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FILED
10/12/2023 12:04 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 2
Resident FONTENOT, LINDA Identifier 3947 Date Dec 15, 2019
|Section) |Health Conditions
—— =
Surgical Procedures -Complete o1
only if 2 1000
Lo a ——
Check all that apply —— ee — = — a
[ Major Joint Replacement
32300, Knee Replacement- partial
or total
J2310. Hip Replacement - partial or total
| 12320. Ankle Replacement - partial or total
42330. Shoulder Replacement - partial or total
| Spinal Surgery
32400. Involving the spinal cord or major spinalnerves
J2410. Involving fusion of spinal bones
52420. Involving lamina, discs, or facets
12499. Other major spinal surgery_ — as a a
[Other Orthopedic Surgery —____]
42500. Repair fractures of the shoulder (including clavicle and scapula)or arm (but not hand)
32510. Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot)
42520. Repair but not replace joints
32530. Repair other bones (such as hand, foot, jaw)
52599. Other major orthopedic surgery
= ~ — a
[Neurological Surgery ao
42600. Involving the brain, surrounding tissue or blood vessels (excludes skull and skin but includes cranial nerves)
42610. Involving
the peripheral or autonomic nervous system - open or percutaneous
J2620, Insertion or removal of spinal or brain neurostimulators, electrodes, catheters, or CSF drainage devices
42699. Other major neurological surgery —. = - _ ———
‘Cardiopulmonary Surgery — =< a
42700. Invoh g the heart or major blood vessels
- open or percutaneous procedures
42710. Involving the respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords - open or endoscopic
42799. Other major cardiopulmonary surgery —— ——
nitourinary Surgery
[J 12800. tnvol g male or female organs (suchas
‘as prostate, ‘testes, ovaries, uterus,vagina, external genitalia)
oO 42810, Involving the kidneys, ureters, adrenal glands, or bladder - open or laparoscopic (includes creation or removal of
nephrostomies or urostomies)
ey 42899. Other major genitourinary surgery =
| Other Major Surgery
es 32900. Involving tendons, ligaments, or muscles
42910. Involving the gastrointestinal tract or abdominal contents from the esophagus to the anus, the biliary tree, gall bladder, liver,
| pancreas, or spleen - open or laparoscopic (including creation
or removal of ostomies or percutaneous feeding tubes, or hernia repair)
ie 52920. Involving the endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, or thymus - open
[e) 42930. Involving the breast
_ 42940. Repair of deep ulcers, internal brachytherapy, bone marrow or stem cell harvest or transplant
O1 55000, Other major surgery not listed above
sta ———!
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019 Page 31 of 51
BROOKHAVEN 000050
Resident FONTENOT, LINDA Identifier 3947 Date Dec 15, 2019
Section K — Swallowing/Nutritional
[ Status
—== ————————= = = =
K0100. Swallowing Disorder
©=ns and symptoms of possible swallowing disorder _ = |
Check all that apply
L
A. Loss of liquids/solids from mouth when eating or drinking
oO B. Holding food in mouth/cheeks or residual food in mouth after meals
€. Coughing or choking during meals or when swallowing medications
[1] | D. Complaints of difficulty or pain with swallowing
O Z. None of the above
K0200. Height and Weight- While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up
T
| A. Height (in inches). Record most recent height measure since the most recent admission/entry or reentry
inches a a
B. Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to standard
facility practice (e.g,, in a.m. after voiding, before meal, with shoes off, etc.)
