Preview
FILED: WESTCHESTER COUNTY CLERK 02/01/2023 06:17 PM INDEX NO. 64205/2020
NYSCEF DOC. NO. 133 RECEIVED NYSCEF: 02/01/2023
Exhibit D
FILED: WESTCHESTER COUNTY CLERK 02/01/2023 06:17 PM INDEX NO. 64205/2020
NYSCEF DOC. NO. 133 RECEIVED NYSCEF: 02/01/2023
____________________________________________
Print: Tue, 25 Aug 20 O940 | Bouknight,Rose_m 6049894-3 IP
Page 200 of 210 | DIS-6D16-1 Age: 79Y Sex: F
Jacobi Medical Center | DOB: 22 Mar 1941 MR# 6049894
| Adm: 9 Jun 18 0354 Dis: 16 Jun 18 1000 |
| Att Phys: Cha Fong,Colin D., MD
| Service: Internal Medicine
...___________________________________________
Chart Update
Chart Group: All Chart Review Items -- continued
15Jun 2351 Med Nurse's Note -- contd
Fri, Surg (7/O4)
air
Characteristics : warm
Skin Turgor : poor
Edema : B/L FEET Description: puffy
Wound Care : not applicable
Bed : Hill Rom (Versa-Care)
Pressure Ulcer Risk : 11 Sensory Perception: slightly
limited/responds to verbal commands
but cannot always communicate
discomfort Moisture: very moist/skin
is often but not always moist.
change once per shift. Activity:
bedfast/confined to bed Mobility:
very limited/makes occasional slight
changes in body or
extremity position
Nutrition: Generally eats only about
1/2 of
any food offered or receives
less than optimum amount of liquid
diet or tube feeding. Friction/Shear:
problem/requires moderate to maximum
assistance in moving. Risk: 6-18 =
at risk
Pressure UIcer : Location: coccyx/sacrum Stage: stage 4
deep ulcer, tissue/bone exposed
Assessment: not a full assessment
Dressing: Dressing changed as per
protocol.
Location: RIGHT HIP Stage: stage 2 red
skin, epidermis damaged Assessment:
not a full assessment Dressing:
Dressing changed as per protocol.
Location: RT FOOT Stage: stage 2 red skin,
epidermis damaged Assessment: not a
full assessment Dressing: Dressing
changed as per protocol.
Location: LEFT FOOT Stage: stage 2 red
skin, epidermis damaged Assessment:
not a full assessment Dressing:
Dressing changed as per protocol.
Turn and Position : Patient turned q 2h.
Precautions : assess skin daily. keep skin clear and dry.
Patient is incontinent, instituted protocol
for perineal care of the incontinent. Use
Bouknight,Rose_m 8049894-3 DIS-5D1 MR# 6049894
FILED: WESTCHESTER COUNTY CLERK 02/01/2023 06:17 PM INDEX NO. 64205/2020
NYSCEF DOC. NO. 133 RECEIVED NYSCEF: 02/01/2023
____________________________________________
Print: Tue, 25 Aug 20 0942 | Bouknight,Rose_m 6049894-4 EP
Page 9 of 15 | DIS-EP Age: 79Y Sex: F
Jacobi Medical Center | DOB: 22 Mar 1941 MR# 6049894
[ Adm: 19 Jun 18 1417 DIs: 19 Jun 18 2359 |
| Att Phys:
LI,Slu Fal, MD
| Service: Emergency
.__________________________________________
Chart Update
Chart Group: AII Chart Review Items -- continued
final
Tue, 19Jun 1733 ED Provider Initial Note
Source of History : Patient;
Time Pt Seen :
Attending : Slu Fai Li, MD
Provider : Rostislav Gorbatov, MD
Nursing Note Reviewed : Nursing note reviewed.
HPI/Exam/Assm't/Plan : Admission Note
Name: Rose Bouknight
MRN: 6049894
Date: 06/1918
CC: Back pain
HPI: 77yo F w/ CKD4, dementia, severe
h/o
drug reactions c/w SJS, DVT on AC GIB c/b s/p
IVC filter and eventually resumption of AC,
and severe malnutrition s/p PEG sent from NH
for back pain. Patient recently admitted from
6/9-6/16 foranemia, found to have
leukocytosis for which a CT abdomen was
performed without acute findings. Today,
patient was sent from Workman's circle for
fall 6/18 with request to have orthopedic
evaluation. Per patient, she is complaining
"painful" side"
of pain along the "left of
her body. Unable to point to specific
location. Describes pain mostly in the left
quadrant" her body. Later
"lower of states
that she wants to get on her feet because
they are not doing anything at this time. She
has no other clear complaints at this time,
but denies review of systems.
