Preview
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 54 RECEIVED NYSCEF: 06/03/2022
EXHIBIT J-4
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 54 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 Deroziere, Karen. RN (continued) Version 1 of 1 at 2/15/2017
8:54 PM
Problem: Skin Integrity
Goal: Skin integrity is maintained or improved
Outcome: Progressing
Signed by Deroziere, Karen, RN on 2/15/2017
8:54 PM
Progress Notes by Rose, Lisa, RN Version 1 of 1 at 2/16/2017
7:30 AM
Author:Rose, Lisa, RN Service:
(none) Author Type:
Registered Nurse
Filed:
2/16/20177:46 AM Date of Service:
2/16/20177:30 AM Status:Signed
Editor:
Rose, Lisa, RN (Registered Nurse)
SBAR report received from Karen RN. Pt resting comfortable in bed with no distress noted.
Signed by Rose, Lisa, RN on 2/16/2017
7:46 AM
Progress Notes by Rose, Lisa, RN Version loflat 2/16/2017
8:17 AM
Author:Rose, Lisa, RN Service:
(none) Author Type:
Registered Nurse
Filed:
2/16/20178:17 AM Date of Service:
2/16/20178:17 AM Status:Signed
Editor:
Rose, Lisa, RN (Registered Nurse)
Pt refused VS and FS this am.
Signed by Rose, Lisa, RN on 2/16/2017
8:17 AM
Progress Notes by Rose, Lisa, RN Version 1 of 1 at 2/16/2017 10:26 AM
Author:Rose, Lisa, RN Service:
(none) Author Type:
Registered Nurse
Filed:
2/16/2017 10:27 AM Date of Service:
2/16/2017 10:26 AM Status:Signed
Editor:
Rose, Lisa, RN (Registered Nurse)
Pt refusing all am medications. Will continue to encourage and educate pt on importance of taking
medication regularly.
Signed by Rose, Lisa, RN on 2/16/2017 10:27 AM
Plan of Care by Rose, Lisa, RN Version 1 of 1 at 2/16/2017 12:32 PM
Author:Rose, Lisa, RN Service:
(none) Author Type:
Registered Nurse
Filed:
2/16/2017 12:32 PM Date of Service:
2/16/2017 12:32 PM Status:Signed
Editor:
Rose, Lisa, RN (Registered Nurse)
Problem: Risk for Falls
Goal: No falls during hospitalization
Patient will not fall during hospitalization.
Outcome: Progressing
Intervention: Fall prevention
Frequent rounding
Visual checks q 1 hour
Call bell in reach
Bed in lowest position.
Signed by Rose, Lisa, RN on 2/16/2017 12:32 PM
Printed on 3/5/18 12;59 PM Page 438
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 54 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)
Plan of Care bv Rose. Lisa. RN (continued) Version 1 of 1 at 2/16/2017 12:32 PM
Progress Notes bv Margolese, Barbara, DTRCDN Version 1 of 1 at 2/16/2017
1:22 PM
Author:Margolese, Barbara, DTRCDN Service:
(none) Author Type:
Dietician
Filed:
2/16/20171:44 PM Date of Service:
2/16/20171:22 PM Status:Signed
Editor:
Margolese, Barbara, DTRCDN (Dietician)
Nutrition Follow Up-
Subjective: Per nurse, pt appetite fair.
Objective:
Principal Problem: Encephalopathy
Diet: Dietary nutrition supplements
Diet dysphagia level 3 advanced (soft)
Food Allergies: NKFA
Medications Noted: Colace
Ht: 5'5" (1.651m)
Wt: 130 lb (58.968 kg)
Skin Integrity: No breakdown documented
Stool: 2/11/17, Rectum
Labs: 2/13/17 POC Glu 126(H)
Assessment: Follow up finds pt tolerating diet with improving oral intake. Stillrefuses
medications. Likes and eats the peanut butter and crackers. Glu (H). Pt has hx: DM, may wish to
restart carb controlled diet now appetite improving. To SNF on discharge.
Nutrition Diagnosis: Poor oral intake related to chronic illness as evidenced by 30 lb. dcrease in
bw 4 weeks pta and continued poor oral intake in hospital, (resolving, intake much improved)
Nutrition Risk: Moderate
Plan:
Nutrition Intervention: Provide magic Cup with meals, peanut butter and crackers
Nutrition Monitoring: Will follow nutrient intake, labs, wt, clinical status
Signed by Margolese, Barbara, DTRCDN on 2/16/2017
1:44 PM
Progress Notes by Deroziere. Karen. RN Version 1 of 1 at 2/16/2017
7:15 PM
Printed on 3/5/18 12:59 PM Page 439
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 54 RECEIVED NYSCEF: 06/03/2022
ORANGE REGIONAL Fayo, Marion
Orange MEDICAL CENTER MRN; DOB; Sex; F
ma %GIONAL 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 Deroziere, Karen. RN (continued) Version 1 of 1 at 2/16/2017
7:15 PM
Author:Deroziere, Karen, RN Service:
Internal Medicine Author Type:
Registered Nurse
Filed:
2/16/20177:54 PM Date of Service:
2/16/20177:15 PM Status:
Signed
Editor:
Deroziere, Karen, RN (Registered Nurse)
SBAR from Lisa RN, patient in bed, call bell within reach, safety measures maintained.