pounds
K0300. Weight Loss
Loss of 5% or more in the last month or loss of 10% or more in last 6 months
Enter Code 0. Noor unknown
1 Yes, on physician-prescribed weight-loss regimen
2. Yes, not on physician-prescribed weight-loss regimen
K0310. Weight Gain
Gain of 5% or more in the last month or gain of 10% or more in last 6 months
Enter Code 9, No or unknown
1 Yes, on physician- prescribed weight-gain regimen
2. Yes, not on physician-prescribed weight-gain regimen
0. Nutritional Approaches
Check all of the following nutritional approaches that were performed during the last 7 days
1, While NOT a Resident
Performed while NOT a resident of this facility and within the last 7 days. Only check column 1 if L
resident entered (admission or reentry) IN THE LAST 7 DAYS. If resident last entered 7 or more days While NOTa
ago, leave column 1 blank Resident Resident
2. While a Resident
Performed——swhile a resident of this facility and within the last 7 days | Check all that apply|
A. Parenteral/IV feeding
oO oO
B. Feeding tube - nasogastric or abdominal (PEG) ie) fee}
. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food,
thickened liquids)
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
=
Z. None of the above : oO
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019 Page 32 0f 51
BROOKHAVEN 000051
Resident FONTENOT, LINDA Identifier 3947 Date Dec 15,2019
[Section K Swallowing/Nutritional
| Status
K0710. Percent Intake by Artificial Route
R ite -- Complete KO710 only if Column 1 and/or Column 2 are checked for KO510A and/or KO510B
a ———— ——
‘hilea Resident
erformed while a resident of this facility and within the last 7 days 2. 3,
3. During Entire 7 Days While a During Entire
Performed during the entire last 7 days Resident
|
7 Days
[| t Enter Codes t
A. Proportion of total calories the resident received through parenteral or tube feeding
O
1 25% or less
2. 26-50%
3. 51% or more
O
= 4
B. Average fluid intake per day by IV or tube feeding
1 500 cc/day or less
2. 501 cc/day or more O L
Section L | Oral/Dental Status
10200. Dental
} Check all that apply
A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose)
B. No natural teeth or tooth fragment(s) (edentulous)
. Abnormal mouth tissue (ulcers, masses, oral lesions, including under denture or partial if one is worn)
D. Obvious or likely cavity or broken natural teeth — =
E. Inflamed or—o
bleeding gums or loose natural teeth_ = —
F,Mouth or facial pain, discomfort or difficulty with chewing_ —
G. Unable to examine
= te |
Z. None of the above were present
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019 Page 33 of 51
BROOKHAVEN 000052
Resident FONTENOT, LINDA Identifier 3947 Date Dec 15,2019
[Section M | Skin Conditions
Report based on highest stage of existing ulcers/i njuries at their worst;
do not "reverse" stage
M0100. Determination of Pressure Ulcer/Injury Risk
——
|} check all that apply —
es} A. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device
as
B. Formal assessment instrument/tool (e.g., Braden, Norton, or other)
& C. Clinical assessment
O Z. None of the above
M0150, Risk of Pressure Ulcers/Injuries
Ent Is this resident at k of developing pressure ulcers/injuries?
0. No
1, Tee
M0210. Unhealed Pressure Ulcers/Injuries
EnterCode | Does this resident have one or more unhealed pressure ulcers/injuries?
0. No —> Skip to M1030, Number of Venous and Arterial Ulcers
| i Yes —> Continue to M0300, Current Number of Unhealed Pressure Ulcers/injuries at Each Stage
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
cece
A. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not
have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues
Enter Number
1, Number of Stage 1 pressure injuries
/'B. Stage 2: Partial thickness loss of dermis presentingas a shallow open ulcer with a red or pink wound bed, without slough. May also
present as an intact or open/ruptured blister
Enter Number
1. Numberof Stage2 pressure ulcers - If0 > Skip to M0300C, Stage 3
7 2. Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted
at the time of admission/entry or reentry
— —- = —ainteel
