CENTER MRN; DOB; Sex; F
ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017
MEDICAL CENTER MIDDLETOWN NY 10940-
2650
Inpatient Record
Encounter Notes (continued)
Progress Notes by Quilatan, Romeo, MD Version 1 of 1 at 1/23/2017 11:54 AM
Author:Quilatan, Romeo, MD Service:
(none) Author Type:
Physician
Filed:
1/23/20177:22 PM Date of Service:
1/23/2017 11:54 AM Status:
Signed
Editor:
Quilatan, Romeo, MD (Physician)
Greater Hudson Valley Health System
Progress Note
Subjective
Subjective:
Symptoms: (Patient seen today awake and alert, denies any pain, no sob, states she feels better. No new
complaints.).
Objective
Objective:
General Appearance: Comfortable.
Vital signs: (most recent): Blood pressure 130/60, pulse 53, temperature 97.9 °F (36.6 °C), temperature source
Oral, resp. rate 20, height 5' 5" (1.651 m), weight 130 lb (58.968 kg), Sp02 95 %, not currently breastfeeding.
Lungs: Normal effort. She is not in respiratory distress. Breath sounds clear to auscultation. No wheezes or
rales.
Heart: Normal rate. Regular rhythm.
Extremities: There is no dependent edema.
Neurological: Patient is alert and oriented to person, place and time.
Abdomen: Abdomen is soft and non-distended. Bowel sounds are normal. There is no abdominal
tenderness.
Labs:
Patient refusing blood work
Ct Brain Wo Contrast
1/15/2017 EXAMINATION: CT BRAIN WO CONTRAST HISTORY: AMS possible stroke, hx of stroke
COMPARISON: 12/08/2016. TECHNIQUE: Axial images the brain were obtained without intravenous contrast.
Images were obtained from the vertex through the skull base. FINDINGS: Diffuse atrophy and microvascular
occlusive changes are again seen. There is no acute hemorrhage, mass, mass effect or shift. There are no
extra-axial fluid collections.
1/15/2017 IMPRESSION: No change. No acute intracerebral pathology.
Xr Chest Ap Portable
1/15/2017 EXAMINATION: XR CHEST SINGLE VIEW PORTABLE HISTORY: Sepsis COMPARISON:
Printed on 3/5/18 12:59 PM Page 289
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022
ORANGE REGIONAL Fayo, Marion
Orange MEDICAL CENTER MRN; DOB; Sex; F
ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017
MEDICAL CENTER MIDDLETOWN NY 10940-
2650
Inpatient Record
Encounter Notes (continued)
Progress Notes by Quilatan. Romeo. MD (continued) Version 1 of 1 at 1/23/2017 11:54 AM
12/04/2016. TECHNIQUE: Frontal portable view FINDINGS: The heart is normal in size. The lungs are clear.
The bones and soft tissues are unremarkable.
1/15/2017 IMPRESSION: No acute pulmonary disease.
Assessment
Plan:
(1. Sepsis/SIRS POA (Leukocytosis, fever,, hypotension, UTI)
UTI- klebsiella sensitive Rocephine
> improved no fever, no leukocytosis
> stillrefusing blood work
> completed IV ceftriaxone D7/7
> Blood culture no growth for 48 hour
2. Nausea and vomiting-resolved
> Uncertain etiology
> abdomen is benign, denies abdominal pain
> px has been refusing blood draw making me unable to have a better clinical picture of the px status
3. Capacity
> Isaw px with psychiatry this morning, even though I explained to her in detail about her diagnosis and risk of
no blood work to direct care she was still resistant to the blood draw
> Psychiatry deemed her with no capacity to decide on her care. However cleared that no psychiatric
intervention is needed at this time
3. Elevated Troponin no ACS likely due to #1
Ischemic Cardiomyopathy-EF 18%
Hx of NSTEMI
Hyperlipidemia
> no chest pain, denies sob although with rales on exam
> CXR today showing no acute pathology
> continue aspirin ,plavix, coreg, imdur
> Cardiology recommended no further cardio evalaution
> Will continue to hold lisinopril for now since we are not certain of her renal function since she keeps on
refusing her lab draws.
> will restart spironolactone
> hydralazine 10 mg po q. 8 was started
4. AKI on CKD 3
> Px clinically stable, normal vital signs, no nausea no vomiting
> She still is resisting blood work and we would need to physically restrain her to do a blood draw. This can just
cause injury to her and the staff. Unless there is a change in her clinical status then we will wait until she is
more open to blood draw.
4. COPD
Printed on 3/5/18 12:59 PM Page 290
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022
ORANGE REGIONAL Fayo, Marion
ORANGE MEDICAL CENTER MRN; DOB; Sex; F
ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017
MEDICAL CENTER MIDDLETOWN NY 10940-
2650
Inpatient Record
Encounter Notes (continued)
Progress Notes by Quilatan. Romeo. MD (continued) Version 1 of 1 at 1/23/2017 11:54 AM
> stable, no sob
> continue bronchodilators
5. DM
> BS quite controlled not at goal
> continue POCT, SSI
> will monitor and titrate
> Px has been refusing her doses
6. DVT prophylaxis
> continue sq heparin
7. Pt and sister confirmed DNR
8. Dispo
> continue PT/OT
9. Dispo
> DC one bed available in sub acute as long as stable
> Ihave discussed with px about her status, labs, imagine and plan of care to which she agreed except for the
blood draws and insulin. Given px refusal to blood draws that are important to further determine needs for her
care. Psyche consult for decisional capacity placed but still pending.
).
