Preview
FILED: WESTCHESTER COUNTY CLERK 02/01/2023 06:17 PM INDEX NO. 64205/2020
NYSCEF DOC. NO. 131 RECEIVED NYSCEF: 02/01/2023
Exhibit B
FILED: WESTCHESTER COUNTY CLERK 02/01/2023 06:17 PM INDEX NO. 64205/2020
NYSCEF DOC. NO. 131 RECEIVED NYSCEF: 02/01/2023
Date: Jul 11, 2018 Glen island Center For and Rehabilitation - SNF Facility # 1078
Nursing
Time: 14:50:47 ET Progress Notes
User: Jodannah Venzon-Mecua Page # 6
Resident Name: Rose Bouknight (13579) Location: - Admission Date: 11/21/2017
Author: Cabahug, Diandra - Registered Nurse [e-SIGNED]
Effective Date: 11/22/2017 15:10
Type: H&P note
Admitted for:: Short term stay, Rehabilitation (PT OT SLP)
Medical History: 76 y/o female pt with h/o DMN, Gout, CKD stage 2-3, HTN, appendicular abscess and c-diff admitted from Jacobi
Hosp. pt was in the hospital due skin eruptions and ulcerations. Also, found to have UTI treated with ABTs ,Anemia treated with
multiple blood transfusions and DVT initially treated with lovenox but due to low h/h and +ve stool occult blood d/dd anticoagulants
and placed IVC filter. now here STR
Assesment/ Findinas: Oxygen Therapy, Wound/ulcer care, IVF therapy / IV med
Treatment Initiated/ Received In Hospital: medicatios reviewed, see list
Plan Of Care:
Author: Mahdi Abdullah - Physician
[e-SIGNED]
Effective Date: 11/22/2017 12:08
Type: Social Service Narrative
Notes:: Family informed via VM that room change is canceled at this time.
Notes::
Author: Lauren Ciuti - social worker [e-SIGNED]
Effective Date: 11/22/2017 11:52
Type: Social Service Narrative
Notes:: SWK left VM for brother to provide introduction and contact info as well as to inform of room change to 120A secondary to
clinicai need. Monitor plan of care.
Notes::
Author: Lauren Ciuti- social worker (e-SIGNED)
Effective Date: 11/22/2017 06:54
NURSES'
Type: NOTES
Resident is alert and responsive. No acute distress noted. VS WNL. Appears adjusting well to the unit. All care rendered.
Author: Armyl Joseph Marquez - Registered Nurse [e-SIGNED]
Effective Date: 11/22/2017 06:41
Type: eMar - Medication Administration Note
Levothyroxine Sodium Tablet25 MCG Give 1 tablet by mouth one time a day for Hypothyroidism Pending delivery
Author: Armyl Joseph Marquez - Registered Nurse [e-SIGNED]
Effective Date: 11/22/2017 00:12
NURSES'
Type: NOTES
Resident is alert and responsive. In no acute distress. 1/7 admission adjusting well to unit. Took due medications well. No issues or
complaints noted. All care rendered. Will continue to monitor.
Author: Cabahug, Diandra - Registered Nurse [e-SIGNED]
Effective Date: 11/21/2017 23:28
Type: Plan of Care Note
Text.
Note Admitted at 7:55 pm per stretcher , accompanied by two EMS from Jacobi medical center with Dx of Steven's-Johnson's
Syndrome, eruptive drug reaction, GI bleed, gout flare, UTl, LLE DVT s/p IVD filter, RUE DVT from PICC tine, Dementia baseline,
CKD Stage 2-3, HTN , prior appendicular abscess and hx of C-Diff infection, a 76 y/o female, Alert oriented x1 to person only,
introduced to staff and room orientation done, call bell within reached.Noted with multiple skin impairments, with multiple dark skin
pigmentation all over the body, with right inner leg open area 2x1 cm, with upper right buttock 0.8 x 0.5 x 0.1 cm deep, with right lower
right buttock 2 x 0.5 cm x 0.1 deep, with linear open area left lateral leg, healed scar on the left upper extremity, with scar on the mid
chest 2 x 4 , noted dry skin and bunions. With 3+ pitting edema on BLEx and edema 3+ on right upper extremity, Hx DVT RUe.Family
at bedside upon admission. Total dependence on ADL's. Incontinent of bowel and bladder.Unable to weigh pt upon admission.Will
continue to monitor the resident.
