Preview
FILED
10/12/2023 12:14 PM
FELICIA PITRE
DISTRICT CLERK
DALLAS CO., TEXAS
Rosa Delacerda DEPUTY
CAUSE NO. DC-21-08674
FRANTEISHA FONTENOT; DARREN IN THE DISTRICT COURT
KING; MARVIN PRIDE and YALONDA
WRIGHT, EACH INDIVIDUALLY AND
ON BEHALF OF THE ESTATE OF LINDA
FONTENOT WILLIAMS, DECEASED,
VS. 11674 JUDICIAL DISTRICT
DHC OPCO-CARROLLTON, LLC d/b/a
BROOKHAVEN NURSING AND
REHABILITATION CENTER and
THI OF TEXAS AT RICHARDSON, LLC
d/b/a THE VILLAGE AT RICHARDSON DALLAS COUNTY, TEXAS
DEFENDANT DHC OPCO-CARROLLTON, LLC d/b/a BROOKHAVEN NURSING &
REHABILITATION CENTER’S MOTION TO RECONSIDER COURT’S ORDER
GRANTING MOTION TO COMPEL AND FOR SANCTIONS
PART 4
3/15/2021 Medicare Shift Documention (Dynasty)
Shortness of Breath (Dyspnea) "
2a. On exertion u
2b. Atrest. "
Abnormal lung sounds u
Cough present "
Cyanosis 1
Does resident use oxygen? If yes, note rate in next question. a
1 No
2. Yes
Oxygen at what rate? "
Z
Oxygen via: 4
9. Respiratory Services provided. 4
10. Trachenstamy Gare provided "
41. Notable changes in respiratory function. "
Cardiovascular 1 Pulse regular rate and rhythm "
2. Peripheral pulses palpable "
3. Capillary refil. 4
a, <3 sec - Normal
b. > 3sec <5 sec- Slugish
c. >5 sec - Abnormal
4. EDEMA
Aa. Edema present "
4b. Location "
4c. Pitting "
0. None
1+ Mild pitting, slight indentation, no perceptable swelling of the leg
2+, Moderate pitting, indentation subsides rapidly
3+, Deep pitting, indentation remains for a short time, leg looks swollen
44 Very deep pitting, indentation lasts a long time, leg is very swollen
5. Episodes of chest pain "
6. Notable changes to cardiovascular status. "
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IKHAVEN 000177
3/15/2021 Medicare Shift Documention (Dynasty)
I Neurological/Sensory/Communication 1. PERRLA w
{; 2. Decreased grasp “
| 3. Decreased movement R
4, Vertigo "
‘Syncope "
Dizziness "
Tremors 4
Adequate hearing u
Wears hearing aid "
10. Adequate vision #
1 Wears glasses u
12. Clear and appropriate speech. "
13, Notable changes to neurological/sensory or communication status. "
Pain 41. VERBAL PAIN DESCRIPTION
fa. Resident verbalizes presence of pain. 8
4b. Scale out of 10 4
1 2: 3, 4 5. 6, 7. 8. 9, 10.
1c, Location u
4d. Notes 1
2. NON-VERBAL INDICATOR PAIN
2a, Resident demonstrates non-verbal signs of pain. "
2b. Describe uw
Medication/Orders 4. ORDERS
fa. Lab orders received "
1b. Medication orders received. "
1c. Treatment orders received. “
1d, Notes 4
2. MEDICATIONS
2a, IV Medication "
2b. Treat Infection 4
2c. IM Medication n
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SROOKHAVEN 00017!
3/15/2021 Medicare Shift Documention (Dynasty)
2d. IV Fluids "
2e. Note any adverse affects to medications. "
3. Notes on medications and treatments. 4
Skilled Services 1. Therapy / Rehabilitative Services
fa. Physical Therapy "
4b. Occupational Therapy "
1c. Speech Therapy 8
2. DAILY SKILLED SERVICES PROVIDED
2a, Evaluation and update of Care plan "
2b. Observation/Assessment of resident's condition 4
Teaching and Training
2c. (ex, post-op care, medication, pain mgnmt) Describe in Notes (2d) u
3. ADDITIONAL DIRECT SKILLED NURSING SERVICES
3a. Dialysis "
3b. Tube Feeding 4
3c. Restorative Nursing Services u
3d. Post-surgical services "
3e. Diabetic monitoring u
4. Skilled Progress Notes & it
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BROOKHAVEN 000179
3/15/2021 Medicare Shift Documention (Dynasty)
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SROOKHAVEN 000180
3/15/2021 Activity Interview for Daily and Activity Preferences (3.0) (Dynasty)
{ Seare!