Electronically signed by:
Romeo Quilatan
1/23/2017
Signed by Quilatan, Romeo, MD on 1/23/2017
7:22 PM
Consults by Giurca, Dan, MD Version 1 of 1 at 1/23/2017 11:56 AM
Author:Giurca, Dan, MD Service:Psychiatry Author Type:
Physician
Filed:
1/23/2017 12:07 PM Date of Service:
1/23/2017 11:56 AM Status:
Signed
Editor:
Giurca, Dan, MD (Physician)
Consult Orders:
1. Inpatient consult to Psychiatry [53187441] ordered by Quilatan, Romeo, MD at 01/23/17 1055
ID - 63 y.o. female
CC -1 don't like needles
HPI -1 reviewed the electronic medical record, evaluated the patient, discussed the case with the
Printed on 3/5/18 12;59 PM Page 291
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022
ORANGE REGIONAL Fayo, Marion
ORANGE MEDICAL CENTER MRN; DOB; Sex; F
ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017
MEDICAL CENTER MIDDLETOWN NY 10940-
2650
Inpatient Record
Encounter Notes (continued)
Consults by Giurca. Dan, MD (continued) Version 1 of 1 at 1/23/2017 11:56 AM
primary team. The patient was admitted for hyponatremia and has been refusing labs, insulin. She
has a hx of depression, was admitted here at least once, takes zoloft. She states she is not on any
psy meds but the active orders show otherwise. Her credibility is limited due to dementia. She
denies depression, suicidal ideation, homicidal ideation, auditory hallucinations, paranoia. No
behavior issues are noted. She was not able to verbalize a full understanding of her illness, need
for tx, consequences of refusing tx. She is dismissive of dm, kidney disease, and only
acknowledges them when asked. She was not able to list them as current problems on her own.
She does not appear to have the capacity to refuse tx.
PPH - denies but emr shows prior admission
Suicide - denies
Violence - denies
Weapon - denies
Legal - denies
Drug - denies
Abuse - denies
PMH-
Past Medical History
Diagnosis Date
• CHF (congestive heart failure)
systolic
• Hypertension
• Diabetes
• COPD (chronic obstructive pulmonary disease)
• Pure hypercholesterolemia
• Noncompliance
• Arthritis
• Renal disorder
• Stroke 2010
weakness left leg
• Coronary artery disease 8/2015
cardiac stents
• Dementia due to Alzheimer's disease
• Cardiomyopathy, ischemic
Allergy - Review of patient's allergies indicates no known allergies.
Meds -
Prescriptions prior to admission
Medication Sig Dispense Refill Last Dose
• albuterol (PROVENTIL, Take 2.5 mg by
Printed on 3/5/18 12;59 PM Page 292
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022
ORANGE REGIONAL Fayo, Marion
ORANGE MEDICAL CENTER MRN; DOB; Sex; F
ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017
MEDICAL CENTER MIDDLETOWN NY 10940-
2650
Encounter Notes (continued)
Consults bv Giurca. Dan, MD (continued) Version 1 of 1 at 1/23/2017 11:56 AM
VENTOLIN) (2.5 MG/3ML) 0.083% nebulization every 6
nebulizer solution (six) hours as needed
for Wheezing or
Shortness of Breath.
• aspirin 81 MG EC tablet Take 1 tablet by mouth 30 tablet 1
daily.
• atorvastatin (LIPITOR) 20 MG Take 1 tablet by mouth 30 tablet 3 11/3/2016 at
tablet daily. Unknown
time
• carveidilol (COREG) 25 MG tablet Take 25 mg by mouth 11/4/2016 at
2 (two) times daily with Unknown
meals. time
• Cholecalciferol (VITAMIN D) 400 Take 1 tablet by mouth 150 tablet
UNITS TABS daily.
• clopicdogrel (PLAVIX) 75 MG tablet Take 75 mg by mouth 11/4/2016 at
daily. Unknown
time
• (donepezil (ARICEPT) 5 MG tablet Take 5 mg by mouth 11/3/2016 at
nightly. Unknown
time
• famotidine (PEPCID) 20 MG tablet Take 20 mg by mouth
daily.
• fluticasone-salmeterol (ADVAIR) Inhale 1 puff into the 1 Inhaler 0 11/4/2016 at
250-50 MCG/DOSE inhaler lungs every 12 (twelve) Unknown
hours. time
• furosemide (LASIX) 20 MG tablet Take 20 mg by mouth
every evening.
• furosemide (LASIX) 40 MG tablet Take 40 mg by mouth
daily.
• hydrALAZINE (APRESOLINE) 50 Take 1 tablet by mouth
MG tablet 3 (three) times daily.
• isosorbide mononitrate (IMDUR) Take 30 mg by mouth 11/4/2016 at
30 MG 24 hr tablet daily. Unknown
time
• lisinopril (PRINIVIL,ZESTRIL) 20 Take 1 tablet by mouth 30 tablet 1
MG tablet daily.
• sertraline (ZOLOFT) 50 MG tablet Take 50 mg by mouth 11/4/2016 at
daily. Unknown
time
• spironolactone (ALDACTONE) 25 Take 25 mg by mouth 11/4/2016 at
MG tablet daily. Unknown
time
Printed on 3/5/18 12;59 PM Page 293
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022
ORANGE REGIONAL Fayo, Marion
ORANGE MEDICAL CENTER MRN; DOB; Sex; F
ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017
MEDICAL CENTER MIDDLETOWN NY 10940-
2650
Encounter Notes (continued)
Consults bv Giurca. Dan, MD (continued) Version 1 of 1 at 1/23/2017 11:56 AM
Family -
Family History
Problem Relation Age of Onset
• Cancer Father
• Diabetes Father
• Heart disease Father
Social - reports that she quit smoking about 12 months ago. She has never used smokeless tobacco.