Author: Marivic Manlapaz - RN
[e-SIGNED]
FILED: WESTCHESTER COUNTY CLERK 02/01/2023 06:17 PM INDEX NO. 64205/2020
NYSCEF DOC. NO. 131 RECEIVED NYSCEF: 02/01/2023
Date: Jul 11, 2018 Glen Island Center For and Rehabilitation - SNF Facility # 1078
Nursing
Time: 14:50:47 ET Progress Notes
User: Jodannah Venzon-Mecua Page # 1
Reeldent Name: Rose Bouknight (13579) Location: - Admission Date: 11/21/2017
Medical Record #"
13579 Gender: F Date of Birth: 3/22/1941
Physician: Abdullah, Mahdi Pharmacy: Pharmscript
Allergies: Allopurinol, Ceftriaxone, Colchicine, Cyproheptedine, Furosemide, Levaquin, Procardia, Tomato
Diagnoses: URINARY TRACT INFECTION, SITE NOT SPECIFIED, HISTORY OF FALLING, ACUTE EMBOLISM AND
THROMBOSIS OF UNSPECIFIED DEEP VEINS OF LEFT LOWER EXTREMITY, STEVENS-JOHNSON
SYNDROME, PRESENCE OF OTHER VASCULAR IMPLANTS AND GRAFTS, OTHER LACK OF
COORDINATION, MUSCLE WEAKNESS (GENERALIZED), OTHER ABNORMALITIES OF GAIT AND
MOBILITY, STIFFNESS OF UNSPECIFIED JOINT, NOT ELSEWHERE CLASSlFIED, PAIN IN
UNSPECIFIED JOINT, PRESSURE ULCER OF RIGHT BUTTOCK, STAGE 2, GASTRITIS, UNSPECIFIED,
WITHOUT BLEEDING, ACQUIRED ABSENCE OF OTHER SPECIFIED PARTS OF DIGESTIVE TRACT,
DIVERTICULITIS OF SMALL INTESTINE WITH PERFORATION AND ABSCESS WITHOUT BLEEDING,
DYSPHAGIA, ORAL PHASE, ANEMIA, UNSPECIFIED, GOUT, UNSPECIFIED, CHRONIC KIDNEY
DISEASE, STAGE 2 (MILD), HYPOTHYROlDISM, UNSPECIFIED, MAJOR DEPRESSIVE DISORDER,
SINGLE EPISODE, UNSPECIFIED, ESSENTIAL (PRIMARY) HYPERTENSION, UNSPECIFIED DEMENTIA
WITHOUT BEHAVIORAL DISTURBANCE
Effective Date: 1/10/2018 10:13
Type: Seeial-Seivice-Namative
Wrong Resident -
Wrong Resident - Notesi÷
Strike Out Date: 1/11/2018 10:39
Author: Lauren Ciuti - social worker [e-SIGNED]
Effective Date: 12/8/2017 10:56
Type: Social Service Narrative
Ng : SWK aware of hospitalization, monitor for retum.
Author: Lauren Ciuti - social worker [e-SIGNED]
Effective Date: 12/7/2017 00:18
NURSES'
Type: NOTES
Patient admitted with Dx. UTI Next of kin by the name of Kevin Lynch aware
Author: Andrea Jose - Registered Nurse [e-SIGNED]
Effective Date: 12/B/2017 17:16
NURSES'
Type: NOTES
Note Text Seen and examined by Dr.Abdullah and ordered to transfer to Montefiore Mt. Vemon Hospital for changed of mental
status. Next of kin by the name of Kevin Lynch notified and requested to transfer patient to Jacobi Medical Center NP Orhan notified
and agreed. Jacobi Medical Center ER aware. Vital signs BP 129/85 PR 79 Resp. 18 Temp. 96.8 02sat 94% Resident left at 5:00pm
via stretcher accompanied by 2 ambulance attendant from Senior Care Ambulance Service. ID band in place. Copy of the UA/CS
results attached to transfer documents.
Author: Andrea Jose - Registered Nurse [e-SIGNED]
Effective Date: 12/B/2017 16:50
Type: Gr41er-Nete
wrong chart -
wrong chart -
wrong chart -
Strike Out Date: 12/7/2017 13:26
Author: Gretchen Rios - Registered Nurse [e-SIGNED]
Effective Date: 12/6/2017 14:45
NURSES'
Type: NOTES
alert and responsive. still with poor appetite. received T.0 from NP Orhan, to start D5 1/2 NS at 75cc/hr x 7days and ciprofloxacin
200mg IV Q12H x 7days for UTl. resident was uncooperative and refused IV insertion. NOK, Kevin was informed.
