Preview
iD: YORK OUN PK 06 DM INDEX NO. 451549/2023
NYSCEF BOC. NO. 495 RECEIVED NYSCEF: 06/28/2023
PETTIGREW EXHIBIT 60
= i IDI INDEX NO. 451549/20230;
NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023
MAR Report [NOT DOCUMENTED]
Holliswood - MAR Report [NOT DOCUMENTED]
Date Name Medication
ie ape nomeey stom saae neem
ee
05/29/2020 00:00
th tran SSS
Give 2 tablet by mouth every 6 hours for Fever/ Presumed COVID for 14 Days - Acetaminophen
Tablet 325 MGGive 2 tablet by mouth every 6 hours for Fever/ Presumed COVID for 14 Days
05/29/2020 06:00 Instill 1 drop in left eye two times a day for glaucoma - Dorzolamide HCI-Timolol Mal Solution
22.3-6.8 MG/MLInstill 1 drop in left eye two times a day for glaucoma
05/29/2020 06:00 Give 1 tablet by mouth one time a day for hypothyroidism - Levothyroxine Sodium Tablet 75
MCGGive 1 tablet by mouth one time a day for hypothyroidism
05/29/2020 06:00 Give 2 tablet by mouth every 6 hours for Fever/ Presumed COVID for 14 Days - Acetaminophen
Tablet 325 MGGive 2 tablet by mouth every 6 hours for Fever/ Presumed COVID for 14 Days
05/29/2020 06:30 Instill 1 drop in left eye three times a day for glaucoma - Brimonidine Tartrate Solution 0.2
%lnstill 1 drop in left eye three times a day for glaucoma
05/29/2020 06:30 Instill 1 drop in both eyes two times a day for glaucoma - Dorzolamide HCI Solution 2 %lnstill 1
drop in both eyes two times a day for glaucoma
05/29/2020 06:30 Give 1 tablet by mouth one timea day for Hypothyroidism - Levothyroxine Sodium Tablet 25
MCGGive 1 tablet by mouth one time a day for Hypothyroidism
05/29/2020 06:30 Give 1 tablet by mouth one time a day for GERD - Esomeprazole Magnesium Tablet Delayed
Release 20 MGGive 1 tablet by mouth one time a day for GERD
05/29/2020 07:00 every day shift for shortness of breath - RN Respiratory PRE Assessment: Check for breath
sounds, 02 sat, sputum, sputum color, PR and RRevery day shift for shortness of breath
05/29/2020 07:00 every shift - MAY CRUSH MEDS AND PUT IN THE FOOD OR APPLESAUCE IF NOT
CONTRAINDICATED every shift
0121209
(FILED: NEW YORK COUNTY CLERK 0672872023 O05 og0PM. INDEX NO. 451549/20230;
NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023
MAR Report [NOT DOCUMENTED]
05/29/2020 07:00 Give 1 tablet by mouth every day and evening shift for PAIN for 15 Days Give 30 mn prior
wound care - Percocet Tablet 5-325 MG (oxyCODONE-Acetaminophen)Give 1 tablet by mouth
every day and evening shift for PAIN for 15 Days Give 30 mn prior wound care
05/29/2020 07:00 every shift - RN Respiratory POST Assessment: Check for breath sounds, 02 sat, sputum, sputum
color, PR and RRevery shift
05/29/2020 07:00 every shift - RN Respiratory PRE Assessment: Check for breath sounds, 02 sat, sputum, sputum
color, PR and RRevery shift
05/29/2020 07:45 one time a day for copd - rm respiratory: pre duoneb administration assessment: check lung
sounds, 02 sat%, pulse and resp rate, sputum and sputum colorone time a day for copd
05/29/2020 08:00 Give 1 tablet by mouth two times a day for anxiety - BusPIRone HCI Tablet 10 MGGive 1 tablet
by mouth two times a day for anxiety
05/29/2020 08:00 every 12 hours - RN Respiratory POST Assessment: Check for breath sounds, 02 sat, sputum,
sputum color, PR and RRevery 12 hours
05/29/2020 08:00 every 12 hours - RN Respiratory PRE Assessment: Check for breath sounds, 02 sat, sputum,
sputum color, PR and RRevery 12 hours
05/29/2020 08:30 ‘one time a day for copd - m respiratory: post duoneb administration: check lung sounds,02 sat
%, pulse and resp rateone time a day for copd
05/29/2020 10:00 Give 1 tablet by mouth one time a day for depression - CeleXA Tablet 10 MG (Citalopram
Hydrobromide)Give 1 tablet by mouth one time a day for depression
05/29/2020 10:00 Give 1 tablet by mouth one time a day for HTN - Metoprolol Succinate ER Tablet Extended
Release 24 Hour 25 MGGive 1 tablet by mouth one time a day for HTN
05/29/2020 10:00 ‘one time a day for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D =
Diminished, W = Wheezes, O = Other - Complete VS with SP02 &Lung Sounds Daily
‘one time a day for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D =
Diminished, W = Wheezes, O = Other
=
05/29/2020 10:00 one time a day for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D =
Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms,
document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s) check Daily
‘one time a day for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D =
Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms,
document in PN and notify MD
0121210
=: £ 1D INDEX NO. 451549/20230;
NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023
MAR Report [NOT DOCUMENTED]
05/29/2020 10:00 two times a day 80z PO - Glucerna Shaketwo times a day 80z PO
05/29/2020 10:00 three times a day 80z PO - Suplenathree times a day 80z PO
05/29/2020 14:00 ‘one time a day 80z PO - Ensure Plusone time a day 80z PO
05/29/2020 14:00 three times a day 80z PO - Suplenathree times a day 80z PO
05/29/2020 15:00 every shift for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D =
Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms,
document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s) check Q
Shift every shift for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D =
Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms,
document in PN and notify MD
05/29/2020 15:00 every shift for Respiratory Documentation for 14 Days Lung Sounds Key: C = Clear, V =
Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other
symptoms, document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s)
check Q Shift every shift for Respiratory Documentation for 14 Days Lung Sounds Key: C = Clear,
V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any
other symptoms, document in PN and notify MD
05/29/2020 15:00 every shift for Readmission for 30 Days - Vital signs Q shift x 30 daysevery shift for Readmission
for 30 Days
05/29/2020 15:00 every shift for Respiratory Documentation for 14 Days Lung Sounds Key: C = Clear, V =
Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other
symptoms, document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s)
check Q Shift x 14 days every shift for Respiratory Documentation for 14 Days Lung Sounds Key:
C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or
No) If any other symptoms, document in PN and notify MD
05/29/2020 15:00 every shift for 7 Days - Vital signs Q shift times 7 daysevery shift for 7 Days
0121211
(FILED: NEW YORK COUNTY CLERK 0672872023 05 23goRM. INDEX NO. 451549/20230;
NYSCEF BOC. NO. 495 RECEIVED NYSCEF 06/28/2023
MAR Report [NOT DOCUMENTED]
05/29/2020 15:00 every shift for Respiratory Documentation until 06/06/2020 14:59 Lung Sounds Key: C = Clear, V
= Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any
other symptoms, document in PN and notify MD - Complete VS with SP02, Lung Sounds,
Symptom(s) check Q Shift x 14 days every shift for Respiratory Documentation until 06/06/2020
14:59 Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other
Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD
05/29/2020 15:00 every shift for Monitoring for 14 Days Lung Sounds Key: C = Clear, V = Vesicular, D =
Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms,
document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom({s) check Q
Shift x 14 days every shift for Monitoring for 14 Days Lung Sounds Key: C = Clear, V = Vesicular,
D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other
symptoms, document in PN and notify MD
05/29/2020 15:00 every shift for Monitoring Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W =
Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and
notify MD - Complete VS with SPO2, Lung Sounds, Symptom(s) check Q Shift every shift for
Monitoring Lung Sounds Key:C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O =
Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD
05/29/2020 15:00 every shift - Monitor urinary output QSHIFTevery shift
05/29/2020 15:00 every shift for New admission/Monitoring for 30 Days - Vital Signs Q Shift time 30 daysevery
shift for New admission/Monitoring for 30 Days
05/29/2020 16:00 two times a day for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D =
Diminished, W = Wheezes, O = Other - Complete VS with SP02 &Lung Sounds BID
two times a day for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D =
Diminished, W = Wheezes, O = Other
ay
05/29/2020 16:30
in
before meals and at bedtime for DM - FS before meals and at bedtime Call MD if above 350 or
below 70 before meals and at bedtime for DM
05/29/2020 18:00 Give 12.5 mg by mouth two times a day for HTN - Metoprolol Tartrate TabletGive 12.5 mg by
mouth two times a day for HTN
0121212
(FILED: NEW YORK COUNTY CLERK 0672872023 05 23goRM. INDEX NO. 451549/202301
NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023
MAR Report [NOT DOCUMENTED]
05/29/2020 20:00 every 12 hours - RN Respiratory POST Assessment: Check for breath sounds, 02 sat, sputum,
sputum color, PR and RRevery 12 hours
05/29/2020 20:00 every 12 hours - RN Respiratory PRE Assessment: Check for breath sounds, 02 sat, sputum,
sputum color, PR and RRevery 12 hours
Bee
= pee
—_
05/29/2020 21:00 Give 1 tablet by mouth at bedtime for Depression - Mirtazapine Tablet 15 MGGive 1 tablet by
_ Mouth at bedtime for Depression
05/29/2020 21:00 "before meals and at bedtime for DM - FS before meals and at bedtime Call MD if above 350 or
below 70 before meals and at bedtime for DM
sanion
05/29/2020 23:00
Sisson mera
Apply to right dorsal foot topically every night shift for wound care post cleanse with saline
wrap with gauze - Medihoney Wound/8um Dressing Paste (Wound Dressings)Apply to right
dorsal foot topically every night shift for wound care post cleanse with saline wrap with gauze
05/29/2020 23:00 es every shift for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D =
Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms,
document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s) check Q
Shift every shift for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D =
Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms,
document in PN and notify MD
0121213
(FILED: NEW YORK COUNTY CLERK 0672872023 O05 Fog0RM. INDEX NO. 451549/20230;
NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023
MAR Report [NOT DOCUMENTED]
05/29/2020 23:00 every shift - Fluid Restriction 1200cc/day: Dietary will provide 720cc/day. Nursing will provide
480cc/day. Amount per shift: 7-3 shift = 240cc, 3-11 shift = 120cc, 11-7 shift = 120ccevery shift
05/29/2020 23:00 every shift for Respiratory Documentation for 14 Days Lung Sounds Key: C = Clear, V =
Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other
symptoms, document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s)
check Q Shift every shift for Respiratory Documentation for 14 Days Lung Sounds Key: C = Clear,
V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any
other symptoms, document in PN and notify MD
05/29/2020 23:00 every shift for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D =
Diminished, W = Wheezes, O = Other - Complete VS with SP02 &Lung Sounds Q4
hrs every shift for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D =
Diminished, W = Wheezes, O = Other
05/29/2020 23:00 Apply to Bilateral forearms topically every day and night shift for Redness - Bacitracin Ointment
500 UNIT/GMApply to Bilateral forearms topically every day and night shift for Redness
ae
05/29/2020 23:00 every shift - 1000cc Fluid Restriction: Dietary to provide 720cc/dayand Nursing to provide
280cc/day. Amount per shift: 7-3 shift = 120cc, 3-11 shift = 120cc, 11-7 shift = 40cc every shift
05/29/2020 23:00 every shift for Readmission for 30 Days - Vital Signs Q shift time 30 daysevery shift for
Readmission for 30 Days
05/29/2020 23:00 every shift for Respiratory Documentation for 14 Days Lung Sounds Key: C = Clear, V =
Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other
symptoms, document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s)
check Q Shift x 14 days every shift for Respiratory Documentation for 14 Days Lung Sounds Key:
C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or
No) If any other symptoms, document in PN and notify MD
05/29/2020 23:00 Apply to left lateral heel topically every night shift for wound care post cleanse with saline- wrap
with gauge - Santyl Ointment 250 UNIT/GM (Collagenase)Apply to left lateral heel topically
every night shift for wound care post cleanse with saline- wrap with gauge
0121214
= i IDI INDEX NO. 451549/20230;
NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023
MAR Report [NOT DOCUMENTED]
05/29/2020 23:00 every shift for Monitoring for 14 Days Lung Sounds Key: C = Clear, V = Vesicular, D =
Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms,
document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s) check Q
Shift x 14 days every shift for Monitoring for 14 Days Lung Sounds Key: C = Clear, V = Vesicular,
D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other
symptoms, document in PN and notify MD
05/29/2020 23:00 every shift - May crush medications if not contraindicated every shift
sowie WN
05/29/2020 23:00
rine
every shift G- tube- flush tube with 30 ml of water before and after medications and 30
ml's when starting and stopping tube feeding. - Enteral Feed Orderevery shift G- tube-
flush tube with 30 m! of water before and after medications and 30 ml's when starting
and stopping tube feeding.