lc. ‘Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible ut bone, tendon ormuscle isnot exposed, Slough may be
present but does not obscure the depth of tissue loss. May include undermining and tunneling
Enter Number
1, Number of Stage 3 pressure ulcers - If0 > Skipto M0300D, Stage 4
2. Number of these Stage3 pressure ulcers that were present upon admission/entry or reentry- enter how many were
noted at the time of admission/entry or reentry
D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the
wound bed. Often includes undermining and tunneling
Enter umber
1, Number of Stage 4 pressure ulcers- If 0 —> Skip to MO300E, Unstageable - Non-removable dressing/device
Enter Number
2. Number of these Stage4 pressure ulcers that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry
= cat S = a a a
M0300 continued on next page
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019 Page 34 of 51
BROOKHAVEN 000053
Resident FONTENOT, LINDA Identifier 3947 Date Dec 15,2019
[Section NM _| Skinee
Conditions _ = tees ee
| M0300. Current Number of Unhealed Pressure Uleers/Injuies at Each Stage- Continued
= = =
jeE. Unstageable- Non-removable dressing/device: Known but not stageable due to non-removable dressing/device
Enter Number
Number of unstageable pressure ulcers/injuries due to non-removable dressing/device - if0 —» Skip to MO300F,
Unstageable - Slough and/or eschar
Enter Number
2. Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry - enter how many
| were noted at the time of admission/entry or reentry
F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar
Enter Number
1 Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar - If O—> Skip to M0300G,
Unstageable - Deep tissue injury
Enter Number
Number of these unstageable pressure ulcers that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry
G. Unstageable- Deep tissue injury:
Enter Number
1. Number of unstageable pressure injuries presenting as deep tissue injury - If 0 > Skip to M1030,
Number of Venous and Arterial Ulcers
Enter Number
2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry
M1030. Number of Venous and Arterial Ulcers
—
Enter Number
Enter the total number of venous and arterial ulcers present
0
1 40. Other Ulcers, Wounds and Skin Problems
cat Check all that apply a
| Foot Problems
te) | A. Infection | of the foot (e.g., cellulitis, purulent drainage)
oO B. Diabetic foot ulcer(s)
ai ae a —
Oo €. Other open lesion(s) onthe foot
: a — = a ———
Other Problems
Pr
O |p. _ Open lesion(s) other than ulcers, rashes, cuts (e.g, cancer lesion)
& |e. “Surgical wound(s)
= ao
O F.
| Burn(s)
s) (second ¢or ‘third degree)
=
O 1G. Skin tear(s)
a —
O | H. Moisture Associated ‘Skin Damage (MASD) (e.g, incontinence-associated dermatitis [|AD],Perspiration, drainage)
a a a ——
‘No
None ofof t the Above -
es pi ——
O |zZ. None of the above were present
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019 Page 35 of 51
BROOKHAVEN 000054
Resident FONTENOT, LINDA identifier 3947 Date Dec 15, 2019
[Section M
=—
[Skin aConditions
M1200. Skin and Ulcer/Injury Treatments
Ss — a —
cl ck all that apply
A. Pressure reducing device for chair
B. Pressure reducing device for bed
| €. Turning/repositioning program
a i — = 5 — are
| D. Nutrition or hydration intervention to manage skin problems
—
E, Pressure ulcer/injury care
a
F, Surgical wound care
G. Application of nonsurgical dressings (with or without topical medications) other than to feet
H. Applications of ointments/medications other than to feet
1 Application of dressings to feet (with or without topical medications)
Z. None of the above were provided
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019 Page 36 of 51
BROOKHAVEN 000055
3/15/2021 Medicare Shift Documention (Dynasty)
J. Neurological/Sensory/Communication 1 PERRLA "
Decreased grasp
Decreased movement a
Vertigo 8
Syncope u
Dizziness uw
Tremors "
Adequate hearing u
Wears hearing aid "
10. Adequate vision "
4 Wears glasses "
12. Clear and appropriate speech. K
13. Notable changes to neurological/sensory or communication status. "
Pain 4. VERBAL PAIN DESCRIPTION
ta. Resident verbalizes presence of pain. "
4b. Scale out of 10 #
1 2, 3. 4 5. 6, 8. 9. 10.