She reports that she drinks about 0.6 oz of alcohol per week. She reports that she does not use illicit
drugs.
Medical ROS - Pertinent items are noted in HPI.
Psy ROS - none
Vital Signs -
Filed Vitals:
01/23/17 1059
BP: 130/60
Pulse: 53
Temp:
Resp:
Sp02:
Labs -
CBC:
Lab Results
Component Value Date
WBC 9.3 01/16/2017
RBC 4.99 01/16/2017
HGB 14.2 01/16/2017
HCT 42.7 01/16/2017
MCV 85.6 01/16/2017
ROW 14.0 01/16/2017
PLT 160 01/16/2017
, CMP
Lab Results
Component Value Date
NA 133* 01/16/2017
K 4.2 01/16/2017
CL 103 01/16/2017
Printed on 3/5/18 12;59 PM Page 294
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022
ORANGE REGIONAL Fayo, Marion
Orange MEDICAL CENTER MRN; DOB; Sex; F
ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017
MEDICAL CENTER MIDDLETOWN NY 10940-
2650
Inpatient Record
Encounter Notes (continued)
Consults bv Giurca. Dan, MD (continued) Version 1 of 1 at 1/23/2017 11:56 AM
C02 21* 01/16/2017
BUN 54* 01/16/2017
CREATININE 2.09* 01/16/2017
GLUCOSE 109 01/16/2017
PROT 6.8 01/15/2017
LABALBU 3.2* 01/15/2017
CALCIUM 83* 01/16/2017
ALKPHOS 72 01/15/2017
ALT 17 01/15/2017
AST 25 01/15/2017
Imaging - Ct Brain Wo Contrast
1/15/2017 EXAMINATION: CT BRAIN WO CONTRAST HISTORY: AMS possible stroke, hx of
stroke COMPARISON: 12/08/2016. TECHNIQUE: Axial images the brain were obtained without
intravenous contrast. Images were obtained from the vertex through the skull base. FINDINGS:
Diffuse atrophy and microvascular occlusive changes are again seen. There is no acute hemorrhage,
mass, mass effect or shift. There are no extra-axial fluid collections.
1/15/2017 IMPRESSION: No change. No acute intracerebral pathology.
Xr Chest Ap Portable
1/21/2017 EXAMINATION: XR CHEST SINGLE VIEW PORTABLE HISTORY: Wheezing.
COMPARISON: 01/15/2017. TECHNIQUE: A single AP view of the chest was obtained, with study
limited secondary to low lung volumes. FINDINGS: The trachea is midline. The mediastinum and hila
are unremarkable. The heart size is enlarged, with coronary artery stent present. The lungs and
costophrenic angles are clear. Visualized osseous structures are unremarkable. Aortic arch is
calcified
1/21/2017 IMPRESSION: Unremarkable limited portable chest radiograph. No evidence of acute
pulmonary disease or interval change. Cardiomegaly. Aortic and coronary atherosclerosis.
Xr Chest Ap Portable
1/15/2017 EXAMINATION: XR CHEST SINGLE VIEW PORTABLE HISTORY: Sepsis
COMPARISON: 12/04/2016. TECHNIQUE: Frontal portable view FINDINGS: The heart is normal in
size. The lungs are clear. The bones and soft tissues are unremarkable.
1/15/2017 IMPRESSION: No acute pulmonary disease.
EKG -
Printed on 3/5/18 12:59 PM Page 295
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022
ORANGE REGIONAL Fayo, Marion
Orange MEDICAL CENTER MRN; DOB; Sex; F
ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017
MEDICAL CENTER MIDDLETOWN NY 10940-
2650
Inpatient Record
Encounter Notes (continued)
Consults bv Giurca. Dan, MD (continued) Version 1 of 1 at 1/23/2017 11:56 AM
ECG Results
ED EKG 12 LEAD (Final result) Component (Lab Inquiry)
Collection D
Time Result Time S BP BP Vent Atrial P-R QRS Q-T QTC R
01/15/17 01/16/17 78 78 182 96 452 515 51
15:30:53 08:48:16 75
Collection
Time Result Time T
01/15/17 01/16/17 270
15:30:53 08:48:16
Final result
Narrative:
Sinus rhythm with frequent premature ventricular complexes
Left axis deviation
Anterior infarct, age undetermined
T wave abnormality, consider inferolateral ischemia
Prolonged QT
Abnormal ECG
When compared with ECG of 16-DEC-2016 11:21,
premature ventricular complexes are now present
PR interval has decreased
Right bundle branch block is no longer present
Anterior infarct is now present
Confirmed by HURWITZ MD, SETH (21) on 1/16/2017 8:48:15 AM
MENTAL STATUS EXAM
Appearance - stated age
Consciousness - alert
Orientation - person, place, time
Psychomotor - decreased
Mood - euthymic
Affect - mood congruent
Speech - normal
Thought process - concrete
Thought content - denies delusions
Printed on 3/5/18 12:59 PM Page 296
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022
ORANGE REGIONAL Fayo, Marion
ORANGE MEDICAL CENTER MRN; DOB; Sex; F
ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017
MEDICAL CENTER MIDDLETOWN NY 10940-
2650
Inpatient Record
Encounter Notes (continued)
Consults bv Giurca. Dan, MD (continued) Version 1 of 1 at 1/23/2017 11:56 AM
Suicidal - denies
Homicidal - denies
Perception - denies hallucinations
Memory - impaired, 3/3 immediate, 1/3 at 3 min
Cognition - limited
Insight - limited
Judgment - limited
Impulse control - fair
DIAGNOSIS
dementia
ASSESSMENT
63 y.o. female with a history of dementia, admitted for hyponatremia, is refusing labs and insulin. She
does not have the capacity to understand the extent of her illness and make decisions about her care.