05/29/2020 23:00 every shift for Fall risk - FALL PRECAUTIONSevery shift for Fall risk
<8
05/29/2020 23:00
NL asmmciinn
every shift for gastrostomy status - Keep head of bed elevated 30-40 degrees when
feeding.every shift for gastrostomy status
05/29/2020 23:00 a every shift for peg tube - Check for placement before feeding and medication pass.every shift
for peg tube
05/29/2020 23:00 a every shift for New admission for 30 Days - Vital signs Q shift times 30 daysevery shift for New
admission for 30 Days
05/29/2020 23:00 es every shift for COPD - Keep of Head of Bed elevated to prevent shortness of breath when lying
flat in the bed. every shift for COPD
05/29/2020 23:00 every shift for New admission for 30 Days - Vitals Signs Q shift time 30 daysevery shift for New
admission for 30 Days
05/29/2020 23:00 every shift for New admission for 30 Days - Vitals signs Q shift x30 daysevery shift for New
admission for 30 Days
0121215
=: £ 1D INDEX NO. 451549/20230;
NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023
MAR Report [NOT DOCUMENTED]
05/29/2020 23:00 Give 1 tablet by mouth every night shift for Hypothyroidism - Synthroid Tablet 75 MCG
(Levothyroxine Sodium)Give 1 tablet by mouth every night shift for Hypothyroidism
05/29/2020 23:00 every shift - Encourage PO fluidsevery shift
05/29/2020 23:00 every shift for New admission - Vitals Signs Q shift x 30 daysevery shift for New admission
05/29/2020 23:00 every shift for 7 Days - Vital signs Q shift times 7 daysevery shift for 7 Days
05/29/2020 23:00 every shift for Resident is a peg tube feeder - Check for placement before each feeding and
medication pass.every shift for Resident is a peg tube feeder
05/29/2020 23:00 every night shift - Check wanderguard for functioningevery night shift
05/29/2020 23:00 every shift - Check Wanderguard placement every shift
05/29/2020 23:00 Give 2 tablet by mouth every night shift for Pain give 30 mn prior dressing change -
Acetaminophen Tablet 325 MGGive 2 tablet by mouth every night shift for Pain give 30 mn prior
dressing change
05/29/2020 23:00 Apply to left bunion topically every night shift for wound care - Skin Prep Spray Miscellaneous
(Ostomy Supplies)Apply to left bunion topically every night shift for wound care
05/29/2020 23:00 Apply to right ankle topically every night shift for wound care post cleanse with saline , wrap
with gauze - Skin Prep Wipes Miscellaneous (Ostomy Supplies)Apply to right ankle topically
every night shift for wound care post cleanse with saline , wrap with gauze
05/29/2020 23:00 Apply to RT Foot/1st 2nd 3rd toes topically every night shift for wound care post cleanse with
saline wrap with gauze - Skin Prep Wipes Miscellaneous (Ostomy Supplies)Apply to RT Foot/1st
2nd 3rd toes topically every night shift for wound care post cleanse with saline wrap with gauze
05/29/2020 23:00 every shift for New admission for 30 Days - Vital Signs Q Shift Time 30 daysevery shift for New
admission for 30 Days
05/29/2020 23:00 Give 2 tablet by mouth every night shift for Pain give 2 hrs prior wound care - Tylenol Tablet 325
MG (Acetaminophen)Give 2 tablet by mouth every night shift for Pain give 2 hrs prior wound
care
0121216
(FILED: NEW YORK COUNTY CLERK 0672872023 O05 og0PM. INDEX NO. 451549/20230;
NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023
MAR Report [NOT DOCUMENTED]
05/29/2020 23:00 every shift for Readmission for 30 Days - Vitals Signs Q shift x 30 daysevery shift for
Readmission for 30 Days
05/29/2020 23:00 every shift for Monitoring Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W =
Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and
notify MD - Complete VS with SP02, Lung Sounds, Symptom(s) check Q Shift every shift for
Monitoring Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O =
Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD
05/29/2020 23:00 every shift for Risk for elopement - Check wanderguard for functioning every shift for Risk for
elopement
05/29/2020 23:00 every shift for Risk for elopement - Check wanderguard placement every shift for Risk for
elopement
05/29/2020 23:00 every shift for Left Mastectomy - DO NOT TAKE BLOOD PRESSURE ON THE LEFT ARMevery shift
for Left Mastectomy
05/29/2020 23:00 every shift G- tube- flush tube with 30 ml of water before and after medications and 30-60
ml's when starting and stopping tube feeding. - Enteral Feed Orderevery shift G- tube-
flush tube with 30 ml of water before and after medications and 30-60 ml's when starting
and stopping tube feeding
05/29/2020 23:00 every shift - Fluid Restriction 1000mi/day: Dietary will provide 720mI/day. Nursing will provide
280mI/day. Amount per shift: 7-3 shift = 120ml, 3-11 shift = 120ml, 11-7 shift = 40mlevery shift
05/29/2020 23:00 every shift - Keep of Head of Bed elevated to prevent shortness of breath when lying flat in the
bed.every shift
05/29/2020 23:00 Apply to left and right foot topically every evening and night shift for Tinea pedis for 21 Days
clean with soap and water, pat dry, and apply cream - Tolnaftate Cream 1 %Apply to left and