1c. Location 4
1d. Notes "
ek pate cement
2. NON-VERBAL INDICATOR PAIN
2a. Resident demonstrates non-verbal signs of pain. "
2b. Describe u
Medication/Orders 1. ORDERS
ta. Lab orders received "
4b. Medication orders received. "
te. Treatment orders received. u
4d. Notes "
2. MEDICATIONS
2a, IV Medication "
2b. Treat Infection 4
2c. IM Medication "
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BROOKHAVEN 000056
3/15/2021 Medicare Shift Documention (Dynasty)
2d. IV Fluids "
2e. Note any adverse affects to medications. “
3. Notes on medications and treatments. "
M. Skilled Services 1. Therapy/ Rehabilitative Services
fa. Physical Therapy u
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 a
Teaching and Training
2c. (ex. post-op care, medication, pain mgnmt) Describe in Notes (2d) "
3. ADDITIONAL DIRECT SKILLED NURSING SERVICES
3a. Dialysis n
3b. Tube Feeding "
3c, Restorative Nursing Services u
3d. Post-surgical services "
3e, Diabetic monitoring "
4. Skilled Progress Notes "
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BROOKHAVEN 000057
3/15/2021 Medicare Shift Documention (Dynasty)
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BROOKHAVEN 000058
HISTORY AND
PHYSICIAL
Date: May 17, 2021 Brookhaven Nursing and Rehab Facility#
Time: 15:39:14 CT Progress Notes
User: Pamela McGee Page #1
Resident Name: LINDA FONTENOT (3947) Location: - Admission Date: 12/11/2019
Medical Record #: 3947 Gender: F Date
of Birth:
Phy: jan: PATEL, KETAN Pharmacy: OMNICARE OF FORT WORTH
Allergies: Hydralazine
Diagnoses: PNEUMONIA, UNSPECIFIED ORGANISM, PAROXYSMAL ATRIAL FIBRILLATION, SCHIZOPHRENIA,
UNSPECIFIED, ELEVATED WHITE BLOOD CELL COUNT, UNSPECIFIED, UNSPECIFIED
ABNORMALITIES OF GAIT AND MOBILITY, MUSCLE WEAKNESS (GENERALIZED), MUSCLE WASTING
AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE, COGNITIVE COMMUNICATION
DEFICIT, DYSPHAGIA, OROPHARYNGEAL PHASE, ESSENTIAL (PRIMARY) HYPERTENSION,
ENCOUNTER FOR OTHER SPECIFIED AFTERCARE, BIPOLAR DISORDER, UNSPECIFIED, ACUTE
PANCREATITIS WITHOUT NECROSIS OR INFECTION, UNSPECIFIED
Effective Date: 12/12/2019 15:54
Type: Physician's History and Physical
Note Te:
History ani 3 Physical Exam:
HPI:
66 years years old female adm to hospital with abdominal pain. She was diagnosed with gall stone pancreatitis and a large 25cm
retroperitoneal mass. She underwent resection of mass by Dr Gogel. Pt is now adm to snf.
she remains confused. pt denies any n or v
no fever
no chills
no abdominal pain
Past Medical History
anemia
schizophrenia
anxiety
depression
Past Surgical History
as above
Family History: Non-contributory
Social History:
Lives - @ home
Smoking no
ETOH no
Drugs no
BROOKHAVEN 000060
Date: May 17, 2021 Brookhaven Nursing and Rehab Facility #
Time: 39:14 CT Progress Notes
User: Pamela McGee Page #2
Resident Name: LINDA FONTENOT (3947) Location: - Admission Date: 12/11/2019
Allergies:
Medication List: As per EMR / Reviewed
Review of Systems:
4. 1. Constitutional symptoms
Yes: Generalized weakness
1. 2. Eyes
Yes:
No: Vision problem, Blurry vision, Red eye
1. 3. Ears, Nose, Mouth & Throat
Yes:
No: Hearing Loss, vertigo, sore throat, ear discharge
1. 4. Respiratory
Yes:
No: SOB, Cough, Blood in sputum
1. 5. Cardiovascular
Yes:
No: Chest Pain, Palpitation, Exertional SOB,
1. 6. Gastrointestinal
Yes
No: Loss of appetite, Abdominal Pain, N, V
1. 7. Genitourinary
Yes:
No: Dysuria, Hematuria, Urinary incontinence
1. 8. Musculoskeletal
Yes:
No: Muscle pain, joint pain
1. 9. Integumentary (Skin and/or Breast)
BROOKHAVEN 000061
Date: May 17, 2021 Brookhaven Nursing and Rehab Facility #
Time: 314 CT Progress Notes
User: Pamela McGee Page #3
Resident Name: LINDA FONTENOT (3947) Location: - Admission Date: 12/11/2019
Yes:
No: Rash, Skin lesions, Itching
1. 10. Neurological
Yes
No: Headahce, Dizziness, speech problem
4. 11. Psychiatric
Yes:
No: Anxiety, Depression, Sleep problem
1. 12. Hematologic/Lymphatic
Yes:
No: Anemia, Bleeding disorder, bruising
PHYSICAL EXAMINATION:
GENERAL: NAD
VITAL SIGNS: Reviewd. Afebrile. Stable
HEENT: Atraumatic and Normocephalic head. No ear or nasal discharge nated. Oral mucosa is moist.