Activity Interview for Daily and Activity Preferences (3.0) (Dynasty)
Resider FONTENOT, LINDA (3947)
Description Admission
Date: 12/14/2019 15:24
Section Status: Signed
Lock Date: 1/4/2020 18:40
Cancel
ins. INSTRUCTIONS Attempt to interview all residents able to communicate. It resident Is unable to complete, ullurnpl lu Lummplete interview
with family member or significant other. 8
a. Should interview for Daily and Activity Preferences be Conducted? - Attempt to interview ail residents able to
communicate. MDS uv
0. No
1. Yes
- Not assessed
A Interview for 1, How important is it to you to choose what clothes to wear? MDS 4
Daily
Preferences. 1 Very important
2, Somewhat important
3. Not very important
4. Not important at ail
5. Important, but can't do or no choice
9. No response or non-responsive
Not assessed
2. How important is it to you to take care of your personal belongings or things? MDS
1 Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9 No response or non-responsive
- Not assessed
3. How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? MDS 1H
1 Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
- Not assessed
4, How important is it to you to have snacks available between meals? MDS H
1 Very important
Saran - StSeTETsg--H11D1 40 Morbid obesity
Most Recent Height u
Height: 66.0 (Inches) Date: 12/12/2019 14:55
Method: Lying down
Altered food or fluid consistency? "
2, Automatic If any of the following are checked, skip Section III. Start an interim plan
Referrals to
RDN/NDTRILDN: of care for the patient/resident per the Care Pathways and refer to the
nutrition consultant (RDN/LDN/NDTR)
1, Check any items that apply. "
1, Diagnosis of Malnutrition or Failure to Thrive 2. TEITPNIPPN 3. Dialysis 4, Stages 2-4 pressure
injuries 6. NPO or clear liquid > 3 days
3, Mini Nutritional
Assessment Complete the Mini Nutritional Assessment. If the total score is 11 points
(MNA) or less, start an interim plan of care for the patient/resident per the Care
Pathways and refer to the nutrition consultant (RDN/LDN/NDTR)
4 Mini Nutritional Assessment Score "
1.11 points or less 2.1244
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BROOKHAVEN 000185
3/15/2021 Nutrition Risk Screen - V 2
4. 41. Check item that applys n
1. Not at risk 2. Automatic Referral (Section ll) 3. Referred to RDN/NDTRILDN for MNA score of 11 points
or less
2, Interim Interventions per Care Pathways "
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Brookhaven Nursing and Rehab PointClickCare Privacy Policy
1855 Cheyenne Drive 5570 Expl er Drive Customer Support
Carroliton, TX 75010-2201 Missi ga. sri Ww OC4 Version 4.3.3.9 www21-pec-web-main-
Pr fe: (972) 394-7141 Help 8 905) 81 7-6167 66 Ad 9-4kv42
PCC acility 1D 9 Free BOC pyright 2 10-2021 kCar
Phone (905) 88 888: 55 || hnologie: Inc All ngh
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3/15/2021 Nutrition Risk Screen - V 2
(a | Search
Nutrition Risk Screen - V 2
Resident: FONTENOT, LINDA (3947)
Descriptio Admission
Date: 12/14/2019 15:24
Section Statu: Signed
Lock Da’ 1/2/2020 15:46
[Previous Sec n| (Cancel |
1
1 RDN, NDTR, LDN Review Summar;ary
an =
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Brookhaven Nursing and Rehab PointClickCare Privacy Policy
Cheyenne Drive 0 Explorer Drive Customer Support
Carrollton, TX 201 sauga, Ontario LAW 9 www21-pec-web-main-
Phone: (972) 394-7141 Hel jesk: (B77) 722-2431 817-6167 dde9. KxBW
PCC Facility 10: 9 Toll Free: (800) 277-5889 | Cop ight 2021 PointClickCare
Phone: 05) 858-8885 | jolagies Inc. Ai ights ved
Fax: 858-2248
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3/18/2021 Medicare Shift Documention (Dynasty)
sas
a + Search
Medicare Shift Documention (Dynasty)
Resident: FONTENOT, LINDA (3947)
Description 6-2 Shift
Date: 12/14/2019 07:05
Section Status: Signed
Lock Date: 12/14/2019 23:15
| Cancel
32
1 INSTRUCTIONS Document all skilled services provided for resident on
each shift
Vital Signs 4 Most Recent Temperature E #
Temperature: 97.8 (CF) Date: 12/14/2019 07:05
Route: Temporal Artery
Most Recent Pulse E u
Pulse: 80 (bpm) Date: 12/14/2019 07:06
Pulse Type: Regular
Most Recent Respiration £1
Respiration: 18 (Breaths/min) Date: 12/14/2019 07:06
Most Recent Blood Pressure E
Blood Pressure: 99 / 58 (mmHg) Date: 12/14/2019 07:07
Positio dying Warm
Is resident a Diabetic? If yes, note most recent blood sugar below. u
1 No
2. Yes
5a, Most Recent Blood Glucose 4
Blood Glucose: (mg/dL) Date:
Most Recent 02 sats En
2 sats: 94 (%) Date: 42/14/2019 07:0)
Method: Room Air
B. Level of 4a. Sensory and Neurological - check all that apply "