right foot topically every evening and night shift for Tinea pedis for 21 Days clean with soap and
water, pat dry, and apply cream
05/29/2020 23:00 Apply to right heel topically every day and night shift for wound care clean with NS, pat dry,
apply Santyl oint, and dry dressing - Santyl Ointment 250 UNIT/GM (Collagenase)Apply to right
heel topically every day and night shift for wound care clean with NS, pat dry, apply Santyl oint,
and dry dressing
05/29/2020 23:00 Give 2 tablet by mouth every night shift for pain 30 MINUTES PRIOR TO DRESSING CHANGE -
Tylenol Tablet 325 MG (Acetaminophen)Give 2 tablet by mouth every night shift for pain 30
MINUTES PRIOR TO DRESSING CHANGE
0121217
=: £ 1D INDEX NO. 451549/20230;
NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023
MAR Report [NOT DOCUMENTED]
05/29/2020 23:00 every shift for Hypoxia - Give 2L of 02 via Nasal cannula to maintain SPO2 >=93%every
shift for Hypoxia
05/29/2020 23:00 Apply to left dorsal foot topically every day and night shift for wound care post cleanse with
saline, wrap with gauze - Medihoney Ca Alginate 4"xS" Pad (Wound
Dressings)Apply to left dorsal foot topically every day and night shift for wound care post
cleanse with saline, wrap with gauze
05/29/2020 23:00 Apply to Left lower leg topically every day and night shift for wound care POST Cleanse with
saline wrap with gauze - Medihoney Ca Alginate 4"x5", Pad (Wound
Dressings)Apply to Left lower leg topically every day and night shift for wound care POST
Cleanse with saline wrap with gauze
05/29/2020 23:00 every shift for New admission for 30 Days - Vital signs @ shift time 30 daysevery shift for New
admission for 30 Days
05/29/2020 23:00 every shift - Give 240cc Nectar Thick water PO for hydration.every shift
05/29/2020 23:00 every shift - 100m! fluid restriction: Dietary to provide 720ml/day and Nursing to provide 280
ml/day. Amount per shift: 7-3 shift = 120ml, 3-11 shift = 120ml, 11-7 shift = 40mlevery shift
05/29/2020 23:00 every shift for COPD - Keep of Head of Bed elevated to prevent shortness of breath when lying
flat in the bed.every shift for COPD
05/29/2020 23:00 Give 2 tablet by mouth every shift for Pain give 30 mn prior dressing change - Tylenol Tablet
325 MG (Acetaminophen)Give 2 tablet by mouth every shift for Pain give 30 mn prior dressing
change
05/29/2020 23:00 every shift for New admission for 30 Days - Vital signs Q shift x30 daysevery shift for New
admission for 30 Days
05/29/2020 23:00 every shift - Fluid Restriction 1500cc/day: Dietary will provide 1080cc/day. Nursing will provide
420cc/day. Amount per shift: 7-3 shift = 200cc, 3-11 shift = 120cc, 11-7 shift = 100ccevery shift
05/29/2020 23:00 every shift for monitoring for 7 Days - Vital signs Q shift times 7 daysevery shift for monitoring
for 7 Days
05/29/2020 23:00 Apply to right heel topically every night shift for wound care Post cleanse with saline wrap with
gauze - Skin Prep Wipes Miscellaneous (Ostomy Supplies)Apply to right heel topically every
night shift for wound care Post cleanse with saline wrap with gauze
10
0121218
=: £ 1D INDEX NO. 451549/20230;
NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023
MAR Report [NOT DOCUMENTED]
05/29/2020 23:00 every shift for Pain evaluation - Pain Evaluation Q shiftevery shift for Pain evaluation
05/29/2020 23:00 every shift - MAY CRUSH MEDS IF NOT CONTRAINDICATED AND PUT IN COFFEE OR
FOODevery shift
05/29/2020 23:00 every night shift for Ascites - Abdominal girth to be measured daily before breakfast. every
night shift for Ascites
05/29/2020 23:00 every shift for SOB - Oxygen 2 Liters via nasal cannulaevery shift for SOB
05/29/2020 23:00 Use 75 ml/hr intravenously every shift for Poor PO intake for 3 Days - Dextrose-NaCl Solution 5-
0.45 % (Dextrose-Sodium Chloride)Use 75 ml/hr intravenously every shift for Poor PO intake for
3 Days
05/29/2020 23:00 every shift for MED ADMIN - MAY CRUSH MEDICATION IF NOT CONTRAINDICATED and mix in
foodevery shift for MED ADMIN
05/29/2020 23:00 every shift - Check Wanderguard Placementevery shift
05/29/2020 23:00 every shift 480cc PO - Provide 480cc (2 cups) PO Honey Thickened Water every shift.every shift
480cc PO
05/29/2020 23:00 every shift Flush 250cc every shift and 30 cc AC/PC every feeding - Enteral Feed Orderevery shift
Flush 250cc every shift and 30 cc AC/PC every feeding
05/29/2020 23:00 every shift - May crush meds if not contraindicated - May mix with Milk every shift
05/29/2020 23:00 Apply to mid back topically every shift for back wound post cleanse with saline, cover with DPD
- Medihoney Ca Alginate 4 (Wound Dressings)Apply to mid back topically every shift for back
wound post cleanse with saline, cover with DPD
05/29/2020 23:00 every shift - RN Respiratory POST Assessment: Check for breath sounds, 02 sat, sputum, sputum
color, PR and RRevery shift
05/29/2020 23:00 every shift - RN Respiratory PRE Assessment: Check for breath sounds, 02 sat, sputum, sputum
color, PR and RRevery shift
05/29/2020 23:00 every shift for For elopement potential. - Check wanderguard for placement q shift.every shift
for For elopement potential.