The case manager is working towards a supervised setting after dc. The patient does not manifest
symptoms or behavior that would need inpatient psy admission. The patient is not an imminent
danger to self or others.
PLAN
psy cleared for discharge
Med tx as per the primary team
Signed by Giurca, Dan, MD on 1/23/2017 12:07 PM
Progress Notes by Kaur, Narjeet, RN Version 1 of 1 at 1/23/2017 12:52 PM
Author:Kaur, Narjeet, RN Service:
(none) Author Type:
Registered Nurse
Filed:
1/23/2017 12:52 PM Date of Service:
1/23/2017 12:52 PM Status:Signed
Editor:
Kaur, Narjeet, RN (Registered Nurse)
Patient again refused her labs, MD made aware.
Signed by Kaur, Narjeet, RN on 1/23/2017 12:52 PM
Plan of Care by Kaur, Narjeet, RN Version 1 of 1 at 1/23/2017 1 2:54 PM
Author:Kaur, Narjeet, RN Service:
(none) Author Type:
Registered Nurse
Filed:
1/23/2017 12:54 PM Date of Service:
1/23/2017 12:54 PM Status:Signed
Editor:
Kaur, Narjeet, RN (Registered Nurse)
Problem: Safety
Goal: PT will be free from accidental physical injury
Outcome: Progressing
Bed is at lower position.
Side rails are up and bed is locked.
Personal alarm is in place.
Call bell and table in reach.
Hourly rounding in progress to address needs.
Printed on 3/5/18 12;59 PM Page 297
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022
ORANGE REGIONAL Fayo, Marion
ORANGE MEDICAL CENTER MRN; DOB; Sex; F
ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017
MEDICAL CENTER MIDDLETOWN NY 10940-
2650
Inpatient Record
Encounter Notes (continued)
Plan of Care by Kaur, Narjeet, RN (continued) Version 1 of 1 at 1/23/2017 1 2:54 PM
Signed by Kaur, Narjeet, RN on 1/23/2017 1 2:54 PM
Progress Notes by Pengel, Doretha, MSW Version 2 of 2 at 1/23/2017
1:56 PM
Author:Pengel, Doretha, MSW Service:
(none) Author Type:
Case Manager
Filed:
1/23/20173:26 PM Date of Service:
1/23/2017
1:56 PM Status:
Addendum
Editor:
Pengel, Doretha, MSW (Case Manager)
Related Notes:
Original Note by Pengel, Doretha, MSW (Case Manager) filed at 1/23/2017
2:02 PM
Case Management Progress Note:
Patient still with no bed offers for subacute rehab. CM left a voice message for Medicaid Unit
Supervisor at 291-2800 regarding medicaid application status. In addition, per psychiatry patient
doesn't have decisional capacity to make medical decision. In addition, CM followed up with Northern
Group liaison Regarding potential bed offers. Patient was not medically accepted to any Northern
Group subacute rehab facilities. Patient's clinicals and PRI sent to Orange, Sullivan and Rockland
County for nursing home placement. CM also contacted patient's insurance Blue Cross and Blue
Shield and left a voice message for Erin Koza at 800 537-7371 ext 7094 regarding patient's benefits.
Signature; Doretha Pengel
Date: 1/23/2017
Time: 1:56 PM
Signed by Pengel, Doretha, MSW on 1/23/2017
3:26 PM
Progress Notes by Pengel. Doretha. MSW Version 1 of 2 at 1/23/2017
1:56 PM
Author:Pengel, Doretha, MSW Service:
(none) Author Type:
Case Manager
Filed:
1/23/20172:02 PM Date of Service:
1/23/2017
1:56 PM Status:Signed
Editor:
Pengel, Doretha, MSW (Case Manager)
Related Notes:
Addendum by Pengel, Doretha, MSW (Case Manager) filed at 1/23/2017 3:26 PM
Case Management Progress Note:
Patient still with no bed offers for subacute rehab. CM left a voice message for Medicaid Unit
Supervisor at 291-2800 regarding medicaid application status. In addition, per psychiatry patient
doesn't have decisional capacity to make medical decision. In addition, CM followed up with
Northern Group liaison Regarding potential bed offers. Patient was not medically accepted to any
Northern Group subacute rehab facilities. Patient's clinicals and PRI sent to Orange, Sullivan and
Rockland County for nursing home placement.