PMH: As above
PSH: As above
MEDS:
Levothyroxine 25mcg daily
Folic acid 1 tab daily
Ferrous sulfate 325mg daily
Bouknight,Rose_m 6049894-4 DIS-EP MR# 6049894
FILED: WESTCHESTER COUNTY CLERK 02/01/2023 06:17 PM INDEX NO. 64205/2020
NYSCEF DOC. NO. 133 RECEIVED NYSCEF: 02/01/2023
____________________________________________
Print: Tue, 25 Aug 20 0942 | Bouknight,Rose_m 6049894-4 EP
Page 8 of 15 | DIS-EP Age: 79Y Sex: F
Jacobi Medical Center | DOB: 22 Mar 1941 MR# 6049894
| Adm: 19 Jun 18 1417 Dis: 19 Jun 18 2359 |
| Att Phys:
LI,Slu Fal, MD
| Service: Emergency
____________________________________________
Chart Update
Chart Group: All Chart Review Items -- continued
final
Tue, 19Jun 1530 ED RN Progress Note
Note : Patient is alert and oriented to self and
place, sent to ED from nursing home s/p
possible fall while ambulating- patient is
non-ambulatory. Patient breathing unlabored
on room air, skin warm and dry to touch, is
contracted and unable to reposition self in
bed. Patient noted with multiple pressure
ulcers: stage 3 to sacrum, stage 3 to R foot,
stage 2 to medial L ankle, stage 2 to lateral
L ankle, stage 2 to R hip, stage 2 to L knee,
and stage 2 to L foot, all dressings are
clean/dry/intact. Initial MD evaluation
complete, #20 IV placed to R FA, labs
collected and sent. Patient in no acute
distress, ED evaluation in progress, will
monitor.
Kelley Cabrera, RN
Report Date: (19 Jun 18 1614)
final
Tue, 19Jun 1554 Peds/Adult ED Vital Signs (PCT/PCA)
Vital Signs : P: 66 bpm R: 16 T: 97.2 F (36.2 C) 89.45
kg (197 lbs 3 oz) BP: 12O/68 mmHg
Pulse Ox: 99 %
Olare Stephenson, PCA
Report Date: (19 Jun 18 1556)
Bouknight,Rose_m 6049894-4 DIS-EP MR# 6049894
Preview
FILED: WESTCHESTER COUNTY CLERK 02/01/2023 06:17 PM INDEX NO. 64205/2020 NYSCEF DOC. NO. 133 RECEIVED NYSCEF: 02/01/2023 Exhibit D FILED: WESTCHESTER COUNTY CLERK 02/01/2023 06:17 PM INDEX NO. 64205/2020 NYSCEF DOC. NO. 133 RECEIVED NYSCEF: 02/01/2023 ____________________________________________ Print: Tue, 25 Aug 20 O940 | Bouknight,Rose_m 6049894-3 IP Page 200 of 210 | DIS-6D16-1 Age: 79Y Sex: F Jacobi Medical Center | DOB: 22 Mar 1941 MR# 6049894 | Adm: 9 Jun 18 0354 Dis: 16 Jun 18 1000 | | Att Phys: Cha Fong,Colin D., MD | Service: Internal Medicine ...___________________________________________ Chart Update Chart Group: All Chart Review Items -- continued 15Jun 2351 Med Nurse's Note -- contd Fri, Surg (7/O4) air Characteristics : warm Skin Turgor : poor Edema : B/L FEET Description: puffy Wound Care : not applicable Bed : Hill Rom (Versa-Care) Pressure Ulcer Risk : 11 Sensory Perception: slightly limited/responds to verbal commands but cannot always communicate discomfort Moisture: very moist/skin is often but not always moist. change once per shift. Activity: bedfast/confined to bed Mobility: very limited/makes occasional slight changes in body or extremity position Nutrition: Generally eats only about 1/2 of any food offered or receives less than optimum amount of liquid diet or tube feeding. Friction/Shear: problem/requires moderate to maximum assistance in moving. Risk: 6-18 = at risk Pressure UIcer : Location: coccyx/sacrum Stage: stage 4 deep ulcer, tissue/bone exposed Assessment: not a full assessment Dressing: Dressing changed as per protocol. Location: RIGHT HIP Stage: stage 2 red skin, epidermis damaged Assessment: not a full assessment Dressing: Dressing changed as per protocol. Location: RT FOOT Stage: stage 2 red skin, epidermis damaged Assessment: not a full assessment Dressing: Dressing changed as per protocol. Location: LEFT FOOT Stage: stage 2 red skin, epidermis