Signed by Deroziere, Karen, RN on 2/16/2017 7:54 PM
Plan of Care by Deroziere, Karen, RN Version loflat 2/16/2017
7:53 PM
Author:Deroziere, Karen, RN Service:
Internal Medicine Author Type:
Registered Nurse
Filed:
2/16/20177:53 PM Date of Service:
2/16/20177:53 PM Status:
Signed
Editor:
Deroziere, Karen, RN (Registered Nurse)
Problem: Risk for Falls
Goal: No falls during hospitalization
Patient will not fall during hospitalization.
Outcome: Progressing
Signed by Deroziere, Karen, RN on 2/16/2017 7:53 PM
Progress Notes by Deroziere, Karen, RN Version 1 of 1 at 2/16/2017 10:15 PM
Author:Deroziere, Karen, RN Service:
Internal Medicine Author Type:
Registered Nurse
Filed:
2/17/2017 12:25 AM Date of Service:
2/16/2017 10:15 PM Status:Signed
Editor:
Deroziere, Karen, RN (Registered Nurse)
Patient OOB to bathroom had large BM, then went back to bed and vomited moderate amount of
undigested food. Zofran po given, vomiting resolved.
Signed by Deroziere, Karen, RN on 2/17/2017 12:25 AM
Progress Notes by Deroziere, Karen. RN Version 1 of 1 at 2/16/2017 11:35 PM
Author:Deroziere, Karen, RN Service:
Internal Medicine Author Type:
Registered Nurse
Filed:
2/16/2017 11:37 PM Date of Service:
2/16/2017 11:35 PM Status:Signed
Editor:
Deroziere, Karen, RN (Registered Nurse)
02/16/17 2316
Vital Signs
Heart Rate 67
Heart Rate
Monitor
Source
Resp 20
BP 184/86 mmHg
BP Location Right arm
BP elevated patient has been refusing all her BP medications x 24 hours which MD is aware, also
clonidine patch is missing from right deltoid. Instructed patient she should take her BP med as
ordered which she agreed to. Hydralazine 50 mg po given. Will get clonidine patch reordered.
Signed by Deroziere, Karen, RN on 2/16/2017 11:37 PM
Printed on 3/5/18 12;59 PM Page 440
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 54 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 Gorman-Cobb, Theresa. RN Version 1 of 1 at 2/17/2017 10:55 AM
Author:Gorman-Cobb, Theresa, RN Service:
(none) Author Type:
Case Manager
Filed:
2/17/2017 10:56 AM Date of Service:
2/17/2017 10:55 AM Status:
Signed
Editor:
Gorman-Cobb, Theresa, RN (Case Manager)
Case Management Progress Note:
CM Manager received a message from Marina, Attorney working on guardiansip who stated she
needed additional information. CM Manager called her back and she is out of the office. Secretary
stated she have Marina call back when she gets back in.
Signature; Theresa Gorman-Cobb
Date: 2/17/2017
Time: 10:55 AM
Signed by Gorman-Cobb, Theresa, RN on 2/17/2017 10:56 AM
Progress Notes by Gerstner, Renee D., RN Version loflat 2/17/2017 11:34 AM
Author:Gerstner, Renee D., RN Service:
(none) Author Type:
Registered Nurse
Filed:
2/17/2017 11:35 AM Date of Service:
2/17/2017 11:34 AM Status:Signed
Editor:
Gerstner, Renee D., RN (Registered Nurse)
Pt AAOx3, refusing AM medications. Dr. Khan aware. Pt denies any pain at this time. Abd SNT,
BS+x4. Pt encouraged to sit in chair during and after meals to aid in digestion.
Call bell in reach.
Signed by Gerstner, Renee D., RN on 2/17/2017 11:35 AM
Progress Notes by Khan, Erum S., MD Version 1 of 1 at 2/17/2017
3:55 PM
Author:Khan, Erum S., MD Service:
MEDICINE Author Type:
Physician
Filed:
2/17/20173:56 PM Date of Service:
2/17/20173:55 PM Status:
Signed
Editor:
Khan, Erum S., MD (Physician)
Inpatient Progress Note
Subjective
Subjective:
Symptoms: Stable. No shortness of breath, chest pain or chest pressure. (Resting in bed-
Refuse medications off an don .
No vomiting for last few days .).
Diet: Adequate intake.
Activity level: Returning to normal.
Pain: She reports no pain.
Objective
Objective:
General Appearance: Comfortable and in no acute distress.
Printed on 3/5/18 12:59 PM Page 441
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 54 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 Khan, Erum S., MD (continued) Version 1 of 1 at 2/17/2017
3:55 PM
Vital signs: (most recent): Blood pressure 159/73, pulse 63, temperature 98.5 °F (36.9 °C), temperature source
Oral, resp. rate 20, height 5' 5" (1.651 m), weight 130 lb (58.968 kg), Sp02 97 %, not currently breastfeeding.
Vital signs are normal.