Printed on 3/5/18 12;59 PM Page 298
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022
ORANGE REGIONAL Fayo, Marion
ORANGE
ma Regional
MEDICAL CENTER
707 EAST MAIN STREET
MRN;
Adm; 1/15/2017,
Preview
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022 EXHIBIT J-3 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022 ORANGE REGIONAL Fayo, Marion ORANGE MEDICAL CENTER MRN; DOB; Sex; F ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017 MEDICAL CENTER MIDDLETOWN NY 10940- 2650 Inpatient Record Encounter Notes (continued) Version 1 of 1 at 1/22/2017 11:33 PM Vital Signs Temp 97.6 "F (36.4 "C) Temp Source Oral Heart Rate 52 Resp 20 BP 191/81 mmHg BP Location Right arm BP Method Automatic 25 mg Hydralazine given. Page placed to MD Signed by Rose, Melissa, RN on 1/22/2017 11:34 PM Progress Notes by Rose, Melissa. RN Version 1 of 1 at 1/23/2017 1:43 AM Author:Rose, Melissa, RN Service: (none) Author Type: Registered Nurse Filed: 1/23/20171:43 AM Date of Service: 1/23/2017 1:43 AM Status:Signed Editor: Rose, Melissa, RN (Registered Nurse) BP now 124/60. Will continue to monitor pt Signed by Rose, Melissa, RN on 1/23/2017 1:43 AM Plan of Care by Rose, Melissa, RN Version 1 of 1 at 1/23/2017 5:47 AM Author:Rose, Melissa, RN Service: (none) Author Type: Registered Nurse Filed: 1/23/20175:47 AM Date of Service: 1/23/2017 5:47 AM Status: Signed Editor: Rose, Melissa, RN (Registered Nurse) Problem: Safety Goal: PT will be free from accidental physical injury Outcome: Progressing Problem: Daily Care Goal: Daily care needs are met Outcome: Met this Shift Signed by Rose, Melissa, RN on 1/23/2017 5:47 AM Progress Notes by Kaur, Narjeet, RN Version 1 of 1 at 1/23/2017 8:42 AM Author:Kaur, Narjeet, RN Service: (none) Author Type: Registered Nurse Filed: 1/23/20178:44 AM Date of Service: 1/23/2017 8:42 AM Status:Signed Editor: Kaur, Narjeet, RN (Registered Nurse) Patient is alert and awake, lying comfortably in bed. Patient blood pressure is 167/70 and coreg 25 mg given. Patient denied pain/discomfort. Call bell and table in reach. Hourly rounding in progress to address needs. Signed by Kaur, Narjeet, RN on 1/23/2017 8:44 AM Printed on 3/5/18 12;59 PM Page 288 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022 ORANGE REGIONAL Fayo, Marion ORANGE MEDICAL CENTER MRN; DOB; Sex; F ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017 MEDICAL CENTER MIDDLETOWN NY 10940- 2650 Inpatient Record Encounter Notes (continued) Progress Notes by Quilatan, Romeo, MD Version 1 of 1 at 1/23/2017 11:54 AM Author:Quilatan, Romeo, MD Service: (none) Author Type: Physician Filed: 1/23/20177:22 PM Date of Service: 1/23/2017 11:54 AM Status: Signed Editor: Quilatan, Romeo, MD (Physician) Greater Hudson Valley Health System Progress Note Subjective Subjective: Symptoms: (Patient seen today awake and alert, denies any pain, no sob, states she feels better. No new complaints.). Objective Objective: General Appearance: Comfortable. Vital signs: (most recent): Blood pressure 130/60, pulse 53, temperature 97.9 °F (36.6 °C), temperature source Oral, resp. rate 20, height 5' 5" (1.651 m), weight 130 lb (58.968 kg), Sp02 95 %, not currently breastfeeding. Lungs: Normal effort. She is not in respiratory distress. Breath sounds clear to auscultation. No wheezes or rales. Heart: Normal rate. Regular rhythm. Extremities: There is no dependent edema. Neurological: Patient is alert and oriented to person, place and time. Abdomen: Abdomen is soft and non-distended. Bowel sounds are normal. There is no abdominal tenderness. Labs: Patient refusing blood work Ct Brain Wo Contrast 1/15/2017 EXAMINATION: CT BRAIN WO CONTRAST HISTORY: AMS possible stroke, hx of stroke COMPARISON: 12/08/2016. TECHNIQUE: Axial images the brain were obtained without intravenous contrast. Images were obtained from the vertex through the skull base. FINDINGS: Diffuse atrophy and microvascular occlusive changes are again seen. There is no acute hemorrhage, mass, mass effect or shift. There are no extra-axial fluid collections. 1/15/2017 IMPRESSION: No change. No acute intracerebral pathology. Xr Chest Ap Portable 1/15/2017 EXAMINATION: XR CHEST SINGLE VIEW PORTABLE HISTORY: Sepsis COMPARISON: Printed on 3/5/18 12:59 PM Page 289 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022 ORANGE REGIONAL Fayo, Marion Orange MEDICAL CENTER MRN; DOB; Sex; F ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017 MEDICAL CENTER MIDDLETOWN NY 10940- 2650 Inpatient Record Encounter Notes (continued) Progress Notes by Quilatan. Romeo. MD (continued) Version 1 of 1 at 1/23/2017 11:54 AM 12/04/2016. TECHNIQUE: Frontal portable view FINDINGS: The heart is normal in size. The lungs are clear. The bones and soft tissues are unremarkable. 