Author: Gretchen Rios - Registered Nurse [e-SIGNED]
Effective Date: 12/B/2017 14:18
Type: Social Service Narrative
Notes:: Brother attended IDCP meeting via teleconference. Medications, treatment and DX were reviewed by staff. Appetite remains
poor, calorie count ordered as well as speech. Supplements and Remeron ordered.Patient desires to retum home upon completion of
rehab. Family is working on 24R care. SWK will assist with DC planning as needed. Monitor plan of care.
Preview
FILED: WESTCHESTER COUNTY CLERK 02/01/2023 06:17 PM INDEX NO. 64205/2020 NYSCEF DOC. NO. 131 RECEIVED NYSCEF: 02/01/2023 Exhibit B FILED: WESTCHESTER COUNTY CLERK 02/01/2023 06:17 PM INDEX NO. 64205/2020 NYSCEF DOC. NO. 131 RECEIVED NYSCEF: 02/01/2023 Date: Jul 11, 2018 Glen island Center For and Rehabilitation - SNF Facility # 1078 Nursing Time: 14:50:47 ET Progress Notes User: Jodannah Venzon-Mecua Page # 6 Resident Name: Rose Bouknight (13579) Location: - Admission Date: 11/21/2017 Author: Cabahug, Diandra - Registered Nurse [e-SIGNED] Effective Date: 11/22/2017 15:10 Type: H&P note Admitted for:: Short term stay, Rehabilitation (PT OT SLP) Medical History: 76 y/o female pt with h/o DMN, Gout, CKD stage 2-3, HTN, appendicular abscess and c-diff admitted from Jacobi Hosp. pt was in the hospital due skin eruptions and ulcerations. Also, found to have UTI treated with ABTs ,Anemia treated with multiple blood transfusions and DVT initially treated with lovenox but due to low h/h and +ve stool occult blood d/dd anticoagulants and placed IVC filter. now here STR Assesment/ Findinas: Oxygen Therapy, Wound/ulcer care, IVF therapy / IV med Treatment Initiated/ Received In Hospital: medicatios reviewed, see list Plan Of Care: Author: Mahdi Abdullah - Physician [e-SIGNED] Effective Date: 11/22/2017 12:08 Type: Social Service Narrative Notes:: Family informed via VM that room change is canceled at this time. Notes:: Author: Lauren Ciuti - social worker [e-SIGNED] Effective Date: 11/22/2017 11:52 Type: Social Service Narrative Notes:: SWK left VM for brother to provide introduction and contact info as well as to inform of room change to 120A secondary to clinicai need. Monitor plan of care. Notes:: Author: Lauren Ciuti- social worker (e-SIGNED) Effective Date: 11/22/2017 06:54 NURSES' Type: NOTES Resident is alert and responsive. No acute distress noted. VS WNL. Appears adjusting well to the unit. All care rendered. Author: Armyl Joseph Marquez - Registered Nurse [e-SIGNED] Effective Date: 11/22/2017 06:41 Type: eMar - Medication Administration Note Levothyroxine Sodium Tablet25 MCG Give 1 tablet by mouth one time a day for Hypothyroidism Pending delivery Author: Armyl Joseph Marquez - Registered Nurse [e-SIGNED] Effective Date: 11/22/2017 00:12 NURSES' Type: NOTES Resident is alert and responsive. In no acute distress. 1/7 admission adjusting well to unit. Took due medications well. No issues or complaints noted. All care rendered. Will continue to monitor. Author: Cabahug, Diandra - Registered Nurse [e-SIGNED] Effective Date: 11/21/2017 23:28 Type: Plan of Care Note Text. Note Admitted at 7:55 pm per stretcher , accompanied by two EMS from Jacobi medical center with Dx of Steven's-Johnson's Syndrome, eruptive drug reaction, GI bleed, gout flare, UTl, LLE DVT s/p IVD filter, RUE DVT from PICC tine, Dementia baseline, CKD Stage 2-3, HTN , prior appendicular abscess and hx of C-Diff infection, a 76 y/o female, Alert oriented x1 to person only, introduced to staff and room orientation done, call bell within reached.Noted with multiple skin impairments, with multiple dark skin pigmentation all over the body, with right inner leg open area 2x1 cm, with upper right buttock 0.8 x 0.5 x 0.1 cm deep, with right lower right buttock 2 x 0.5 cm x 0.1 deep, with linear open area left lateral leg, healed scar on the left upper extremity, with scar on the mid chest 2 x 4 , noted dry skin and