11
0121219
=: £ 1D INDEX NO. 451549/20230;
NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023
MAR Report [NOT DOCUMENTED]
05/29/2020 23:00 every shift for Potential for elopement. - Wanderguard left lower extremity.every shift for
Potential for elopement
05/29/2020 23:00 every shift for Monitoring - Finger stick every shift for Monitoring
05/29/2020 23:00 every shift for Readmission for 30 Days - Vital signs Q shift x30 daysevery shift for Readmission
for 30 Days
05/29/2020 23:00 every shift for edema - do not encourage po fluid .every shift for edema
12
0121220
Preview
iD: YORK OUN PK 06 DM INDEX NO. 451549/2023 NYSCEF BOC. NO. 495 RECEIVED NYSCEF: 06/28/2023 PETTIGREW EXHIBIT 60 = i IDI INDEX NO. 451549/20230; NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023 MAR Report [NOT DOCUMENTED] Holliswood - MAR Report [NOT DOCUMENTED] Date Name Medication ie ape nomeey stom saae neem ee 05/29/2020 00:00 th tran SSS Give 2 tablet by mouth every 6 hours for Fever/ Presumed COVID for 14 Days - Acetaminophen Tablet 325 MGGive 2 tablet by mouth every 6 hours for Fever/ Presumed COVID for 14 Days 05/29/2020 06:00 Instill 1 drop in left eye two times a day for glaucoma - Dorzolamide HCI-Timolol Mal Solution 22.3-6.8 MG/MLInstill 1 drop in left eye two times a day for glaucoma 05/29/2020 06:00 Give 1 tablet by mouth one time a day for hypothyroidism - Levothyroxine Sodium Tablet 75 MCGGive 1 tablet by mouth one time a day for hypothyroidism 05/29/2020 06:00 Give 2 tablet by mouth every 6 hours for Fever/ Presumed COVID for 14 Days - Acetaminophen Tablet 325 MGGive 2 tablet by mouth every 6 hours for Fever/ Presumed COVID for 14 Days 05/29/2020 06:30 Instill 1 drop in left eye three times a day for glaucoma - Brimonidine Tartrate Solution 0.2 %lnstill 1 drop in left eye three times a day for glaucoma 05/29/2020 06:30 Instill 1 drop in both eyes two times a day for glaucoma - Dorzolamide HCI Solution 2 %lnstill 1 drop in both eyes two times a day for glaucoma 05/29/2020 06:30 Give 1 tablet by mouth one timea day for Hypothyroidism - Levothyroxine Sodium Tablet 25 MCGGive 1 tablet by mouth one time a day for Hypothyroidism 05/29/2020 06:30 Give 1 tablet by mouth one time a day for GERD - Esomeprazole Magnesium Tablet Delayed Release 20 MGGive 1 tablet by mouth one time a day for GERD 05/29/2020 07:00 every day shift for shortness of breath - RN Respiratory PRE Assessment: Check for breath sounds, 02 sat, sputum, sputum color, PR and RRevery day shift for shortness of breath 05/29/2020 07:00 every shift - MAY CRUSH MEDS AND PUT IN THE FOOD OR APPLESAUCE IF NOT CONTRAINDICATED every shift 0121209 (FILED: NEW YORK COUNTY CLERK 0672872023 O05 og0PM. INDEX NO. 451549/20230; NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023 MAR Report [NOT DOCUMENTED] 05/29/2020 07:00 Give 1 tablet by mouth every day and evening shift for PAIN for 15 Days Give 30 mn prior wound care - Percocet Tablet 5-325 MG (oxyCODONE-Acetaminophen)Give 1 tablet by mouth every day and evening shift for PAIN for 15 Days Give 30 mn prior wound care 05/29/2020 07:00 every shift - RN Respiratory POST Assessment: Check for breath sounds, 02 sat, sputum, sputum color, PR and RRevery shift 05/29/2020 07:00 every shift - RN Respiratory PRE Assessment: Check for breath sounds, 02 sat, sputum, sputum color, PR and RRevery shift 05/29/2020 07:45 one time a day for copd - rm respiratory: pre duoneb administration assessment: check lung sounds, 02 sat%, pulse and resp rate, sputum and sputum colorone time a day for copd 05/29/2020 08:00 Give 1 tablet by mouth two times a day for anxiety - BusPIRone HCI Tablet 10 MGGive 1 tablet by mouth two times a day for anxiety 05/29/2020 08:00 every 12 hours - RN Respiratory POST Assessment: Check for breath sounds, 02 sat, sputum, sputum color, PR and RRevery 12 hours 05/29/2020 08:00 every 12 hours - RN Respiratory PRE Assessment: Check for breath sounds, 02 sat, sputum, sputum color, PR and RRevery 12 hours 05/29/2020 08:30 ‘one time a day for copd - m respiratory: post duoneb administration: check lung sounds,02 sat %, pulse and resp rateone time a day for copd 05/29/2020 10:00 Give 1 tablet by mouth one time a day for depression - CeleXA Tablet 10 MG (Citalopram Hydrobromide)Give 1 tablet by mouth one time a day for depression 05/29/2020 10:00 Give 1 tablet by mouth one time a day for HTN - Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MGGive 1 tablet by mouth one time a day for HTN 05/29/2020 10:00 ‘one time a day for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other - Complete VS with SP02 &Lung Sounds Daily ‘one time a day for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other = 05/29/2020 10:00 one time a day for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s) check Daily ‘one time a day for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD 0121210 =: £ 1D INDEX NO. 451549/20230; NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023 MAR Report [NOT DOCUMENTED] 05/29/2020 10:00 two times a day 80z PO - Glucerna Shaketwo times a day 80z PO 05/29/2020 10:00 three times a day 80z PO - Suplenathree times a day 80z PO 05/29/2020 14:00 ‘one time a day 80z PO - Ensure Plusone time a day 80z PO 05/29/2020 14:00 three times a day 80z PO - Suplenathree times a day 80z PO 05/29/2020 15:00 every shift for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s) check Q Shift every shift for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD 05/29/2020 15:00 every shift for Respiratory Documentation for 14 Days Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s) check Q Shift every shift for Respiratory