NECK: Supple. No carotid bruits. No lymphadenopathy or thyromegaly.
LUNGS: Clear to auscultation. no use of accessory muscles of respiration. no wheezing
HEART: Regular rate and rhythm without murmur.
ABDOMEN: Large midline surgical wound - dressed. Soft, non-tender, and non-distended Positive bowel sounds. No
hepatosplenomegaly was noted.
EXTREMITIES: No edema. No cyanosis. Normal ROM to joints
NEUROLOGIC: AAO x 3
PSYCHIATRIC: NAD
Labs: Reviewed
X-rays: Reviewed
Other measures:
Pt is non- smoker (CPT II 1036F)
Med list reviewed. D/w team. Monthly meds ordered / reconciled and signed. Documented in the chart. (G 8427)
Advanced Directives ( CPT II 1023F - 1024F)
Assessment and Plan:
1. Gallstone pancreatitis - s/p cholecystectomy
BROOKHAVEN 000062
Date: lay 17, 2021 Brookhaven Nursing and Rehab Facitity #
Time: 39:14 CT Progress Notes
User: Pamela McGee Page #4
Resident Name: LINDA FONTENOT (3947) Location: - Admission Date: 12/11/2019
Large Retroperitoneal Mass - s/p Resection by Dr Gogel - awaiting biopsy results
C diff colitis - resolved
Acute respiratory failure and Pneumonia - improved
Severe PCM
Schizophrenia
Bipolar disorder
AKI
Debility
Admission labs requested
Home meds / Hospital orders will be resumed
physical therapy, occupational therapy and speech therapy evaluation
fall precautions
aspiration precautions
Monitor weight.
Nutrition consult as needed
Optimize oral hydration / nutrition
Monitor for weight loss and intervene as needed
off loading and wound care precautions as needed
Keep follow up with specialist as recommended
comprehensive poc reviewed / signed
Author: Ketan Patel - MD [e-SIGNED]
BROOKHAVEN 000063
3/48/2021 Neurological Checklist (Dynasty)
x] Search
Neurological Checklist (Dynasty)
Re: FONTENOT, LINDA (3947)
Descriptio Neuro-checks
Dat 12/12/2019 10:47
Section Statu: Signed
Lock Date: 12/12/2019 11:17
{ Cancel |
A VITAL SIGNS 1 Most Recont Tomperature Eu
Temperature: 98.3 (°F) Date: 12/12/2019 10:1
Route: ‘Temporal Artery
Most Recent Pulse E 4
Pulse: 89 (bpm) Date: 12/12/2019 10:16
Pulse Type: Regular
Most Recent Respiration E A
Respiration: 20 (Breaths/min) Date: 12/12/2019 10:16
Most Recent Blood Pressure E 1
Blood Pressure: 130 / 76 (mmHg) Date: 12/12/2019 10:16
Position: Sitting Varm
B. ORIENTATION 4 Person 4
0. Yes 1..No
Place "
0. Yes 1..No
Time "
0. Yes 1.No
Situation "
0. Yes 1..No
Notes 4
¢. Loc Alert "
0. Yes 1..No
Non-rousable "
Lethargic u
Drowsy n
Stuporus. "
Confused
7. . Other/Notes. n
o. PUPILS 4 Equal u
0. Yes 4.No
2. Pupil Size and Reaction
2a. Left Reactive to Light H
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BROOKHAVEN 000064
3/15/2021 Neurological Checklist (Dynasty)
0. Yes 4.No
2b. Left Pupil Size 4
4mm. 2mm. 3mm. 4mm 5mm. 6mm, 7mm 8mm. ‘9mm,
10mm.
2c. ight Reactive to Light "
0. Yes 4.No
2d, Right Pupil Size "
1mm, 2mm. 3mm. 4mm. 5mm. 6mm. 7mm 8mm. ‘mm.
10mm.