bunions. With 3+ pitting edema on BLEx and edema 3+ on right upper extremity, Hx DVT RUe.Family at bedside upon admission. Total dependence on ADL's. Incontinent of bowel and bladder.Unable to weigh pt upon admission.Will continue to monitor the resident. Author: Marivic Manlapaz - RN [e-SIGNED] FILED: WESTCHESTER COUNTY CLERK 02/01/2023 06:17 PM INDEX NO. 64205/2020 NYSCEF DOC. NO. 131 RECEIVED NYSCEF: 02/01/2023 Date: Jul 11, 2018 Glen Island Center For and Rehabilitation - SNF Facility # 1078 Nursing Time: 14:50:47 ET Progress Notes User: Jodannah Venzon-Mecua Page # 1 Reeldent Name: Rose Bouknight (13579) Location: - Admission Date: 11/21/2017 Medical Record #" 13579 Gender: F Date of Birth: 3/22/1941 Physician: Abdullah, Mahdi Pharmacy: Pharmscript Allergies: Allopurinol, Ceftriaxone, Colchicine, Cyproheptedine, Furosemide, Levaquin, Procardia, Tomato Diagnoses: URINARY TRACT INFECTION, SITE NOT SPECIFIED, HISTORY OF FALLING, ACUTE EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VEINS OF LEFT LOWER EXTREMITY, STEVENS-JOHNSON SYNDROME, PRESENCE OF OTHER VASCULAR IMPLANTS AND GRAFTS, OTHER LACK OF COORDINATION, MUSCLE WEAKNESS (GENERALIZED), OTHER ABNORMALITIES OF GAIT AND MOBILITY, STIFFNESS OF UNSPECIFIED JOINT, NOT ELSEWHERE CLASSlFIED, PAIN IN UNSPECIFIED JOINT, PRESSURE ULCER OF RIGHT BUTTOCK, STAGE 2, GASTRITIS, UNSPECIFIED, WITHOUT BLEEDING, ACQUIRED ABSENCE OF OTHER SPECIFIED PARTS OF DIGESTIVE TRACT, DIVERTICULITIS OF SMALL INTESTINE WITH PERFORATION AND ABSCESS WITHOUT BLEEDING, DYSPHAGIA, ORAL PHASE, ANEMIA, UNSPECIFIED, GOUT, UNSPECIFIED, CHRONIC KIDNEY DISEASE, STAGE 2 (MILD), HYPOTHYROlDISM, UNSPECIFIED, MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED, ESSENTIAL (PRIMARY) HYPERTENSION, UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE Effective Date: 1/10/2018 10:13 Type: Seeial-Seivice-Namative Wrong Resident - Wrong Resident - Notesi÷ Strike Out Date: 1/11/2018 10:39 Author: Lauren Ciuti - social worker [e-SIGNED] Effective Date: 12/8/2017 10:56 Type: Social Service Narrative Ng : SWK aware of hospitalization, monitor for retum. Author: Lauren Ciuti - social worker [e-SIGNED] Effective Date: 12/7/2017 00:18 NURSES' Type: NOTES Patient admitted with Dx. UTI Next of kin by the name of Kevin Lynch aware Author: Andrea Jose - Registered Nurse [e-SIGNED] Effective Date: 12/B/2017 17:16 NURSES' Type: NOTES Note Text Seen and examined by Dr.Abdullah and ordered to transfer to Montefiore Mt. Vemon Hospital for changed of mental status. Next of kin by the name of Kevin Lynch notified and requested to transfer patient to Jacobi Medical Center NP Orhan notified and agreed. Jacobi Medical Center ER aware. Vital signs BP 129/85 PR 79 Resp. 18 Temp. 96.8 02sat 94% Resident left at 5:00pm via stretcher accompanied by 2 ambulance attendant from Senior Care Ambulance Service. ID band in place. Copy of the UA/CS results attached to transfer documents. Author: Andrea Jose - Registered Nurse [e-SIGNED] Effective Date: 12/B/2017 16:50 Type: Gr41er-Nete wrong chart - wrong chart - wrong chart - Strike Out Date: 12/7/2017 13:26 Author: Gretchen Rios - Registered Nurse [e-SIGNED] Effective Date: 12/6/2017 14:45 NURSES' Type: NOTES alert and responsive. still with poor appetite. received T.0 from NP Orhan, to start D5 1/2 NS at 75cc/hr x 7days and ciprofloxacin 200mg IV Q12H x 7days for UTl. resident was uncooperative and refused IV insertion. NOK, Kevin was informed. Author: Gretchen Rios - Registered Nurse [e-SIGNED] Effective Date: 12/B/2017 14:18 Type: Social Service Narrative Notes:: Brother attended IDCP meeting via teleconference. Medications, treatment and DX were reviewed by staff. Appetite remains poor, calorie count ordered as well as speech. Supplements and Remeron ordered.Patient desires to retum home upon completion of rehab. Family is working on 24R care. SWK will assist with DC planning as needed. Monitor plan of care.