Consiousness/Orientation/Cognition
4 Alert
2. Confused
3 Unresponsive
Lethargic
Slurred Speech
Aphasic
Visual impairment
8, Hearing impairment
2. Resident is oriented to: (Check all that apply) "
1 Time
2. Place
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3/15/2021 Medicare Shift Documention (Dynasty)
3. Person
4. Year
5. NIA
3. Note any changes in Level of Consciousness, Orientation and/or Cognition. If none noted, note
NIA, au
c. Activities of Daily Living/Functional 1, Does not weight bear 4
tatus
Unsteady gait requiring supervision u
Impaired balance "
Weakness 4"
Paralysis "
6. Decreased sensation 0
Ta. Requires assistance with bed mobility "
7b. Requires assistance with transfers. 4"
Te. Requires assistance with eating. 4
7d. Requires assistance with toilet use. "
8. Notable changes in functional ability and/or ADL's. 4
D. Mood and Behaviour 1 Mood and behavior patterns: (Check all that apply) "
1 Persistant anger
2. Unrealistic fears
3. Repetitive concerns
Anxious (non-health related)
Sad/worried facial expressions
Cryingtearful
Withdrawn from interests
Wandering
Verbally abusive
10. Physically abusive
"1 Resistant to care
12, Inappropriate behaviour
13. Negative behaviors not easily altered
14. Confused
15, Talkative
16, Friendly
17, Cooperative
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ROO! IAVEN 000189
3/15/2021 Medicare Shift Documention (Dynasty)
18. Happy/smiling
19. Quiet
20. Passive
21 NIA
fa. No changes to mood and behavior noted. ®
1b. Notable changes in mood and behavior 8
E. Bladder/Genitourinary er Check if no new observations noted during shift 1
1. BLADDER FUNCTION
fa, Bladder tunction unchanged. "
4b. Incontinent of urine: "
te. Distension noted. 4"
E2. ‘Check if resident has an indwelling catheter "
2, CATHETER
2a, Supra-pubic Catheter care provided. "
2b, Foley Catheter care provided. n
2c. Catheter patent, in place and draining. "
3b. Bedpan «
3c. Commode 4
3d. Pads/Briefs "
4. OSTOMIES PRESENT
4a. Urostomy "
Ab. Ostomy patent, in place and cleaned "
5. URINE
5a. Color "
te
5b. Clarity "
5c, Odor 8
t ‘1 \
Notable changes to bladder function. "
F. Bowel/Gastrointestinal 4. BOWEL FUNCTION
fa. Bowel function unchanged u
1b, Incontinent of BM. "
te. Bowel sounds present, "
1d. Diarrhea "
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BROOKHAVEN 000190
3/16/2021 Medicare Shift Documention (Dynasty)
te. Constipation 4
2. OSTOMIES PRESENT
2a. Heostomy u
2b. Colostomy "
2c. Patent and draining. a
3.G!
3a, Nausea "
3b. Vomiting "
3c. Difficulty swallowing. a
4. Notable changes in bowel or GI function. "
Skin/Wound 4. SKIN INTEGRITY
fa. No new changes to skin integrity noted. "
4b. Notable changes to skin integrity. "
2. WOUND CARE
2a. Resident has treatable wounds. u
2b. #, type and location (i.e. #1, pressure, left buttock) "
site
2c. Dressing changed as per treatment orders. 8
2d. Dressing change not required. "
2e. Changes were noted to wound. 4
2f. Notable changes to wound. "
Respiratory Within Normal Limits, 8
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BROOKHAVEN 000191
3/15/2021 Medicare Shift Documention (Dynasty)
Shortness of Breath (Dyspnea) u
2a. On exertion u
2b. At rest. Hu
Abnormal lung sounds u
Cough present 4
Cyanosis "
Does resident use oxygen? If yes, note rate in next question. "
4. No
2. Yes
Oxygen at what rate? u
au
Oxygen via: "
‘
Respiratory Services provided. 8
10. ‘Tracheostomy Care provided "
4 Notable changes in respiratory function. n
Cardiovascular dl Pulse regular rate and rhythm. "
2. Peripheral pulses palpable. u
3. Capillary refi "
a. <3 sec -Normal
b. > 3sec <5 sec - Slugish
c. >5 sec - Abnormal
4, EDEMA
4a. Edema present "
4b. Location u
4c. Pitting u
0. None
14 Mild pitting, slight indentation, no perceptable swelling of the leg
24 Moderate pitting, indentation subsides rapidly
3+. Deep pitting, indentation remains for a short time, leg looks swollen
44 Very deep pitting, indentation lasts a long time, leg is very swollen
5. Episodes of chest pain "
6. Notable changes to cardiovascular status. 4
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BROOKHAVEN 000192
3/15/2021 Medicare Shift Documention (Dynasty)
J. Neurotogical/SensoryiCommunication| 1. PERRLA "
2. Decreased grasp "
3. Decreased movement n
4. Vertigo 8
‘Syncope u
Dizziness u
Tremors 4
Adequate hearing u
Wears hearing aid "
10. Adequate vision #
" Wears glasses "
12. Clear and appropriate speech. #
13, Notable changes to neurological/sensory or communication status "
Pain 1. VERBAL PAIN DESCRIPTION
ta. Resident verbalizes presence of pain, 8
1b. Scale out of 10 "
1 2. 3. 4, 5. 6. 7. 6. 9. 10.