Documentation for 14 Days Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD 05/29/2020 15:00 every shift for Readmission for 30 Days - Vital signs Q shift x 30 daysevery shift for Readmission for 30 Days 05/29/2020 15:00 every shift for Respiratory Documentation for 14 Days Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s) check Q Shift x 14 days every shift for Respiratory Documentation for 14 Days Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD 05/29/2020 15:00 every shift for 7 Days - Vital signs Q shift times 7 daysevery shift for 7 Days 0121211 (FILED: NEW YORK COUNTY CLERK 0672872023 05 23goRM. INDEX NO. 451549/20230; NYSCEF BOC. NO. 495 RECEIVED NYSCEF 06/28/2023 MAR Report [NOT DOCUMENTED] 05/29/2020 15:00 every shift for Respiratory Documentation until 06/06/2020 14:59 Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s) check Q Shift x 14 days every shift for Respiratory Documentation until 06/06/2020 14:59 Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD 05/29/2020 15:00 every shift for Monitoring for 14 Days Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom({s) check Q Shift x 14 days every shift for Monitoring for 14 Days Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD 05/29/2020 15:00 every shift for Monitoring Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD - Complete VS with SPO2, Lung Sounds, Symptom(s) check Q Shift every shift for Monitoring Lung Sounds Key:C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD 05/29/2020 15:00 every shift - Monitor urinary output QSHIFTevery shift 05/29/2020 15:00 every shift for New admission/Monitoring for 30 Days - Vital Signs Q Shift time 30 daysevery shift for New admission/Monitoring for 30 Days 05/29/2020 16:00 two times a day for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other - Complete VS with SP02 &Lung Sounds BID two times a day for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other ay 05/29/2020 16:30 in before meals and at bedtime for DM - FS before meals and at bedtime Call MD if above 350 or below 70 before meals and at bedtime for DM 05/29/2020 18:00 Give 12.5 mg by mouth two times a day for HTN - Metoprolol Tartrate TabletGive 12.5 mg by mouth two times a day for HTN 0121212 (FILED: NEW YORK COUNTY CLERK 0672872023 05 23goRM. INDEX NO. 451549/202301 NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023 MAR Report [NOT DOCUMENTED] 05/29/2020 20:00 every 12 hours - RN Respiratory POST Assessment: Check for breath sounds, 02 sat, sputum, sputum color, PR and RRevery 12 hours 05/29/2020 20:00 every 12 hours - RN Respiratory PRE Assessment: Check for breath sounds, 02 sat, sputum, sputum color, PR and RRevery 12 hours Bee = pee —_ 05/29/2020 21:00 Give 1 tablet by mouth at bedtime for Depression - Mirtazapine Tablet 15 MGGive 1 tablet by _ Mouth at bedtime for Depression 05/29/2020 21:00 "before meals and at bedtime for DM - FS before meals and at bedtime Call MD if above 350 or below 70 before meals and at bedtime for DM sanion 05/29/2020 23:00 Sisson mera Apply to right dorsal foot topically every night shift for wound care post cleanse with saline wrap with gauze - Medihoney Wound/8um Dressing Paste (Wound Dressings)Apply to right dorsal foot topically every night shift for wound care post cleanse with saline wrap with gauze 05/29/2020 23:00 es every shift for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s) check Q Shift every shift for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD 0121213 (FILED: NEW YORK COUNTY CLERK 0672872023 O05 Fog0RM. INDEX NO. 451549/20230; NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023 MAR Report [NOT DOCUMENTED] 05/29/2020 23:00 every shift - Fluid Restriction 1200cc/day: Dietary will provide 720cc/day. Nursing will provide 480cc/day. Amount per shift: 7-3 shift = 240cc, 3-11 shift = 120cc, 11-7 shift = 120ccevery shift 05/29/2020 23:00 every shift for Respiratory Documentation for 14 Days Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s) check Q Shift every shift for Respiratory Documentation for 14 Days Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD 05/29/2020 23:00 every shift for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other - Complete VS with SP02 &Lung Sounds Q4 hrs every shift for Respiratory Documentation Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other 05/29/2020 23:00 Apply to Bilateral forearms topically every day and night shift for Redness - Bacitracin Ointment 500 UNIT/GMApply to Bilateral forearms topically every day and night shift for Redness ae 05/29/2020 23:00 every shift - 1000cc Fluid Restriction: Dietary to provide 720cc/dayand Nursing to provide 280cc/day. Amount per shift: 7-3 shift = 120cc, 3-11 shift = 120cc, 11-7 shift = 40cc every shift 05/29/2020 23:00 every shift for Readmission for 30 Days - Vital Signs Q shift time 30 daysevery shift for Readmission for 30 Days 05/29/2020 23:00 every shift for Respiratory Documentation for 14 Days Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s) check Q Shift x 14 days every shift for Respiratory Documentation for 14 Days Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD 05/29/2020 23:00 Apply to left lateral heel topically every night shift for wound care post cleanse with saline- wrap with gauge - Santyl Ointment 250 UNIT/GM (Collagenase)Apply to left lateral heel topically every night shift for wound care post cleanse with saline- wrap with gauge 0121214 = i IDI INDEX NO. 451549/20230; NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023 MAR Report [NOT DOCUMENTED] 05/29/2020 23:00 every shift for Monitoring for 14 Days Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s) check Q Shift x 14 days every shift for Monitoring for 14 Days Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD 05/29/2020 23:00 every shift - May crush medications if not contraindicated every shift sowie WN 05/29/2020 23:00 rine every shift G- tube- flush tube with 30 ml of water before and after medications and 30 ml's when starting and stopping tube feeding. - Enteral Feed Orderevery shift G- tube- flush tube with 30 m! of water before and after medications and 30 ml's when starting and stopping tube feeding. 