damaged Assessment: not a full assessment Dressing: Dressing changed as per protocol. Turn and Position : Patient turned q 2h. Precautions : assess skin daily. keep skin clear and dry. Patient is incontinent, instituted protocol for perineal care of the incontinent. Use Bouknight,Rose_m 8049894-3 DIS-5D1 MR# 6049894 FILED: WESTCHESTER COUNTY CLERK 02/01/2023 06:17 PM INDEX NO. 64205/2020 NYSCEF DOC. NO. 133 RECEIVED NYSCEF: 02/01/2023 ____________________________________________ Print: Tue, 25 Aug 20 0942 | Bouknight,Rose_m 6049894-4 EP Page 9 of 15 | DIS-EP Age: 79Y Sex: F Jacobi Medical Center | DOB: 22 Mar 1941 MR# 6049894 [ Adm: 19 Jun 18 1417 DIs: 19 Jun 18 2359 | | Att Phys: LI,Slu Fal, MD | Service: Emergency .__________________________________________ Chart Update Chart Group: AII Chart Review Items -- continued final Tue, 19Jun 1733 ED Provider Initial Note Source of History : Patient; Time Pt Seen : Attending : Slu Fai Li, MD Provider : Rostislav Gorbatov, MD Nursing Note Reviewed : Nursing note reviewed. HPI/Exam/Assm't/Plan : Admission Note Name: Rose Bouknight MRN: 6049894 Date: 06/1918 CC: Back pain HPI: 77yo F w/ CKD4, dementia, severe h/o drug reactions c/w SJS, DVT on AC GIB c/b s/p IVC filter and eventually resumption of AC, and severe malnutrition s/p PEG sent from NH for back pain. Patient recently admitted from 6/9-6/16 foranemia, found to have leukocytosis for which a CT abdomen was performed without acute findings. Today, patient was sent from Workman's circle for fall 6/18 with request to have orthopedic evaluation. Per patient, she is complaining "painful" side" of pain along the "left of her body. Unable to point to specific location. Describes pain mostly in the left quadrant" her body. Later "lower of states that she wants to get on her feet because they are not doing anything at this time. She has no other clear complaints at this time, but denies review of systems. PMH: As above PSH: As above MEDS: Levothyroxine 25mcg daily Folic acid 1 tab daily Ferrous sulfate 325mg daily Bouknight,Rose_m 6049894-4 DIS-EP MR# 6049894 FILED: WESTCHESTER COUNTY CLERK 02/01/2023 06:17 PM INDEX NO. 64205/2020 NYSCEF DOC. NO. 133 RECEIVED NYSCEF: 02/01/2023 ____________________________________________ Print: Tue, 25 Aug 20 0942 | Bouknight,Rose_m 6049894-4 EP Page 8 of 15 | DIS-EP Age: 79Y Sex: F Jacobi Medical Center | DOB: 22 Mar 1941 MR# 6049894 | Adm: 19 Jun 18 1417 Dis: 19 Jun 18 2359 | | Att Phys: LI,Slu Fal, MD | Service: Emergency ____________________________________________ Chart Update Chart Group: All Chart Review Items -- continued final Tue, 19Jun 1530 ED RN Progress Note Note : Patient is alert and oriented to self and place, sent to ED from nursing home s/p possible fall while ambulating- patient is non-ambulatory. Patient breathing unlabored on room air, skin warm and dry to touch, is contracted and unable to reposition self in bed. Patient noted with multiple pressure ulcers: stage 3 to sacrum, stage 3 to R foot, stage 2 to medial L ankle, stage 2 to lateral L ankle, stage 2 to R hip, stage 2 to L knee, and stage 2 to L foot, all dressings are clean/dry/intact. Initial MD evaluation complete, #20 IV placed to R FA, labs collected and sent. Patient in no acute distress, ED evaluation in progress, will monitor. Kelley Cabrera, RN Report Date: (19 Jun 18 1614) final Tue, 19Jun 1554 Peds/Adult ED Vital Signs (PCT/PCA) Vital Signs : P: 66 bpm R: 16 T: 97.2 F (36.2 C) 89.45 kg (197 lbs 3 oz) BP: 12O/68 mmHg Pulse Ox: 99 % Olare Stephenson, PCA Report Date: (19 Jun 18 1556) Bouknight,Rose_m 6049894-4 DIS-EP MR# 6049894