1c. Location H
4d. Notes "
2. NON-VERBAL INDICATOR PAIN
2a, Resident demonstrates non-verbal signs of pain, "
2b. Describe uw
Medication/Orders 4, ORDERS
fa, Lab orders received "
4b. Medication orders received. u
1c. Treatment orders received. "
1d. Notes "
2. MEDICATIONS
2a. IV Medication "
2b. Treat Infection "
2c. IM Medication "
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BROOKHAVEN 000193
3/15/2021 Medicare Shift Documention (Dynasty)
2d. IV Fluids "
2e. Note any adverse affects to medications. "
3. Notes on medications and treatments. 4
Skilled Services 1. Therapy / Rehabilitative Services
fa. Physical Therapy "
tb. Occupational Therapy "
te. Speech Therapy 8
2. DAILY SKILLED SERVICES PROVIDED
2a. Evaluation and update of Care plan u
2b. Observation/Assessment of resident's condition a
Teaching and Training
2c, (ex. post-op care, medication, pain mgnmt) Deserihe in Notes (24) 0
3. ADDITIONAL DIRECT SKILLED NURSING SERVICES
3a. Dialysis "
3b. Tube Feeding "
3c. Restorative Nursing Services 0
3d. Post-surgical services
3e. Diabetic monitoring "
4, Skilled Progress Notes
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en ESAI accossi
inn t-8A7 3sec <5 sec - Slugish
c. > 5 sec - Abnormal
4, EDEMA
4a. Edema present
4b. Location u
4c. Pitting "
0. None
14 Mild pitting, slight indentation, no perceptable swelling of the leg
2+. Moderate pitting, indentation subsides rapidly
3+, Deep pitting, indentation remains for a short time, leg looks swollen
4. Very deep pitting, indentation lasts a long time, leg is very swollen
5. Episodes of chest pain H
6. Notable changes to cardiovascular status. "
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BROOKHAVEN 000204
3/15/2021 Medicare Shift Documention (Dynasty)
J. Neurological/Sensory/Communication| 1. PERRLA 4
2. Decreased grasp "
3 Decreased movement 4
4. Vertigo n
Syncope a
Dizziness "
Tremors 4
Adequate hearing "
9. Wears hearing aid ”
10, Adequate vision 4
" Wears glasses u
12, Clear and appropriate speech. 4
13, Notable changes to neurological/sensory or communication status. "
Pain 4. VERBAL PAIN DESCRIPTION
fa. Resident verbalizes presence of pain. 4
1b. Scale out of 10 "
1 2, 3. 4 5, 6. 7. 8. 9. 10,
1c. Location "
4d. Notes W
2. NON-VERBAL INDICATOR PAIN
2a. Resident demonstrates non-verbal signs of pain, "
2b. Describe u
Medication/Orders 4, ORDERS
Aa. Lab orders received uw
1b Medication orders received. K
te. Treatment orders received. "
1d. Notes "
2. MEDICATIONS
2a, IV Medication 4
2b. Treat Infection 4
2c. IM Medication “"
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3/15/2021 Medicare Shift Documention (Dynasty)
2d. IV Fluids "
2e. Note any adverse affects to medications. "
3. Notes on medications and treatments, "
Skilled Services 4. Therapy / Rehabilitative Services
fa. Physical Therapy uw
‘1b. Occupational Therapy 4"
te. Speech Therapy #
2. DAILY SKILLED SERVICES PROVIDED
2a, Evaluation and update of Care plan u
2b. Observation/Assessment of resident's condition H
Teaching and Training
2c. (ex. post op care, medicatinn, pain mgnmt) Describe in Notes (24) "
3. ADDITIONAL DIRECT SKILLED NURSING SERVICES
3a, : "
3b. \ Feeding 4
3c. Restorative Nursing s "
3d. Post-surgical ser s 4
3e jabetic monitori u
Skilled Pr "
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BROOKHAVEN 000206
3/15/2021 Medicare Shift Documention (Dynasty)
Brookhaven Nursing and Rehab PointClickCare Privacy Policy
1855 Cheyenne Drive 5570 Explorer Drive Customer Support
roliton, TX 75010-2204 Mississau Ontario L4 NOC4 Version 4.3.3.9 www21-p seb-main
Phone: (972) 394-7441 Help Desk: (877) 72 90! ) 8 67 6064744d Sts¢
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FILED 10/12/2023 12:14 PM FELICIA PITRE DISTRICT CLERK DALLAS CO., TEXAS Rosa Delacerda DEPUTY CAUSE NO. DC-21-08674 FRANTEISHA FONTENOT; DARREN IN THE DISTRICT COURT KING; MARVIN PRIDE and YALONDA WRIGHT, EACH INDIVIDUALLY AND ON BEHALF OF THE ESTATE OF LINDA FONTENOT WILLIAMS, DECEASED, VS. 11674 JUDICIAL DISTRICT DHC OPCO-CARROLLTON, LLC d/b/a BROOKHAVEN NURSING AND REHABILITATION CENTER and THI OF TEXAS AT RICHARDSON, LLC d/b/a THE VILLAGE AT RICHARDSON DALLAS COUNTY, TEXAS DEFENDANT DHC OPCO-CARROLLTON, LLC d/b/a BROOKHAVEN NURSING & REHABILITATION CENTER’S MOTION TO RECONSIDER COURT’S ORDER GRANTING MOTION TO COMPEL AND FOR SANCTIONS PART 4 3/15/2021 Medicare Shift Documention (Dynasty) Shortness of Breath (Dyspnea) " 2a. On exertion u 2b. Atrest. " Abnormal lung sounds u Cough present " Cyanosis 1 Does resident use oxygen? If yes, note rate in next question. a 1 No 2. Yes Oxygen at what rate? " Z Oxygen via: 4 9. Respiratory Services provided. 