Output: Producing urine.
HEENT: Normal HEENT exam.
Lungs: Normal respiratory rate and normal effort.
Heart: Normal rate. Regular rhythm.
Extremities: Normal range of motion.
Neurological: Patient is alert.
Skin: Warm and dry.
Abdomen: Abdomen is soft. Bowel sounds are normal. There is no abdominal tenderness.
Pupils: Pupils are equal, round, and reactive to light.
Pulses: Distal pulses are intact.
Filed Vitals:
02/16/17 1948 02/16/17 2316 02/17/17 0208 02/17/17 0756
BP: 184/86 167/74 159/73
Pulse: 67 63
Temp: 98.5 °F (36.9 °C) 98.5 °F (36.S
TempSrc: Oral Oral
Resp: 20 20
Height:
Weight:
Sp02: 96% 97%
PainSc: 0 - No pain 0 - No pain
Intake/Output Summary (Last 24 hours) at 02/17/17 1555
Last data filed at 02/17/17 1453
1 Gross per 24 hour
Intake 240 ml
Output 0 ml
iNet 240 ml
I/O last 3 completed shifts:
In: 820 [P.O.:820]
Out: -
Labs:
Printed on 3/5/18 12:59 PM Page 442
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 54 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)
Proaress Notes bv Khan, Erum S., MD (continued) Version 1 of 1 at 2/17/2017
3:55 PM
Recent Results (from the past 336 hour(s))
Glucose POC
Collection Time: 02/03/17 9:09 PM
Result Value Ref Range
Glucose POC 140 (H) 70-110 mg/dL
Glucose POC
Collection Time: 02/06/17 5:56 PM
Result Value Ref Range
Glucose POC 132 (H) 70-110 mg/dL
Glucose POC
Collection Time: 02/06/17 9:24 PM
Result Value Ref Range
Glucose POC 138(H) 70-110 mg/dL
Glucose POC
Collection Time: 02/08/17 12:53 PM
Result Value Ref Range
Glucose POC 137 (H) 70-110 mg/dL
Glucose POC
Collection Time: 02/08/17 5:56 PM
Result Value Ref Range
Glucose POC 134 (H) 70-110 mg/dL
Glucose POC
Collection Time: 02/09/17 5:39 PM
Result Value Ref Range
Glucose POC 139 (H) 70-110 mg/dL
Glucose POC
Collection Time: 02/09/17 9:12 PM
Result Value Ref Range
Glucose POC 138 (H) 70-110 mg/dL
Glucose POC
Collection Time: 02/10/17 9:17 PM
Result Value Ref Range
Glucose POC 135 (H) 70-110 mg/dL
Glucose POC
Collection Time: 02/11/17 8:01 AM
Result Value Ref Range
Glucose POC 117(H) 70-110 mg/dL
Glucose POC
Collection Time: 02/11/17 5:50 PM
Result Value Ref Range
Glucose POC 136(H) 70-110 mg/dL
Glucose POC
Collection Time: 02/11/17 8:53 PM
Result Value Ref Range
Glucose POC 105 70-110 mg/dL
Glucose POC
Collection Time: 02/12/17 8:45 PM
Printed on 3/5/18 12;59 PM Page 443
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 54 RECEIVED NYSCEF: 06/03/2022
ORANGE REGIONAL Fayo, Marion
Orange MEDICAL CENTER MRN; DOB; Sex; F
ma %GIONAL 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017
MEDICAL CENTER MIDDLETOWN NY 10940-
2650
Encounter Notes (continued)
Proaress Notes bv Khan, Erum S., MD (continued) Version 1 of 1 at 2/17/2017
3:55 PM
Result Value Ref Range
Glucose POC 151 (H) 70-110 mg/dL
Glucose POC
Collection Time: 02/13/17 5:59 PM
Result Value Ref Range
Glucose POC 126 (H) 70-110 mg/dL
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.
Xr Abdomen Ap And Decubitus And Or Erect
2/4/2017 EXAMINATION: XR ABDOMEN INC DECUB AND OR ERECT HISTORY: recurrent vomiting
COMPARISON: Prior radiographs of the abdomen and pelvis from 02/24/2016 are available. TECHNIQUE:
Flat and upright of the abdomen. FINDINGS: There are dilated, air-filled loops of small bowel in the left
paraumbilical region with air mixed with stool in the colon, consistent with a focal ileus. No organomegaly or
pneumoperitoneum is identified. No radiopaque renal or biliary calculi are demonstrated. Surgical clips are
identified in the right upper quadrant of the abdomen and pelvis. There is an L scoliosis of the thoracic and
lumbar spine and degenerative changes of the spine are noted. There are multiple pelvic phleboliths.
Printed on 3/5/18 12:59 PM Page 444
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 54 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)
Proaress Notes bv Khan, Erum S., MD (continued) Version 1 of 1 at 2/17/2017
3:55 PM
2/4/2017 IMPRESSION: Focal left paraumbilical ileus.
Above labs and imaging studies reviewed.