05/29/2020 23:00 every shift for Fall risk - FALL PRECAUTIONSevery shift for Fall risk <8 05/29/2020 23:00 NL asmmciinn every shift for gastrostomy status - Keep head of bed elevated 30-40 degrees when feeding.every shift for gastrostomy status 05/29/2020 23:00 a every shift for peg tube - Check for placement before feeding and medication pass.every shift for peg tube 05/29/2020 23:00 a every shift for New admission for 30 Days - Vital signs Q shift times 30 daysevery shift for New admission for 30 Days 05/29/2020 23:00 es every shift for COPD - Keep of Head of Bed elevated to prevent shortness of breath when lying flat in the bed. every shift for COPD 05/29/2020 23:00 every shift for New admission for 30 Days - Vitals Signs Q shift time 30 daysevery shift for New admission for 30 Days 05/29/2020 23:00 every shift for New admission for 30 Days - Vitals signs Q shift x30 daysevery shift for New admission for 30 Days 0121215 =: £ 1D INDEX NO. 451549/20230; NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023 MAR Report [NOT DOCUMENTED] 05/29/2020 23:00 Give 1 tablet by mouth every night shift for Hypothyroidism - Synthroid Tablet 75 MCG (Levothyroxine Sodium)Give 1 tablet by mouth every night shift for Hypothyroidism 05/29/2020 23:00 every shift - Encourage PO fluidsevery shift 05/29/2020 23:00 every shift for New admission - Vitals Signs Q shift x 30 daysevery shift for New admission 05/29/2020 23:00 every shift for 7 Days - Vital signs Q shift times 7 daysevery shift for 7 Days 05/29/2020 23:00 every shift for Resident is a peg tube feeder - Check for placement before each feeding and medication pass.every shift for Resident is a peg tube feeder 05/29/2020 23:00 every night shift - Check wanderguard for functioningevery night shift 05/29/2020 23:00 every shift - Check Wanderguard placement every shift 05/29/2020 23:00 Give 2 tablet by mouth every night shift for Pain give 30 mn prior dressing change - Acetaminophen Tablet 325 MGGive 2 tablet by mouth every night shift for Pain give 30 mn prior dressing change 05/29/2020 23:00 Apply to left bunion topically every night shift for wound care - Skin Prep Spray Miscellaneous (Ostomy Supplies)Apply to left bunion topically every night shift for wound care 05/29/2020 23:00 Apply to right ankle topically every night shift for wound care post cleanse with saline , wrap with gauze - Skin Prep Wipes Miscellaneous (Ostomy Supplies)Apply to right ankle topically every night shift for wound care post cleanse with saline , wrap with gauze 05/29/2020 23:00 Apply to RT Foot/1st 2nd 3rd toes topically every night shift for wound care post cleanse with saline wrap with gauze - Skin Prep Wipes Miscellaneous (Ostomy Supplies)Apply to RT Foot/1st 2nd 3rd toes topically every night shift for wound care post cleanse with saline wrap with gauze 05/29/2020 23:00 every shift for New admission for 30 Days - Vital Signs Q Shift Time 30 daysevery shift for New admission for 30 Days 05/29/2020 23:00 Give 2 tablet by mouth every night shift for Pain give 2 hrs prior wound care - Tylenol Tablet 325 MG (Acetaminophen)Give 2 tablet by mouth every night shift for Pain give 2 hrs prior wound care 0121216 (FILED: NEW YORK COUNTY CLERK 0672872023 O05 og0PM. INDEX NO. 451549/20230; NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023 MAR Report [NOT DOCUMENTED] 05/29/2020 23:00 every shift for Readmission for 30 Days - Vitals Signs Q shift x 30 daysevery shift for Readmission for 30 Days 05/29/2020 23:00 every shift for Monitoring Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD - Complete VS with SP02, Lung Sounds, Symptom(s) check Q Shift every shift for Monitoring Lung Sounds Key: C = Clear, V = Vesicular, D = Diminished, W = Wheezes, O = Other Symptom Key: Y/N (Yes or No) If any other symptoms, document in PN and notify MD 05/29/2020 23:00 every shift for Risk for elopement - Check wanderguard for functioning every shift for Risk for elopement 05/29/2020 23:00 every shift for Risk for elopement - Check wanderguard placement every shift for Risk for elopement 05/29/2020 23:00 every shift for Left Mastectomy - DO NOT TAKE BLOOD PRESSURE ON THE LEFT ARMevery shift for Left Mastectomy 05/29/2020 23:00 every shift G- tube- flush tube with 30 ml of water before and after medications and 30-60 ml's when starting and stopping tube feeding. - Enteral Feed Orderevery shift G- tube- flush tube with 30 ml of water before and after medications and 30-60 ml's when starting and stopping tube feeding 05/29/2020 23:00 every shift - Fluid Restriction 1000mi/day: Dietary will provide 720mI/day. Nursing will provide 280mI/day. Amount per shift: 7-3 shift = 120ml, 3-11 shift = 120ml, 11-7 shift = 40mlevery shift 05/29/2020 23:00 every shift - Keep of Head of Bed elevated to prevent shortness of breath when lying flat in the bed.every shift 05/29/2020 23:00 Apply to left and right foot topically every evening and night shift for Tinea pedis for 21 Days clean with soap and water, pat dry, and apply cream - Tolnaftate Cream 1 %Apply to left and right foot topically every evening