4 10. Trachenstamy Gare provided " 41. Notable changes in respiratory function. " Cardiovascular 1 Pulse regular rate and rhythm " 2. Peripheral pulses palpable " 3. Capillary refil. 4 a, <3 sec - Normal b. > 3sec <5 sec- Slugish c. >5 sec - Abnormal 4. EDEMA Aa. Edema present " 4b. Location " 4c. Pitting " 0. None 1+ Mild pitting, slight indentation, no perceptable swelling of the leg 2+, Moderate pitting, indentation subsides rapidly 3+, Deep pitting, indentation remains for a short time, leg looks swollen 44 Very deep pitting, indentation lasts a long time, leg is very swollen 5. Episodes of chest pain " 6. Notable changes to cardiovascular status. " hiinesianas94 nnintelicunare enmirarelchartimdsimdesertion isn?F SOI assessid=8369064relURL=/admin/clienUcp assessment.isp&ESOLclienti IKHAVEN 000177 3/15/2021 Medicare Shift Documention (Dynasty) I Neurological/Sensory/Communication 1. PERRLA w {; 2. Decreased grasp “ | 3. Decreased movement R 4, Vertigo " ‘Syncope " Dizziness " Tremors 4 Adequate hearing u Wears hearing aid " 10. Adequate vision # 1 Wears glasses u 12. Clear and appropriate speech. " 13, Notable changes to neurological/sensory or communication status. " Pain 41. VERBAL PAIN DESCRIPTION fa. Resident verbalizes presence of pain. 8 4b. Scale out of 10 4 1 2: 3, 4 5. 6, 7. 8. 9, 10. 1c, Location u 4d. Notes 1 2. NON-VERBAL INDICATOR PAIN 2a, Resident demonstrates non-verbal signs of pain. " 2b. Describe uw Medication/Orders 4. ORDERS fa. Lab orders received " 1b. Medication orders received. " 1c. Treatment orders received. “ 1d, Notes 4 2. MEDICATIONS 2a, IV Medication " 2b. Treat Infection 4 2c. IM Medication n oa 1 104 maintatinvrare eaminareichartimdsimdssection.iso?7ES OLassessid=8369068retURL =/admin/clienvcp_assessment jsp&ESOLclienti 7 68 SROOKHAVEN 00017! 3/15/2021 Medicare Shift Documention (Dynasty) 2d. IV Fluids " 2e. Note any adverse affects to medications. " 3. Notes on medications and treatments. 4 Skilled Services 1. Therapy / Rehabilitative Services fa. Physical Therapy " 4b. Occupational Therapy " 1c. Speech Therapy 8 2. DAILY SKILLED SERVICES PROVIDED 2a, Evaluation and update of Care plan " 2b. Observation/Assessment of resident's condition 4 Teaching and Training 2c. (ex, post-op care, medication, pain mgnmt) Describe in Notes (2d) u 3. ADDITIONAL DIRECT SKILLED NURSING SERVICES 3a. Dialysis " 3b. Tube Feeding 4 3c. Restorative Nursing Services u 3d. Post-surgical services " 3e. Diabetic monitoring u 4. Skilled Progress Notes & it Led Ate oe noth in te ne di dx nid % iota e a Pe ie | Cancel Click Here to View Quick Entry - Keyboard Navigation Tips httos:/www21 oointclickcare.com/care/chartmds/mdssection.jsp7ESOLassessid=836906&retURL=/admin/clienVop_assessment.jsp&ESOLclientid=9 718 BROOKHAVEN 000179 3/15/2021 Medicare Shift Documention (Dynasty) Brookhaven Nursing and Rehab PointClickCare Privacy Policy A 5: 5 Cheyenne Drive 5: 70 Explorer Drive Customer Support Carrollton, TX 75010-2204 Mississauga, Ontario L4w 0C4 Version 4.3.3.9 www21-peo-web-main: Phone: (972) 394-7141 Help Desk: (877) 722-2431 | (905) 817-6167 6c64744de emg?tz PCC Faality 1D: 9 Toll Free: (800) 277-5889 | Copyright 2000-2021 PointClickCare Phone: (905) 858-8885 | Technologies Inc. All rights reserved Fax: (905) 868-2248 hitns:/ianiaw?1 nnintelirkeare enm/earelchartimdsimdssection isn?FSOl assess j=836906&retURL=/admin/clientico assessment.isp&ESOLclientid=9. 88, SROOKHAVEN 000180 3/15/2021 Activity Interview for Daily and Activity Preferences (3.0) (Dynasty) { Seare! Activity Interview for Daily and Activity Preferences (3.0) (Dynasty) Resider FONTENOT, LINDA (3947) Description Admission Date: 12/14/2019 15:24 Section Status: Signed Lock Date: 1/4/2020 18:40 Cancel ins. INSTRUCTIONS Attempt to interview all residents able to communicate. It resident Is unable to complete, ullurnpl lu Lummplete interview with family member or significant other. 8 a. Should interview for Daily and Activity Preferences be Conducted? - Attempt to interview ail residents able to communicate. MDS uv 0. No 1. Yes - Not assessed A Interview for 1, How important is it to you to choose what clothes to wear? MDS 4 Daily Preferences. 