Active Meds
Medications
0.9% sodium chloride infusion
Frequency: Continuous
Route: Intravenous
clonidine (CATAPRES) 0.1 MG/24 HR 1 patch
Linked Order: And
Frequency: Weekly
Dose: 1 patch
Route: Transdermal
clonidine (CATAPRES-TTS) patch REMOVAL
Linked Order: And
Frequency: Weekly
Route: Transdermal
docusate sodium (COLACE) capsule 100 mg
Frequency: BID
Dose: 100 mg
Route: Oral
furosemide (LASIX) tablet 20 mg
Frequency: Daily
Dose: 20 mg
Route: Oral
hydrALAZINE (APRESOLINE) tablet 50 mg
Frequency: Q8H SCH
Dose: 50 mg
Route: Oral
lisinopril (PRINIVIL,ZESTRIL) tablet 2.5 mg
Frequency: Daily
Dose: 2.5 mg
Route: Oral
ondansetron (ZOFRAN-ODT) disintegrating tablet 4 mg
Frequency: Q8H PRN
Dose: 4 mg
Route: Oral
urea (CARMOL) 10 % cream 1 Application
Frequency: Daily
Dose: 1 Application
Route: Topical
Assessment
Printed on 3/5/18 12;59 PM Page 445
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 54 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 Khan, Erum S., MD (continued) Version 1 of 1 at 2/17/2017
3:55 PM
Assessment:
Condition: In serious condition. Improving.
Plan:
Encourage ambulation.
Present on Admission:
• Encephalopathy acute
• UTI (urinary tract infection)
• Sepsis
• Dementia without behavioral disturbance
• Inadequate social support
Patient treated with Ceftriaxone x 8 days for >100,000 cfu/ml Klebsiella pneumoniae in urine c/s
Unable to return home- no social support- no children and sister does not want to be involved in care
Awaiting state to set up guardianship and for bank information to be obtained so that Medicaid application can
be filed for nursing home placement
Discussed with case managers
Patient is now ALC
• Hypertension
• Cardiomyopathy, ischemic-18 % EF by echo 11/2016
• Chronic systolic CHF (congestive heart failure)
Will continue ASA, Coreg, Plavix, Catapres, Lasix, Hydralazine, Imdur and Zestril
• Dyslipidemia
Will continue statin
• History of stroke
• Right-sided muscle weakness
Will continue ASA and statin
Will continue activity as tolerated
• DVT Prophylaxis: Will continue activity as tolerated while in hospital- refused SCDs
• Disposition: Will discharge to skilled nursing facility once arrangements made per case managers
Will follow as needed
Electronically signed by:
Erum S. Khan, MD
Printed on 3/5/18 12:59 PM Page 446
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 54 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 Khan, Erum S., MD (continued) Version 1 of 1 at 2/17/2017
3:55 PM
Hospitalist
Crystal Run Healthcare LLP
155 Crystal Run Road
Middletown, NY 10941
Phone: (845)703-6999
2/17/2017
3:55 PM
Signed by Khan, Erum S., MD on 2/17/2017
3:56 PM
Plan of Care by Gerstner. Renee D,, RN Version 1 of 1 at 2/17/2017
5:12 PM
Author:Gerstner, Renee D., RN Service:
(none) Author Type:
Registered Nurse
Filed:
2/17/20175:12 PM Date of Service:
2/17/20175:12 PM Status:
Signed
Editor:
Gerstner, Renee D., RN (Registered Nurse)
Problem: Daily Care
Goal: Daily care needs are met
Outcome: Met this Shift
Signed by Gerstner, Renee D., RN on 2/17/2017
5:12 PM
Progress Notes by Gerstner, Renee D., RN Version loflat 2/17/2017
5:57 PM
Author:Gerstner, Renee D., RN Service:
(none) Author Type:
Registered Nurse
Filed:
2/17/20175:58 PM Date of Service:
2/17/20175:57 PM Status:Signed
Editor:
Gerstner, Renee D., RN (Registered Nurse)
No nausea/vomiting this shift. Refusing meds at times. Call bell in reach.
Signed by Gerstner, Renee D., RN on 2/17/2017
5:58 PM
Progress Notes by Deroziere. Karen. RN Version 1 of 1 at 2/17/2017
7:15 PM
Author:Deroziere, Karen, RN Service:
Internal Medicine Author Type:
Registered Nurse
Filed:
2/17/2017 10:35 PM Date of Service:
2/17/20177:15 PM Status:Signed
Editor:
Deroziere, Karen, RN (Registered Nurse)
SBAR from Renee, patient in bed alert and oriented x 4, call within reach, continue to monitor
frequently.