3. Can follow finger with eyes? 4
0. Yes 4.No
4. Notes uw
—, RESPONSES dl . Responds to simple commands? #
0. Yes 1,.No
2 . Verbalizes appropriately’? "
0. Yes 1.NO 2. Unable ly deternine/does not verbalize
3. . Notes "
F. PAIN 4, Verbal expression of pain? "
0. Yes 4. No 2. Unable to determine/does not verbalize
4a. Pain (Score out of 10) "
4 2. 3. 4 5. 6. 7 8. 9. 10.
2. Grimaces, withdraws, shows non-verbal signs of pain? "
0. Yes 1. No
3. Notes "
G, EXTREMETIES 1 . Movement and sensation intact in right arm? "
0. Yes 1..No 2. NIA
2. . Movement and sensation intact in left arm? 4"
0. Yes 4.No 2. N/A
3. . Movement and sensation intact in right leg? "
0. Yes 4..No 2.N/A
4. | Movement and sensation intact in left leg? "
0. Yes 4.No 2..N/A
5. }. Notes: "
H. COMMENTS 4
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FROOKHAVEN 000065
3/15/2021 Neurological Checklist (Dynasty)
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BROOKHAVEN 000066
3/15/2021 Neurological Checklist (Dynasty)
tt | Search
Neurological Checklist (Dynasty)
Resident: FONTENOT, LINDA (3947)
Description: Neuro-checks
Date: 12/12/2019 06:45
Section Status: Signed 7
Lock Date: 12/12/2019 11:15
| Cancel
A. VITAL SIGNS 1 Most Recent Temperature Eu
Temperature: 97.6 (°F) Date; 12/12/2019 06:30
Route: ‘Temporal Artery
Most Recent Pulse E "
Pulse: 76 (bpm) Date: 12/12/2019 06:31
Pulse Type: Regular
Most Recent Respiration € 1
Respiration: 18 (Breaths/min) Date: 12/12/2019 06:30
Most Recent Blood Pressure E u
Blood Pressure: 118 / 70 (mmHg) Date: 12/12/2019 06:30
Position: si 9 Warm
B. ORIENTATION 1 Person 4
0. Yes No
Place "
0. Yes No
Time "
0. Yes No
Situation "
0. Yes No
Notes
c. Loc Alert 8
0. Yes 1 No.
Non-rousable
Lethargic uw
Drowsy n
Stuporus. a
Confused
7. . Other/Notes "
D. PUPILS 1 Equal H
0. Yes 4..No
2. Pupil Size and Reaction
2a. Left Reactive to Light 4
hitns://www?1 nointclickcare.com/care/chartimdsimdssection .iso?7ESOLassessid=836503&retURL=/admin/clientcp assessment jsp&ESOLclientid=9... 113
SROOKHAVEN 000067
3/15/2021 Neurological Checklist (Dynasty)
0. Yes 1.No.
2b. Left Pupil Size "
4mm: 2mm. 3mm. 4mm. 5mm. 6mm. 7mm. amm. 9mm.
10mm.
2c. Right Reactive to Light
0. Yes 1,No
2d. Right Pupil Size n
4mm. 2mm. 3mm. 4mm. 5mm. 6mm. 7mm. 8mm. 9mm.
40mm.
Can follow finger with eyes? "
0. Yes 4.No
Notes u
—. RESPONSES 4. . Responds to simple commands? 4
0. Yes 1..No
2. . Verbalizes appropriately? "
0. Yes 1.NO 2. Unable to determine/does not verhalize
3. . Notes. 4H
F. PAIN 4 Verbal expression of pain? a
0. Yes 1.No 2. Unable to determine/does not verbalize
1a, Pain (Score out of 10) "
4 2. 3. 4. 5. 6. a 8. 9. 10.