1 Very important 2, Somewhat important 3. Not very important 4. Not important at ail 5. Important, but can't do or no choice 9. No response or non-responsive Not assessed 2. How important is it to you to take care of your personal belongings or things? MDS 1 Very important 2. Somewhat important 3. Not very important 4. Not important at all 5. Important, but can't do or no choice 9 No response or non-responsive - Not assessed 3. How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? MDS 1H 1 Very important 2. Somewhat important 3. Not very important 4. Not important at all 5. Important, but can't do or no choice 9. No response or non-responsive - Not assessed 4, How important is it to you to have snacks available between meals? MDS H 1 Very important Saran - StSeTETsg--H11D1 40 Morbid obesity Most Recent Height u Height: 66.0 (Inches) Date: 12/12/2019 14:55 Method: Lying down Altered food or fluid consistency? " 2, Automatic If any of the following are checked, skip Section III. Start an interim plan Referrals to RDN/NDTRILDN: of care for the patient/resident per the Care Pathways and refer to the nutrition consultant (RDN/LDN/NDTR) 1, Check any items that apply. " 1, Diagnosis of Malnutrition or Failure to Thrive 2. TEITPNIPPN 3. Dialysis 4, Stages 2-4 pressure injuries 6. NPO or clear liquid > 3 days 3, Mini Nutritional Assessment Complete the Mini Nutritional Assessment. If the total score is 11 points (MNA) or less, start an interim plan of care for the patient/resident per the Care Pathways and refer to the nutrition consultant (RDN/LDN/NDTR) 4 Mini Nutritional Assessment Score " 1.11 points or less 2.1244 https:/vww21 pointelickcare m/care/chartimds/mdssection jsp?ESOLtab Type=C&ESOL sectioncode=Cust_1&ESOLclientid=955882&ESOLassessi 112 BROOKHAVEN 000185 3/15/2021 Nutrition Risk Screen - V 2 4. 41. Check item that applys n 1. Not at risk 2. Automatic Referral (Section ll) 3. Referred to RDN/NDTRILDN for MNA score of 11 points or less 2, Interim Interventions per Care Pathways " {Cancel} (Next Section Click Here to View Quick Entry - Keyboard Navigation Tips Brookhaven Nursing and Rehab PointClickCare Privacy Policy 1855 Cheyenne Drive 5570 Expl er Drive Customer Support Carroliton, TX 75010-2201 Missi ga. sri Ww OC4 Version 4.3.3.9 www21-pec-web-main- Pr fe: (972) 394-7141 Help 8 905) 81 7-6167 66 Ad 9-4kv42 PCC acility 1D 9 Free BOC pyright 2 10-2021 kCar Phone (905) 88 888: 55 || hnologie: Inc All ngh Fax: ) 85 48 i T Sr ent entumacCRESO! cartinnendasCust 1&ESOL gp EAN i862? 3/15/2021 Nutrition Risk Screen - V 2 (a | Search Nutrition Risk Screen - V 2 Resident: FONTENOT, LINDA (3947) Descriptio Admission Date: 12/14/2019 15:24 Section Statu: Signed Lock Da’ 1/2/2020 15:46 [Previous Sec n| (Cancel | 1 1 RDN, NDTR, LDN Review Summar;ary an = | Previous Section | | Cancel| Click Here to View Quick Entry - Keyboard Navigation Tips Brookhaven Nursing and Rehab PointClickCare Privacy Policy Cheyenne Drive 0 Explorer Drive Customer Support Carrollton, TX 201 sauga, Ontario LAW 9 www21-pec-web-main- Phone: (972) 394-7141 Hel jesk: (B77) 722-2431 817-6167 dde9. KxBW PCC Facility 10: 9 Toll Free: (800) 277-5889 | Cop ight 2021 PointClickCare Phone: 05) 858-8885 | jolagies Inc. Ai ights ved Fax: 858-2248 ban tate MPEEN ohTwnaaCAESOI sertinncnda=Cust 28ESOL SSSalenid HHAAE RQ assGesiy 1/1 3/18/2021 Medicare Shift Documention (Dynasty) sas a + Search Medicare Shift Documention (Dynasty) Resident: FONTENOT, LINDA (3947) Description 6-2 Shift Date: 12/14/2019 07:05 Section Status: Signed Lock Date: 12/14/2019 23:15 | Cancel 32 1 INSTRUCTIONS Document all skilled services provided for resident on each shift Vital Signs 4 Most Recent Temperature E # Temperature: 97.8 (CF) Date: 12/14/2019 07:05 Route: Temporal Artery Most Recent Pulse E u Pulse: 80 (bpm) Date: 12/14/2019 07:06 Pulse Type: Regular Most Recent Respiration £1 Respiration: 18 (Breaths/min) Date: 12/14/2019 07:06 Most Recent Blood Pressure E Blood Pressure: 99 / 58 (mmHg) Date: 12/14/2019 07:07 Positio dying Warm Is resident a Diabetic? If yes, note most recent blood sugar below. u 1 No 2. Yes 5a, Most Recent Blood Glucose 4 Blood Glucose: (mg/dL) Date: Most Recent 02 sats En 2 sats: 94 (%) Date: 42/14/2019 07:0) Method: Room Air B. Level of 4a. Sensory and Neurological - check all that apply " Consiousness/Orientation/Cognition 4 Alert 2. Confused 3 Unresponsive Lethargic Slurred Speech Aphasic Visual impairment 8, Hearing impairment 2. Resident is oriented to: (Check all that apply) " 1 Time 2. Place it a RA REONI aennnei eo@n72NoRro IDI slarimininiantion ascpesa BRAT SORMeYti cas eg V8 3/15/2021 Medicare Shift Documention (Dynasty) 3. Person 4. Year 5. NIA 3. Note any changes in Level of Consciousness, Orientation and/or Cognition. If none noted, note NIA, au c. Activities of Daily Living/Functional 1, Does not weight bear 4 tatus Unsteady gait requiring supervision u Impaired balance " Weakness 4" Paralysis " 6. Decreased sensation 0 Ta. Requires assistance with bed mobility " 7b. Requires assistance with transfers. 