Signed by Deroziere, Karen, RN on 2/17/2017 10:35 PM
Plan of Care by Deroziere. Karen. RN Version 1 of 1 at 2/17/2017 10:33 PM
Author:Deroziere, Karen, RN Service:
Internal Medicine Author Type:
Registered Nurse
Filed:
2/17/2017 10:34 PM Date of Service:
2/17/2017 10:33 PM Status:Signed
Editor:
Deroziere, Karen, RN (Registered Nurse)
Problem: Daily Care
Goal: Daily care needs are met
Outcome: Progressing
Signed by Deroziere, Karen, RN on 2/17/2017 10:34 PM
Progress Notes by Gerstner, Renee D., RN Version 2 of 2 at 2/18/2017
7:28 AM
Printed on 3/5/18 12;59 PM Page 447
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 54 RECEIVED NYSCEF: 06/03/2022
ORANGE REGIONAL Fayo, Marion
Orange MEDICAL CENTER MRN; DOB; Sex; F
ma %GIONAL 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 Gerstner. Renee D., RN (continued)
Preview
FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 54 RECEIVED NYSCEF: 06/03/2022 EXHIBIT J-4 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 54 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 Deroziere, Karen. RN (continued) Version 1 of 1 at 2/15/2017 8:54 PM Problem: Skin Integrity Goal: Skin integrity is maintained or improved Outcome: Progressing Signed by Deroziere, Karen, RN on 2/15/2017 8:54 PM Progress Notes by Rose, Lisa, RN Version 1 of 1 at 2/16/2017 7:30 AM Author:Rose, Lisa, RN Service: (none) Author Type: Registered Nurse Filed: 2/16/20177:46 AM Date of Service: 2/16/20177:30 AM Status:Signed Editor: Rose, Lisa, RN (Registered Nurse) SBAR report received from Karen RN. Pt resting comfortable in bed with no distress noted. Signed by Rose, Lisa, RN on 2/16/2017 7:46 AM Progress Notes by Rose, Lisa, RN Version loflat 2/16/2017 8:17 AM Author:Rose, Lisa, RN Service: (none) Author Type: Registered Nurse Filed: 2/16/20178:17 AM Date of Service: 2/16/20178:17 AM Status:Signed Editor: Rose, Lisa, RN (Registered Nurse) Pt refused VS and FS this am. Signed by Rose, Lisa, RN on 2/16/2017 8:17 AM Progress Notes by Rose, Lisa, RN Version 1 of 1 at 2/16/2017 10:26 AM Author:Rose, Lisa, RN Service: (none) Author Type: Registered Nurse Filed: 2/16/2017 10:27 AM Date of Service: 2/16/2017 10:26 AM Status:Signed Editor: Rose, Lisa, RN (Registered Nurse) Pt refusing all am medications. Will continue to encourage and educate pt on importance of taking medication regularly. Signed by Rose, Lisa, RN on 2/16/2017 10:27 AM Plan of Care by Rose, Lisa, RN Version 1 of 1 at 2/16/2017 12:32 PM Author:Rose, Lisa, RN Service: (none) Author Type: Registered Nurse Filed: 2/16/2017 12:32 PM Date of Service: 2/16/2017 12:32 PM Status:Signed Editor: Rose, Lisa, RN (Registered Nurse) Problem: Risk for Falls Goal: No falls during hospitalization Patient will not fall during hospitalization. Outcome: Progressing Intervention: Fall prevention Frequent rounding Visual checks q 1 hour Call bell in reach Bed in lowest position. Signed by Rose, Lisa, RN on 2/16/2017 12:32 PM Printed on 3/5/18 12;59 PM Page 438 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 54 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) Plan of Care bv Rose. Lisa. RN (continued) Version 1 of 1 at 2/16/2017 12:32 PM Progress Notes bv Margolese, Barbara, DTRCDN Version 1 of 1 at 2/16/2017 1:22 PM Author:Margolese, Barbara, DTRCDN Service: (none) Author Type: Dietician Filed: 2/16/20171:44 PM Date of Service: 2/16/20171:22 PM Status:Signed Editor: Margolese, Barbara, DTRCDN (Dietician) Nutrition Follow Up- Subjective: Per nurse, pt appetite fair. Objective: Principal Problem: Encephalopathy Diet: Dietary nutrition supplements Diet dysphagia level 3 advanced (soft) Food Allergies: NKFA Medications Noted: Colace Ht: 5'5" (1.651m) Wt: 130 lb (58.968 kg) Skin Integrity: No breakdown documented Stool: 2/11/17, Rectum Labs: 2/13/17 POC Glu 126(H) Assessment: Follow up finds pt tolerating diet with improving oral intake. Stillrefuses medications. Likes and eats the peanut butter and crackers. Glu (H). Pt has hx: DM, may wish to restart carb controlled diet now appetite improving. To SNF on discharge. Nutrition Diagnosis: Poor oral intake related to chronic illness as evidenced by 30 lb. dcrease in bw 4 weeks pta and continued poor oral intake in hospital, (resolving, intake much improved) Nutrition Risk: Moderate Plan: Nutrition Intervention: Provide magic Cup with meals, peanut butter and crackers Nutrition Monitoring: Will follow nutrient intake, labs, wt, clinical status Signed by Margolese, Barbara, DTRCDN on 2/16/2017 1:44 PM Progress