1/15/2017 IMPRESSION: No acute pulmonary disease. Assessment Plan: (1. Sepsis/SIRS POA (Leukocytosis, fever,, hypotension, UTI) UTI- klebsiella sensitive Rocephine > improved no fever, no leukocytosis > stillrefusing blood work > completed IV ceftriaxone D7/7 > Blood culture no growth for 48 hour 2. Nausea and vomiting-resolved > Uncertain etiology > abdomen is benign, denies abdominal pain > px has been refusing blood draw making me unable to have a better clinical picture of the px status 3. Capacity > Isaw px with psychiatry this morning, even though I explained to her in detail about her diagnosis and risk of no blood work to direct care she was still resistant to the blood draw > Psychiatry deemed her with no capacity to decide on her care. However cleared that no psychiatric intervention is needed at this time 3. Elevated Troponin no ACS likely due to #1 Ischemic Cardiomyopathy-EF 18% Hx of NSTEMI Hyperlipidemia > no chest pain, denies sob although with rales on exam > CXR today showing no acute pathology > continue aspirin ,plavix, coreg, imdur > Cardiology recommended no further cardio evalaution > Will continue to hold lisinopril for now since we are not certain of her renal function since she keeps on refusing her lab draws. > will restart spironolactone > hydralazine 10 mg po q. 8 was started 4. AKI on CKD 3 > Px clinically stable, normal vital signs, no nausea no vomiting > She still is resisting blood work and we would need to physically restrain her to do a blood draw. This can just cause injury to her and the staff. Unless there is a change in her clinical status then we will wait until she is more open to blood draw. 4. COPD Printed on 3/5/18 12:59 PM Page 290 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022 ORANGE REGIONAL Fayo, Marion ORANGE MEDICAL CENTER MRN; DOB; Sex; F ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017 MEDICAL CENTER MIDDLETOWN NY 10940- 2650 Inpatient Record Encounter Notes (continued) Progress Notes by Quilatan. Romeo. MD (continued) Version 1 of 1 at 1/23/2017 11:54 AM > stable, no sob > continue bronchodilators 5. DM > BS quite controlled not at goal > continue POCT, SSI > will monitor and titrate > Px has been refusing her doses 6. DVT prophylaxis > continue sq heparin 7. Pt and sister confirmed DNR 8. Dispo > continue PT/OT 9. Dispo > DC one bed available in sub acute as long as stable > Ihave discussed with px about her status, labs, imagine and plan of care to which she agreed except for the blood draws and insulin. Given px refusal to blood draws that are important to further determine needs for her care. Psyche consult for decisional capacity placed but still pending. ). Electronically signed by: Romeo Quilatan 1/23/2017 Signed by Quilatan, Romeo, MD on 1/23/2017 7:22 PM Consults by Giurca, Dan, MD Version 1 of 1 at 1/23/2017 11:56 AM Author:Giurca, Dan, MD Service:Psychiatry Author Type: Physician Filed: 1/23/2017 12:07 PM Date of Service: 1/23/2017 11:56 AM Status: Signed Editor: Giurca, Dan, MD (Physician) Consult Orders: 1. Inpatient consult to Psychiatry [53187441] ordered by Quilatan, Romeo, MD at 01/23/17 1055 ID - 63 y.o. female CC -1 don't like needles HPI -1 reviewed the electronic medical record, evaluated the patient, discussed the case with the Printed on 3/5/18 12;59 PM Page 291 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022 ORANGE REGIONAL Fayo, Marion ORANGE MEDICAL CENTER MRN; DOB; Sex; F ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017 MEDICAL CENTER MIDDLETOWN NY 10940- 2650 Inpatient Record Encounter Notes (continued) Consults by Giurca. Dan, MD (continued) Version 1 of 1 at 1/23/2017 11:56 AM primary team. The patient was admitted for hyponatremia and has been refusing labs, insulin. She has a hx of depression, was admitted here at least once, takes zoloft. She states she is not on any psy meds but the active orders show otherwise. Her credibility is limited due to dementia. She denies depression, suicidal ideation, homicidal ideation, auditory hallucinations, paranoia. No behavior issues are noted. She was not able to verbalize a full understanding of her illness, need for tx, consequences of refusing tx. She is dismissive of dm, kidney disease, and only acknowledges them when asked. She was not able to list them as current problems on her own. She does not appear to have the capacity to refuse tx. PPH - denies but emr shows prior admission Suicide - denies Violence - denies Weapon - denies Legal - denies Drug - denies Abuse - denies PMH- Past Medical History Diagnosis Date • CHF (congestive heart failure) systolic • Hypertension • Diabetes • COPD (chronic obstructive pulmonary disease) • Pure hypercholesterolemia • Noncompliance • Arthritis • Renal disorder • Stroke 2010 weakness left leg • Coronary artery disease 8/2015 cardiac stents • Dementia due to Alzheimer's disease • Cardiomyopathy, ischemic Allergy - Review of patient's allergies indicates no known allergies. Meds - Prescriptions prior to admission Medication Sig Dispense Refill Last Dose • albuterol (PROVENTIL, Take 2.5 mg by Printed on 3/5/18 12;59 PM Page 292 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022 ORANGE REGIONAL Fayo, Marion ORANGE MEDICAL CENTER MRN; DOB; Sex; F ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017 MEDICAL CENTER MIDDLETOWN NY 10940- 2650 Encounter Notes (continued) Consults bv Giurca. Dan, MD (continued) Version 1 of 1 at 1/23/2017 11:56 AM VENTOLIN) (2.5 MG/3ML) 0.083% nebulization every 6 nebulizer solution (six) hours as needed for Wheezing or Shortness of Breath. • aspirin 81 MG EC tablet Take 1 tablet by mouth 30 tablet 1 daily. • atorvastatin (LIPITOR) 20 MG Take 1 tablet by mouth 30 tablet 3 11/3/2016 at tablet daily. Unknown time • carveidilol (COREG) 25 MG tablet Take 25 mg by mouth 11/4/2016 at 2 (two) times daily with Unknown meals. time • Cholecalciferol (VITAMIN D) 400 Take 1 tablet by mouth 150 tablet UNITS TABS daily. • clopicdogrel (PLAVIX) 75 MG tablet Take 75 mg by mouth 11/4/2016 at daily. Unknown time • (donepezil (ARICEPT) 5 MG tablet Take 5 mg by mouth 11/3/2016 at nightly. Unknown time • famotidine (PEPCID) 20 MG tablet Take 20 mg by mouth daily. • fluticasone-salmeterol (ADVAIR) Inhale 1 puff into the 1 Inhaler 0 11/4/2016 at 250-50 MCG/DOSE inhaler lungs every 12 (twelve) Unknown hours. time • furosemide (LASIX) 20 MG tablet Take 20 mg by mouth every evening. • furosemide (LASIX) 40 MG tablet Take 40 mg by mouth daily. • hydrALAZINE (APRESOLINE) 50 Take 1 tablet by mouth MG tablet 3 (three) times daily. • isosorbide mononitrate (IMDUR) Take 30 mg by mouth 11/4/2016 at 30 MG 24 hr tablet daily. Unknown time • lisinopril (PRINIVIL,ZESTRIL) 20 Take 1 tablet by mouth 30 tablet 1 MG tablet daily. • sertraline (ZOLOFT) 50 MG tablet Take 50 mg by mouth 11/4/2016 at daily. Unknown time • spironolactone (ALDACTONE) 25 Take 25 mg by mouth 11/4/2016 at MG tablet daily. Unknown time Printed on 3/5/18 12;59 PM Page 293 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022 ORANGE REGIONAL Fayo, Marion ORANGE MEDICAL CENTER MRN; DOB; Sex; F ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017 MEDICAL CENTER MIDDLETOWN NY 10940- 2650 Encounter Notes (continued) Consults bv Giurca. Dan, MD (continued) Version 1 of 1 at 1/23/2017 11:56 AM Family - Family History Problem Relation Age of Onset • Cancer Father • Diabetes Father • Heart disease Father Social - reports that she quit smoking about 12 months ago. She has never used smokeless tobacco. She reports that she drinks about 0.6 oz of alcohol per week. She reports that she does not use illicit drugs. Medical ROS - Pertinent items are noted in HPI. Psy ROS - none Vital Signs - Filed Vitals: 01/23/17 1059 BP: 130/60 Pulse: 53 Temp: Resp: Sp02: Labs - CBC: Lab Results Component Value Date WBC 9.3 01/16/2017 RBC 4.99 01/16/2017 HGB 14.2 01/16/2017 HCT 42.7 01/16/2017 MCV 85.6 01/16/2017 ROW 14.0 01/16/2017 PLT 160 01/16/2017 , CMP Lab Results Component Value Date NA 133* 01/16/2017 K 4.2 01/16/2017 CL 103 01/16/2017 Printed on 3/5/18 12;59 PM Page 294 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022 ORANGE REGIONAL Fayo, Marion Orange MEDICAL CENTER MRN; DOB; Sex; F ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017 MEDICAL CENTER MIDDLETOWN NY 10940- 2650 Inpatient Record Encounter Notes (continued) Consults bv Giurca. Dan, MD (continued) Version 1 of 1 at 1/23/2017 11:56 AM C02 21* 01/16/2017 BUN 54* 01/16/2017 CREATININE 2.09* 01/16/2017 GLUCOSE 109 01/16/2017 PROT 6.8 01/15/2017 LABALBU 3.2* 01/15/2017 CALCIUM 83* 01/16/2017 ALKPHOS 72 01/15/2017 ALT 17 01/15/2017 AST 25 01/15/2017 Imaging - Ct Brain Wo Contrast 1/15/2017 EXAMINATION: CT BRAIN WO CONTRAST HISTORY: AMS possible stroke, hx of stroke COMPARISON: 12/08/2016. TECHNIQUE: Axial images the brain were obtained without intravenous contrast. Images were obtained from the vertex through the skull base. FINDINGS: Diffuse atrophy and microvascular occlusive changes are again seen. There is no acute hemorrhage, mass, mass effect or shift. There are no extra-axial fluid collections. 1/15/2017 IMPRESSION: No change. No acute intracerebral pathology. Xr Chest Ap Portable 1/21/2017 EXAMINATION: XR CHEST SINGLE VIEW PORTABLE HISTORY: Wheezing. COMPARISON: 01/15/2017. TECHNIQUE: A single AP view of the chest was obtained, with study limited secondary to low lung volumes. FINDINGS: The trachea is midline. The mediastinum and hila are unremarkable. The heart size is enlarged, with coronary artery stent present. The lungs and costophrenic angles are clear. Visualized osseous structures are unremarkable. Aortic arch is calcified 1/21/2017 IMPRESSION: Unremarkable limited portable chest radiograph. No evidence of acute pulmonary disease or interval change. Cardiomegaly. Aortic and coronary atherosclerosis. Xr Chest Ap Portable 1/15/2017 EXAMINATION: XR CHEST SINGLE VIEW PORTABLE HISTORY: Sepsis COMPARISON: 12/04/2016. TECHNIQUE: Frontal portable view FINDINGS: The heart is normal in size. The lungs are clear. The bones and soft tissues are unremarkable. 1/15/2017 IMPRESSION: No acute pulmonary disease. EKG - Printed on 3/5/18 12:59 PM Page 295 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022 ORANGE REGIONAL Fayo, Marion Orange MEDICAL CENTER MRN; DOB; Sex; F ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017 MEDICAL CENTER MIDDLETOWN NY 10940- 2650 Inpatient Record Encounter Notes (continued) Consults bv Giurca. Dan, MD (continued) Version 1 of 1 at 1/23/2017 11:56 AM ECG Results ED EKG 12 LEAD (Final result) Component (Lab Inquiry) Collection D Time Result Time S BP BP Vent Atrial P-R QRS Q-T QTC R 01/15/17 01/16/17 78 78 182 96 452 515 51 15:30:53 08:48:16 75 Collection Time Result Time T 01/15/17 01/16/17 270 15:30:53 08:48:16 Final result Narrative: Sinus rhythm with frequent premature ventricular complexes Left axis deviation Anterior infarct, age undetermined T wave abnormality, consider inferolateral ischemia Prolonged QT Abnormal ECG When compared with ECG of 16-DEC-2016 