4" Te. Requires assistance with eating. 4 7d. Requires assistance with toilet use. " 8. Notable changes in functional ability and/or ADL's. 4 D. Mood and Behaviour 1 Mood and behavior patterns: (Check all that apply) " 1 Persistant anger 2. Unrealistic fears 3. Repetitive concerns Anxious (non-health related) Sad/worried facial expressions Cryingtearful Withdrawn from interests Wandering Verbally abusive 10. Physically abusive "1 Resistant to care 12, Inappropriate behaviour 13. Negative behaviors not easily altered 14. Confused 15, Talkative 16, Friendly 17, Cooperative bate eb net to tian ien7ESAI agsassid=8373098retURL=/admin/clienticp_assessmen vse &ESOL clientid=' 218 ROO! IAVEN 000189 3/15/2021 Medicare Shift Documention (Dynasty) 18. Happy/smiling 19. Quiet 20. Passive 21 NIA fa. No changes to mood and behavior noted. ® 1b. Notable changes in mood and behavior 8 E. Bladder/Genitourinary er Check if no new observations noted during shift 1 1. BLADDER FUNCTION fa, Bladder tunction unchanged. " 4b. Incontinent of urine: " te. Distension noted. 4" E2. ‘Check if resident has an indwelling catheter " 2, CATHETER 2a, Supra-pubic Catheter care provided. " 2b, Foley Catheter care provided. n 2c. Catheter patent, in place and draining. " 3b. Bedpan « 3c. Commode 4 3d. Pads/Briefs " 4. OSTOMIES PRESENT 4a. Urostomy " Ab. Ostomy patent, in place and cleaned " 5. URINE 5a. Color " te 5b. Clarity " 5c, Odor 8 t ‘1 \ Notable changes to bladder function. " F. Bowel/Gastrointestinal 4. BOWEL FUNCTION fa. Bowel function unchanged u 1b, Incontinent of BM. " te. Bowel sounds present, " 1d. Diarrhea " https:/www21 .pointclickcare.com/care/chartimds/mdssection jsp?ESOLassessid=8373098retURL=/admin/clien/cp_assessment,jsp&ESOLclientid=! 3/8 BROOKHAVEN 000190 3/16/2021 Medicare Shift Documention (Dynasty) te. Constipation 4 2. OSTOMIES PRESENT 2a. Heostomy u 2b. Colostomy " 2c. Patent and draining. a 3.G! 3a, Nausea " 3b. Vomiting " 3c. Difficulty swallowing. a 4. Notable changes in bowel or GI function. " Skin/Wound 4. SKIN INTEGRITY fa. No new changes to skin integrity noted. " 4b. Notable changes to skin integrity. " 2. WOUND CARE 2a. Resident has treatable wounds. u 2b. #, type and location (i.e. #1, pressure, left buttock) " site 2c. Dressing changed as per treatment orders. 8 2d. Dressing change not required. " 2e. Changes were noted to wound. 4 2f. Notable changes to wound. " Respiratory Within Normal Limits, 8 nee tate natin dated mnOEO cid 827 2NORratl IRI =larminiclienticn assessment isn&FSOLclientid=9 al BROOKHAVEN 000191 3/15/2021 Medicare Shift Documention (Dynasty) Shortness of Breath (Dyspnea) u 2a. On exertion u 2b. At rest. Hu Abnormal lung sounds u Cough present 4 Cyanosis " Does resident use oxygen? If yes, note rate in next question. " 4. No 2. Yes Oxygen at what rate? u au Oxygen via: " ‘ Respiratory Services provided. 8 10. ‘Tracheostomy Care provided " 4 Notable changes in respiratory function. n Cardiovascular dl Pulse regular rate and rhythm. " 2. Peripheral pulses palpable. u 3. Capillary refi " a. <3 sec -Normal b. > 3sec <5 sec - Slugish c. >5 sec - Abnormal 4, EDEMA 4a. Edema present " 4b. Location u 4c. Pitting u 0. None 14 Mild pitting, slight indentation, no perceptable swelling of the leg 24 Moderate pitting, indentation subsides rapidly 3+. Deep pitting, indentation remains for a short time, leg looks swollen 44 Very deep pitting, indentation lasts a long time, leg is very swollen 5. Episodes of chest pain " 6. Notable changes to cardiovascular status. 4 https:/Avww21 .pointelickcare.com/care/chart/mds/mdssection jsp?ESOLassessid=837309&retURL =/admin/clientcp_assessment.jsp&ESOl clientid=9. 58 BROOKHAVEN 000192 3/15/2021 Medicare Shift Documention (Dynasty) J. Neurotogical/SensoryiCommunication| 1. PERRLA " 2. Decreased grasp " 3. Decreased movement n 4. Vertigo 8 ‘Syncope u Dizziness u Tremors 4 Adequate hearing u Wears hearing aid " 10. Adequate vision # " Wears glasses " 12. Clear and appropriate speech. # 13, Notable changes to neurological/sensory or communication status " Pain 1. VERBAL PAIN DESCRIPTION ta. Resident verbalizes presence of pain, 8 1b. Scale out of 10 " 1 2. 