Notes by Deroziere. Karen. RN Version 1 of 1 at 2/16/2017 7:15 PM Printed on 3/5/18 12:59 PM Page 439 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 54 RECEIVED NYSCEF: 06/03/2022 ORANGE REGIONAL Fayo, Marion Orange MEDICAL CENTER MRN; DOB; Sex; F ma %GIONAL 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 Deroziere, Karen. RN (continued) Version 1 of 1 at 2/16/2017 7:15 PM Author:Deroziere, Karen, RN Service: Internal Medicine Author Type: Registered Nurse Filed: 2/16/20177:54 PM Date of Service: 2/16/20177:15 PM Status: Signed Editor: Deroziere, Karen, RN (Registered Nurse) SBAR from Lisa RN, patient in bed, call bell within reach, safety measures maintained. Signed by Deroziere, Karen, RN on 2/16/2017 7:54 PM Plan of Care by Deroziere, Karen, RN Version loflat 2/16/2017 7:53 PM Author:Deroziere, Karen, RN Service: Internal Medicine Author Type: Registered Nurse Filed: 2/16/20177:53 PM Date of Service: 2/16/20177:53 PM Status: Signed Editor: Deroziere, Karen, RN (Registered Nurse) Problem: Risk for Falls Goal: No falls during hospitalization Patient will not fall during hospitalization. Outcome: Progressing Signed by Deroziere, Karen, RN on 2/16/2017 7:53 PM Progress Notes by Deroziere, Karen, RN Version 1 of 1 at 2/16/2017 10:15 PM Author:Deroziere, Karen, RN Service: Internal Medicine Author Type: Registered Nurse Filed: 2/17/2017 12:25 AM Date of Service: 2/16/2017 10:15 PM Status:Signed Editor: Deroziere, Karen, RN (Registered Nurse) Patient OOB to bathroom had large BM, then went back to bed and vomited moderate amount of undigested food. Zofran po given, vomiting resolved. Signed by Deroziere, Karen, RN on 2/17/2017 12:25 AM Progress Notes by Deroziere, Karen. RN Version 1 of 1 at 2/16/2017 11:35 PM Author:Deroziere, Karen, RN Service: Internal Medicine Author Type: Registered Nurse Filed: 2/16/2017 11:37 PM Date of Service: 2/16/2017 11:35 PM Status:Signed Editor: Deroziere, Karen, RN (Registered Nurse) 02/16/17 2316 Vital Signs Heart Rate 67 Heart Rate Monitor Source Resp 20 BP 184/86 mmHg BP Location Right arm BP elevated patient has been refusing all her BP medications x 24 hours which MD is aware, also clonidine patch is missing from right deltoid. Instructed patient she should take her BP med as ordered which she agreed to. Hydralazine 50 mg po given. Will get clonidine patch reordered. Signed by Deroziere, Karen, RN on 2/16/2017 11:37 PM Printed on 3/5/18 12;59 PM Page 440 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 54 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 Gorman-Cobb, Theresa. RN Version 1 of 1 at 2/17/2017 10:55 AM Author:Gorman-Cobb, Theresa, RN Service: (none) Author Type: Case Manager Filed: 2/17/2017 10:56 AM Date of Service: 2/17/2017 10:55 AM Status: Signed Editor: Gorman-Cobb, Theresa, RN (Case Manager) Case Management Progress Note: CM Manager received a message from Marina, Attorney working on guardiansip who stated she needed additional information. CM Manager called her back and she is out of the office. Secretary stated she have Marina call back when she gets back in. Signature; Theresa Gorman-Cobb Date: 2/17/2017 Time: 10:55 AM Signed by Gorman-Cobb, Theresa, RN on 2/17/2017 10:56 AM Progress Notes by Gerstner, Renee D., RN Version loflat 2/17/2017 11:34 AM Author:Gerstner, Renee D., RN Service: (none) Author Type: Registered Nurse Filed: 2/17/2017 11:35 AM Date of Service: 2/17/2017 11:34 AM Status:Signed Editor: Gerstner, Renee D., RN (Registered Nurse) Pt AAOx3, refusing AM medications. Dr. Khan aware. Pt denies any pain at this time. Abd SNT, BS+x4. Pt encouraged to sit in chair during and after meals to aid in digestion. Call bell in reach. Signed by Gerstner, Renee D., RN on 2/17/2017 11:35 AM Progress Notes by Khan, Erum S., MD Version 1 of 1 at 2/17/2017 3:55 PM Author:Khan, Erum S., MD Service: MEDICINE Author Type: Physician Filed: 2/17/20173:56 PM Date of Service: 2/17/20173:55 PM Status: Signed Editor: Khan, Erum S., MD (Physician) Inpatient Progress Note Subjective Subjective: Symptoms: Stable. No shortness of breath, chest pain or chest pressure. (Resting in bed- Refuse medications off an don . No vomiting for last few days .). Diet: Adequate intake. Activity level: Returning to normal. Pain: She reports no pain. Objective Objective: General Appearance: Comfortable and in no acute distress. Printed on 3/5/18 12:59 PM Page 441 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 54 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 