11:21, premature ventricular complexes are now present PR interval has decreased Right bundle branch block is no longer present Anterior infarct is now present Confirmed by HURWITZ MD, SETH (21) on 1/16/2017 8:48:15 AM MENTAL STATUS EXAM Appearance - stated age Consciousness - alert Orientation - person, place, time Psychomotor - decreased Mood - euthymic Affect - mood congruent Speech - normal Thought process - concrete Thought content - denies delusions Printed on 3/5/18 12:59 PM Page 296 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022 ORANGE REGIONAL Fayo, Marion ORANGE MEDICAL CENTER MRN; DOB; Sex; F ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017 MEDICAL CENTER MIDDLETOWN NY 10940- 2650 Inpatient Record Encounter Notes (continued) Consults bv Giurca. Dan, MD (continued) Version 1 of 1 at 1/23/2017 11:56 AM Suicidal - denies Homicidal - denies Perception - denies hallucinations Memory - impaired, 3/3 immediate, 1/3 at 3 min Cognition - limited Insight - limited Judgment - limited Impulse control - fair DIAGNOSIS dementia ASSESSMENT 63 y.o. female with a history of dementia, admitted for hyponatremia, is refusing labs and insulin. She does not have the capacity to understand the extent of her illness and make decisions about her care. The case manager is working towards a supervised setting after dc. The patient does not manifest symptoms or behavior that would need inpatient psy admission. The patient is not an imminent danger to self or others. PLAN psy cleared for discharge Med tx as per the primary team Signed by Giurca, Dan, MD on 1/23/2017 12:07 PM Progress Notes by Kaur, Narjeet, RN Version 1 of 1 at 1/23/2017 12:52 PM Author:Kaur, Narjeet, RN Service: (none) Author Type: Registered Nurse Filed: 1/23/2017 12:52 PM Date of Service: 1/23/2017 12:52 PM Status:Signed Editor: Kaur, Narjeet, RN (Registered Nurse) Patient again refused her labs, MD made aware. Signed by Kaur, Narjeet, RN on 1/23/2017 12:52 PM Plan of Care by Kaur, Narjeet, RN Version 1 of 1 at 1/23/2017 1 2:54 PM Author:Kaur, Narjeet, RN Service: (none) Author Type: Registered Nurse Filed: 1/23/2017 12:54 PM Date of Service: 1/23/2017 12:54 PM Status:Signed Editor: Kaur, Narjeet, RN (Registered Nurse) Problem: Safety Goal: PT will be free from accidental physical injury Outcome: Progressing Bed is at lower position. Side rails are up and bed is locked. Personal alarm is in place. Call bell and table in reach. Hourly rounding in progress to address needs. Printed on 3/5/18 12;59 PM Page 297 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022 ORANGE REGIONAL Fayo, Marion ORANGE MEDICAL CENTER MRN; DOB; Sex; F ma Regional 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017 MEDICAL CENTER MIDDLETOWN NY 10940- 2650 Inpatient Record Encounter Notes (continued) Plan of Care by Kaur, Narjeet, RN (continued) Version 1 of 1 at 1/23/2017 1 2:54 PM Signed by Kaur, Narjeet, RN on 1/23/2017 1 2:54 PM Progress Notes by Pengel, Doretha, MSW Version 2 of 2 at 1/23/2017 1:56 PM Author:Pengel, Doretha, MSW Service: (none) Author Type: Case Manager Filed: 1/23/20173:26 PM Date of Service: 1/23/2017 1:56 PM Status: Addendum Editor: Pengel, Doretha, MSW (Case Manager) Related Notes: Original Note by Pengel, Doretha, MSW (Case Manager) filed at 1/23/2017 2:02 PM Case Management Progress Note: Patient still with no bed offers for subacute rehab. CM left a voice message for Medicaid Unit Supervisor at 291-2800 regarding medicaid application status. In addition, per psychiatry patient doesn't have decisional capacity to make medical decision. In addition, CM followed up with Northern Group liaison Regarding potential bed offers. Patient was not medically accepted to any Northern Group subacute rehab facilities. Patient's clinicals and PRI sent to Orange, Sullivan and Rockland County for nursing home placement. CM also contacted patient's insurance Blue Cross and Blue Shield and left a voice message for Erin Koza at 800 537-7371 ext 7094 regarding patient's benefits. Signature; Doretha Pengel Date: 1/23/2017 Time: 1:56 PM Signed by Pengel, Doretha, MSW on 1/23/2017 3:26 PM Progress Notes by Pengel. Doretha. MSW Version 1 of 2 at 1/23/2017 1:56 PM Author:Pengel, Doretha, MSW Service: (none) Author Type: Case Manager Filed: 1/23/20172:02 PM Date of Service: 1/23/2017 1:56 PM Status:Signed Editor: Pengel, Doretha, MSW (Case Manager) Related Notes: Addendum by Pengel, Doretha, MSW (Case Manager) filed at 1/23/2017 3:26 PM Case Management Progress Note: Patient still with no bed offers for subacute rehab. CM left a voice message for Medicaid Unit Supervisor at 291-2800 regarding medicaid application status. In addition, per psychiatry patient doesn't have decisional capacity to make medical decision. In addition, CM followed up with Northern Group liaison Regarding potential bed offers. Patient was not medically accepted to any Northern Group subacute rehab facilities. Patient's clinicals and PRI sent to Orange, Sullivan and Rockland County for nursing home placement. Printed on 3/5/18 12;59 PM Page 298 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 53 RECEIVED NYSCEF: 06/03/2022 ORANGE REGIONAL Fayo, Marion ORANGE ma Regional MEDICAL CENTER 707 EAST MAIN STREET MRN; Adm; 1/15/2017,