3. 4, 5. 6. 7. 6. 9. 10. 1c. Location H 4d. Notes " 2. NON-VERBAL INDICATOR PAIN 2a, Resident demonstrates non-verbal signs of pain, " 2b. Describe uw Medication/Orders 4, ORDERS fa, Lab orders received " 4b. Medication orders received. u 1c. Treatment orders received. " 1d. Notes " 2. MEDICATIONS 2a. IV Medication " 2b. Treat Infection " 2c. IM Medication " https://www21 pointclickcare.com/care/chart/mds/mdssection jsp?ESOLassessid=8373098retURL=/admin/client/op_assessment jsp&ESOLclientid=9... 68 BROOKHAVEN 000193 3/15/2021 Medicare Shift Documention (Dynasty) 2d. IV Fluids " 2e. Note any adverse affects to medications. " 3. Notes on medications and treatments. 4 Skilled Services 1. Therapy / Rehabilitative Services fa. Physical Therapy " tb. Occupational Therapy " te. Speech Therapy 8 2. DAILY SKILLED SERVICES PROVIDED 2a. Evaluation and update of Care plan u 2b. Observation/Assessment of resident's condition a Teaching and Training 2c, (ex. post-op care, medication, pain mgnmt) Deserihe in Notes (24) 0 3. ADDITIONAL DIRECT SKILLED NURSING SERVICES 3a. Dialysis " 3b. Tube Feeding " 3c. Restorative Nursing Services 0 3d. Post-surgical services 3e. Diabetic monitoring " 4, Skilled Progress Notes Fo pancreatinis a o1e! ste omy of or he aiff or ety ta h on re * ne a aned nea. of recat di noted a zime Ligh ve will inge to mor eport wn n piace Cancel Click Here to View Quick Entry - Keyboard Navigation Tips hoevatntc en ESAI accossi inn t-8A7 3sec <5 sec - Slugish c. > 5 sec - Abnormal 4, EDEMA 4a. Edema present 4b. Location u 4c. Pitting " 0. None 14 Mild pitting, slight indentation, no perceptable swelling of the leg 2+. Moderate pitting, indentation subsides rapidly 3+, Deep pitting, indentation remains for a short time, leg looks swollen 4. Very deep pitting, indentation lasts a long time, leg is very swollen 5. Episodes of chest pain H 6. Notable changes to cardiovascular status. " https:/Mwww21 pointclickcare.com/care/chart/mds/mdssection jsp7ESOLassessid=836852&retURL=/admin/clienticp_assessment jsp&ESOLclientid=! 5/8 BROOKHAVEN 000204 3/15/2021 Medicare Shift Documention (Dynasty) J. Neurological/Sensory/Communication| 1. PERRLA 4 2. Decreased grasp " 3 Decreased movement 4 4. Vertigo n Syncope a Dizziness " Tremors 4 Adequate hearing " 9. Wears hearing aid ” 10, Adequate vision 4 " Wears glasses u 12, Clear and appropriate speech. 4 13, Notable changes to neurological/sensory or communication status. " Pain 4. VERBAL PAIN DESCRIPTION fa. Resident verbalizes presence of pain. 4 1b. Scale out of 10 " 1 2, 3. 4 5, 6. 7. 8. 9. 10, 1c. Location " 4d. Notes W 2. NON-VERBAL INDICATOR PAIN 2a. Resident demonstrates non-verbal signs of pain, " 2b. Describe u Medication/Orders 4, ORDERS Aa. Lab orders received uw 1b Medication orders received. K te. Treatment orders received. " 1d. Notes " 2. MEDICATIONS 2a, IV Medication 4 2b. Treat Infection 4 2c. IM Medication “" [hadttendatendacantinn ien?ESNI assassid=836852&retURL=/adminiclienticp_assessment it jsp&ESOL clientid: BROO! KH.CHAVEN 000208 3/15/2021 Medicare Shift Documention (Dynasty) 2d. IV Fluids " 2e. Note any adverse affects to medications. " 3. Notes on medications and treatments, " Skilled Services 4. Therapy / Rehabilitative Services fa. Physical Therapy uw ‘1b. Occupational Therapy 4" te. Speech Therapy # 2. DAILY SKILLED SERVICES PROVIDED 2a, Evaluation and update of Care plan u 2b. Observation/Assessment of resident's condition H Teaching and Training 2c. (ex. post op care, medicatinn, pain mgnmt) Describe in Notes (24) " 3. ADDITIONAL DIRECT SKILLED NURSING SERVICES 3a, : " 3b. \ Feeding 4 3c. Restorative Nursing s " 3d. Post-surgical ser s 4 3e jabetic monitori u Skilled Pr " (Cancel Click Here to View Quick Entry - Keyboard Navigation Tips oe +> somnarainhartimdeimscartinn iso?ESOLassessid=836852&retURL=/admin/clienUcp_asses jsp&ESOLclientid=9 sment 718 BROOKHAVEN 000206 3/15/2021 Medicare Shift Documention (Dynasty) Brookhaven Nursing and Rehab PointClickCare Privacy Policy 1855 Cheyenne Drive 5570 Explorer Drive Customer Support roliton, TX 75010-2204 Mississau Ontario L4 NOC4 Version 4.3.3.9 www21-p seb-main Phone: (972) 394-7441 Help Desk: (877) 72 90! ) 8 67 6064744d Sts¢ PCC Fai lity 1D: & Toll Free: (800) 277-588: Copyright 00: 021 Click Phone: (905) 858-8885 | Tectinologies Ine. All rights reserve