Khan, Erum S., MD (continued) Version 1 of 1 at 2/17/2017 3:55 PM Vital signs: (most recent): Blood pressure 159/73, pulse 63, temperature 98.5 °F (36.9 °C), temperature source Oral, resp. rate 20, height 5' 5" (1.651 m), weight 130 lb (58.968 kg), Sp02 97 %, not currently breastfeeding. Vital signs are normal. Output: Producing urine. HEENT: Normal HEENT exam. Lungs: Normal respiratory rate and normal effort. Heart: Normal rate. Regular rhythm. Extremities: Normal range of motion. Neurological: Patient is alert. Skin: Warm and dry. Abdomen: Abdomen is soft. Bowel sounds are normal. There is no abdominal tenderness. Pupils: Pupils are equal, round, and reactive to light. Pulses: Distal pulses are intact. Filed Vitals: 02/16/17 1948 02/16/17 2316 02/17/17 0208 02/17/17 0756 BP: 184/86 167/74 159/73 Pulse: 67 63 Temp: 98.5 °F (36.9 °C) 98.5 °F (36.S TempSrc: Oral Oral Resp: 20 20 Height: Weight: Sp02: 96% 97% PainSc: 0 - No pain 0 - No pain Intake/Output Summary (Last 24 hours) at 02/17/17 1555 Last data filed at 02/17/17 1453 1 Gross per 24 hour Intake 240 ml Output 0 ml iNet 240 ml I/O last 3 completed shifts: In: 820 [P.O.:820] Out: - Labs: Printed on 3/5/18 12:59 PM Page 442 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 54 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) Proaress Notes bv Khan, Erum S., MD (continued) Version 1 of 1 at 2/17/2017 3:55 PM Recent Results (from the past 336 hour(s)) Glucose POC Collection Time: 02/03/17 9:09 PM Result Value Ref Range Glucose POC 140 (H) 70-110 mg/dL Glucose POC Collection Time: 02/06/17 5:56 PM Result Value Ref Range Glucose POC 132 (H) 70-110 mg/dL Glucose POC Collection Time: 02/06/17 9:24 PM Result Value Ref Range Glucose POC 138(H) 70-110 mg/dL Glucose POC Collection Time: 02/08/17 12:53 PM Result Value Ref Range Glucose POC 137 (H) 70-110 mg/dL Glucose POC Collection Time: 02/08/17 5:56 PM Result Value Ref Range Glucose POC 134 (H) 70-110 mg/dL Glucose POC Collection Time: 02/09/17 5:39 PM Result Value Ref Range Glucose POC 139 (H) 70-110 mg/dL Glucose POC Collection Time: 02/09/17 9:12 PM Result Value Ref Range Glucose POC 138 (H) 70-110 mg/dL Glucose POC Collection Time: 02/10/17 9:17 PM Result Value Ref Range Glucose POC 135 (H) 70-110 mg/dL Glucose POC Collection Time: 02/11/17 8:01 AM Result Value Ref Range Glucose POC 117(H) 70-110 mg/dL Glucose POC Collection Time: 02/11/17 5:50 PM Result Value Ref Range Glucose POC 136(H) 70-110 mg/dL Glucose POC Collection Time: 02/11/17 8:53 PM Result Value Ref Range Glucose POC 105 70-110 mg/dL Glucose POC Collection Time: 02/12/17 8:45 PM Printed on 3/5/18 12;59 PM Page 443 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 54 RECEIVED NYSCEF: 06/03/2022 ORANGE REGIONAL Fayo, Marion Orange MEDICAL CENTER MRN; DOB; Sex; F ma %GIONAL 707 EAST MAIN STREET Adm; 1/15/2017, D/C; 4/4/2017 MEDICAL CENTER MIDDLETOWN NY 10940- 2650 Encounter Notes (continued) Proaress Notes bv Khan, Erum S., MD (continued) Version 1 of 1 at 2/17/2017 3:55 PM Result Value Ref Range Glucose POC 151 (H) 70-110 mg/dL Glucose POC Collection Time: 02/13/17 5:59 PM Result Value Ref Range Glucose POC 126 (H) 70-110 mg/dL 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. Xr Abdomen Ap And Decubitus And Or Erect 2/4/2017 EXAMINATION: XR ABDOMEN INC DECUB AND OR ERECT HISTORY: recurrent vomiting COMPARISON: Prior radiographs of the abdomen and pelvis from 02/24/2016 are available. TECHNIQUE: Flat and upright of the abdomen. FINDINGS: There are dilated, air-filled loops of small bowel in the left paraumbilical region with air mixed with stool in the colon, consistent with a focal ileus. No organomegaly or pneumoperitoneum is identified. No radiopaque renal or biliary calculi are demonstrated. Surgical clips are identified in the right upper quadrant of the abdomen and pelvis. There is an L scoliosis of the thoracic and lumbar spine and degenerative changes of the spine are noted. There are multiple pelvic phleboliths. Printed on 3/5/18 12:59 PM Page 444 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 54 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) Proaress Notes bv Khan, Erum S., MD (continued) Version 1 of 1 at 2/17/2017 3:55 PM 2/4/2017 IMPRESSION: Focal left paraumbilical ileus. Above labs and imaging studies reviewed. Active Meds Medications 0.9% sodium chloride infusion Frequency: Continuous Route: Intravenous clonidine (CATAPRES) 0.1 MG/24 HR 1 patch Linked Order: And Frequency: Weekly Dose: 1 patch Route: Transdermal