and night shift for Tinea pedis for 21 Days clean with soap and water, pat dry, and apply cream 05/29/2020 23:00 Apply to right heel topically every day and night shift for wound care clean with NS, pat dry, apply Santyl oint, and dry dressing - Santyl Ointment 250 UNIT/GM (Collagenase)Apply to right heel topically every day and night shift for wound care clean with NS, pat dry, apply Santyl oint, and dry dressing 05/29/2020 23:00 Give 2 tablet by mouth every night shift for pain 30 MINUTES PRIOR TO DRESSING CHANGE - Tylenol Tablet 325 MG (Acetaminophen)Give 2 tablet by mouth every night shift for pain 30 MINUTES PRIOR TO DRESSING CHANGE 0121217 =: £ 1D INDEX NO. 451549/20230; NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023 MAR Report [NOT DOCUMENTED] 05/29/2020 23:00 every shift for Hypoxia - Give 2L of 02 via Nasal cannula to maintain SPO2 >=93%every shift for Hypoxia 05/29/2020 23:00 Apply to left dorsal foot topically every day and night shift for wound care post cleanse with saline, wrap with gauze - Medihoney Ca Alginate 4"xS" Pad (Wound Dressings)Apply to left dorsal foot topically every day and night shift for wound care post cleanse with saline, wrap with gauze 05/29/2020 23:00 Apply to Left lower leg topically every day and night shift for wound care POST Cleanse with saline wrap with gauze - Medihoney Ca Alginate 4"x5", Pad (Wound Dressings)Apply to Left lower leg topically every day and night shift for wound care POST Cleanse with saline wrap with gauze 05/29/2020 23:00 every shift for New admission for 30 Days - Vital signs @ shift time 30 daysevery shift for New admission for 30 Days 05/29/2020 23:00 every shift - Give 240cc Nectar Thick water PO for hydration.every shift 05/29/2020 23:00 every shift - 100m! fluid restriction: Dietary to provide 720ml/day and Nursing to provide 280 ml/day. Amount per shift: 7-3 shift = 120ml, 3-11 shift = 120ml, 11-7 shift = 40mlevery shift 05/29/2020 23:00 every shift for COPD - Keep of Head of Bed elevated to prevent shortness of breath when lying flat in the bed.every shift for COPD 05/29/2020 23:00 Give 2 tablet by mouth every shift for Pain give 30 mn prior dressing change - Tylenol Tablet 325 MG (Acetaminophen)Give 2 tablet by mouth every shift for Pain give 30 mn prior dressing change 05/29/2020 23:00 every shift for New admission for 30 Days - Vital signs Q shift x30 daysevery shift for New admission for 30 Days 05/29/2020 23:00 every shift - Fluid Restriction 1500cc/day: Dietary will provide 1080cc/day. Nursing will provide 420cc/day. Amount per shift: 7-3 shift = 200cc, 3-11 shift = 120cc, 11-7 shift = 100ccevery shift 05/29/2020 23:00 every shift for monitoring for 7 Days - Vital signs Q shift times 7 daysevery shift for monitoring for 7 Days 05/29/2020 23:00 Apply to right heel topically every night shift for wound care Post cleanse with saline wrap with gauze - Skin Prep Wipes Miscellaneous (Ostomy Supplies)Apply to right heel topically every night shift for wound care Post cleanse with saline wrap with gauze 10 0121218 =: £ 1D INDEX NO. 451549/20230; NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023 MAR Report [NOT DOCUMENTED] 05/29/2020 23:00 every shift for Pain evaluation - Pain Evaluation Q shiftevery shift for Pain evaluation 05/29/2020 23:00 every shift - MAY CRUSH MEDS IF NOT CONTRAINDICATED AND PUT IN COFFEE OR FOODevery shift 05/29/2020 23:00 every night shift for Ascites - Abdominal girth to be measured daily before breakfast. every night shift for Ascites 05/29/2020 23:00 every shift for SOB - Oxygen 2 Liters via nasal cannulaevery shift for SOB 05/29/2020 23:00 Use 75 ml/hr intravenously every shift for Poor PO intake for 3 Days - Dextrose-NaCl Solution 5- 0.45 % (Dextrose-Sodium Chloride)Use 75 ml/hr intravenously every shift for Poor PO intake for 3 Days 05/29/2020 23:00 every shift for MED ADMIN - MAY CRUSH MEDICATION IF NOT CONTRAINDICATED and mix in foodevery shift for MED ADMIN 05/29/2020 23:00 every shift - Check Wanderguard Placementevery shift 05/29/2020 23:00 every shift 480cc PO - Provide 480cc (2 cups) PO Honey Thickened Water every shift.every shift 480cc PO 05/29/2020 23:00 every shift Flush 250cc every shift and 30 cc AC/PC every feeding - Enteral Feed Orderevery shift Flush 250cc every shift and 30 cc AC/PC every feeding 05/29/2020 23:00 every shift - May crush meds if not contraindicated - May mix with Milk every shift 05/29/2020 23:00 Apply to mid back topically every shift for back wound post cleanse with saline, cover with DPD - Medihoney Ca Alginate 4 (Wound Dressings)Apply to mid back topically every shift for back wound post cleanse with saline, cover with DPD 05/29/2020 23:00 every shift - RN Respiratory POST Assessment: Check for breath sounds, 02 sat, sputum, sputum color, PR and RRevery shift 05/29/2020 23:00 every shift - RN Respiratory PRE Assessment: Check for breath sounds, 02 sat, sputum, sputum color, PR and RRevery shift 05/29/2020 23:00 every shift for For elopement potential. - Check wanderguard for placement q shift.every shift for For elopement potential. 11 0121219 =: £ 1D INDEX NO. 451549/20230; NYSCEF DOC. NO. 495 RECEIVED NYSCEF 06/28/2023 MAR Report [NOT DOCUMENTED] 05/29/2020 23:00 every shift for Potential for elopement. - Wanderguard left lower extremity.every shift for Potential for elopement 05/29/2020 23:00 every shift for Monitoring - Finger stick every shift for Monitoring 05/29/2020 23:00 every shift for Readmission for 30 Days - Vital signs Q shift x30 daysevery shift for Readmission for 30 Days 05/29/2020 23:00 every shift for edema - do not encourage po fluid .every shift for edema 12 0121220