clonidine (CATAPRES-TTS) patch REMOVAL Linked Order: And Frequency: Weekly Route: Transdermal docusate sodium (COLACE) capsule 100 mg Frequency: BID Dose: 100 mg Route: Oral furosemide (LASIX) tablet 20 mg Frequency: Daily Dose: 20 mg Route: Oral hydrALAZINE (APRESOLINE) tablet 50 mg Frequency: Q8H SCH Dose: 50 mg Route: Oral lisinopril (PRINIVIL,ZESTRIL) tablet 2.5 mg Frequency: Daily Dose: 2.5 mg Route: Oral ondansetron (ZOFRAN-ODT) disintegrating tablet 4 mg Frequency: Q8H PRN Dose: 4 mg Route: Oral urea (CARMOL) 10 % cream 1 Application Frequency: Daily Dose: 1 Application Route: Topical Assessment Printed on 3/5/18 12;59 PM Page 445 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 54 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 Khan, Erum S., MD (continued) Version 1 of 1 at 2/17/2017 3:55 PM Assessment: Condition: In serious condition. Improving. Plan: Encourage ambulation. Present on Admission: • Encephalopathy acute • UTI (urinary tract infection) • Sepsis • Dementia without behavioral disturbance • Inadequate social support Patient treated with Ceftriaxone x 8 days for >100,000 cfu/ml Klebsiella pneumoniae in urine c/s Unable to return home- no social support- no children and sister does not want to be involved in care Awaiting state to set up guardianship and for bank information to be obtained so that Medicaid application can be filed for nursing home placement Discussed with case managers Patient is now ALC • Hypertension • Cardiomyopathy, ischemic-18 % EF by echo 11/2016 • Chronic systolic CHF (congestive heart failure) Will continue ASA, Coreg, Plavix, Catapres, Lasix, Hydralazine, Imdur and Zestril • Dyslipidemia Will continue statin • History of stroke • Right-sided muscle weakness Will continue ASA and statin Will continue activity as tolerated • DVT Prophylaxis: Will continue activity as tolerated while in hospital- refused SCDs • Disposition: Will discharge to skilled nursing facility once arrangements made per case managers Will follow as needed Electronically signed by: Erum S. Khan, MD Printed on 3/5/18 12:59 PM Page 446 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 54 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 Khan, Erum S., MD (continued) Version 1 of 1 at 2/17/2017 3:55 PM Hospitalist Crystal Run Healthcare LLP 155 Crystal Run Road Middletown, NY 10941 Phone: (845)703-6999 2/17/2017 3:55 PM Signed by Khan, Erum S., MD on 2/17/2017 3:56 PM Plan of Care by Gerstner. Renee D,, RN Version 1 of 1 at 2/17/2017 5:12 PM Author:Gerstner, Renee D., RN Service: (none) Author Type: Registered Nurse Filed: 2/17/20175:12 PM Date of Service: 2/17/20175:12 PM Status: Signed Editor: Gerstner, Renee D., RN (Registered Nurse) Problem: Daily Care Goal: Daily care needs are met Outcome: Met this Shift Signed by Gerstner, Renee D., RN on 2/17/2017 5:12 PM Progress Notes by Gerstner, Renee D., RN Version loflat 2/17/2017 5:57 PM Author:Gerstner, Renee D., RN Service: (none) Author Type: Registered Nurse Filed: 2/17/20175:58 PM Date of Service: 2/17/20175:57 PM Status:Signed Editor: Gerstner, Renee D., RN (Registered Nurse) No nausea/vomiting this shift. Refusing meds at times. Call bell in reach. Signed by Gerstner, Renee D., RN on 2/17/2017 5:58 PM Progress Notes by Deroziere. Karen. RN Version 1 of 1 at 2/17/2017 7:15 PM Author:Deroziere, Karen, RN Service: Internal Medicine Author Type: Registered Nurse Filed: 2/17/2017 10:35 PM Date of Service: 2/17/20177:15 PM Status:Signed Editor: Deroziere, Karen, RN (Registered Nurse) SBAR from Renee, patient in bed alert and oriented x 4, call within reach, continue to monitor frequently. Signed by Deroziere, Karen, RN on 2/17/2017 10:35 PM Plan of Care by Deroziere. Karen. RN Version 1 of 1 at 2/17/2017 10:33 PM Author:Deroziere, Karen, RN Service: Internal Medicine Author Type: Registered Nurse Filed: 2/17/2017 10:34 PM Date of Service: 2/17/2017 10:33 PM Status:Signed Editor: Deroziere, Karen, RN (Registered Nurse) Problem: Daily Care Goal: Daily care needs are met Outcome: Progressing Signed by Deroziere, Karen, RN on 2/17/2017 10:34 PM Progress Notes by Gerstner, Renee D., RN Version 2 of 2 at 2/18/2017 7:28 AM Printed on 3/5/18 12;59 PM Page 447 FILED: ROCKLAND COUNTY CLERK 06/03/2022 02:18 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 54 RECEIVED NYSCEF: 06/03/2022 ORANGE REGIONAL Fayo, Marion Orange MEDICAL CENTER MRN; DOB; Sex; F ma %GIONAL 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 Gerstner. Renee D., RN (continued)