Grimaces, withdraws, shows non-verbal signs of pain? u
0. Yes 1..No
Notes "
G, EXTREMETIES 1 |. Movement and sensation intact in right arm? "
0. Yes 1..No 2.N/A
. Movement and sensation intact in left arm? "
0. Yes 1. No 2. NIA
Preview
FILED 10/12/2023 12:04 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 2 Resident FONTENOT, LINDA Identifier 3947 Date Dec 15, 2019 |Section) |Health Conditions —— = Surgical Procedures -Complete o1 only if 2 1000 Lo a —— Check all that apply —— ee — = — a [ Major Joint Replacement 32300, Knee Replacement- partial or total J2310. Hip Replacement - partial or total | 12320. Ankle Replacement - partial or total 42330. Shoulder Replacement - partial or total | Spinal Surgery 32400. Involving the spinal cord or major spinalnerves J2410. Involving fusion of spinal bones 52420. Involving lamina, discs, or facets 12499. Other major spinal surgery_ — as a a [Other Orthopedic Surgery —____] 42500. Repair fractures of the shoulder (including clavicle and scapula)or arm (but not hand) 32510. Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot) 42520. Repair but not replace joints 32530. Repair other bones (such as hand, foot, jaw) 52599. Other major orthopedic surgery = ~ — a [Neurological Surgery ao 42600. Involving the brain, surrounding tissue or blood vessels (excludes skull and skin but includes cranial nerves) 42610. Involving the peripheral or autonomic nervous system - open or percutaneous J2620, Insertion or removal of spinal or brain neurostimulators, electrodes, catheters, or CSF drainage devices 42699. Other major neurological surgery —. = - _ ——— ‘Cardiopulmonary Surgery — =< a 42700. Invoh g the heart or major blood vessels - open or percutaneous procedures 42710. Involving the respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords - open or endoscopic 42799. Other major cardiopulmonary surgery —— —— nitourinary Surgery [J 12800. tnvol g male or female organs (suchas ‘as prostate, ‘testes, ovaries, uterus,vagina, external genitalia) oO 42810, Involving the kidneys, ureters, adrenal glands, or bladder - open or laparoscopic (includes creation or removal of nephrostomies or urostomies) ey 42899. Other major genitourinary surgery = | Other Major Surgery es 32900. Involving tendons, ligaments, or muscles 42910. Involving the gastrointestinal tract or abdominal contents from the esophagus to the anus, the biliary tree, gall bladder, liver, | pancreas, or spleen - open or laparoscopic (including creation or removal of ostomies or percutaneous feeding tubes, or hernia repair) ie 52920. Involving the endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, or thymus - open [e) 42930. Involving the breast _ 42940. Repair of deep ulcers, internal brachytherapy, bone marrow or stem cell harvest or transplant O1 55000, Other major surgery not listed above sta ———! MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019 Page 31 of 51 BROOKHAVEN 000050 Resident FONTENOT, LINDA Identifier 3947 Date Dec 15, 2019 Section K — Swallowing/Nutritional [ Status —== ————————= = = = K0100. Swallowing Disorder ©=ns and symptoms of possible swallowing disorder _ = | Check all that apply L A. Loss of liquids/solids from mouth when eating or drinking oO B. Holding food in mouth/cheeks or residual food in mouth after meals €. Coughing or choking during meals or when swallowing medications [1] | D. Complaints of difficulty or pain with swallowing O Z. None of the above K0200. Height and Weight- While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up T | A. Height (in inches). Record most recent height measure since the most recent admission/entry or reentry inches a a B. Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to standard facility practice (e.g,, in a.m. after voiding, before meal, with shoes off, etc.) pounds K0300. Weight Loss Loss of 5% or more in the last month or loss of 10% or more in last 6 months Enter Code 0. Noor unknown 1 Yes, on physician-prescribed weight-loss regimen 2. Yes, not on physician-prescribed weight-loss regimen K0310. Weight Gain Gain of 5% or more in the last month or gain of 10% or more in last 6 months Enter Code 9, No or unknown 1 Yes, on physician- prescribed weight-gain regimen 2. Yes, not on physician-prescribed weight-gain regimen 0. Nutritional Approaches Check all of the following nutritional approaches that were performed during the last 7 days 1, While NOT a Resident Performed while NOT a resident of this facility and within the last 7 days. Only check column 1 if L resident entered (admission or reentry) IN THE LAST 7 DAYS. If resident last entered 7 or more days While NOTa ago, leave column 1 blank Resident Resident 2. While a Resident Performed——swhile a resident of this facility and within the last 7 days | Check all that apply| A. Parenteral/IV feeding oO oO B. Feeding tube - nasogastric or abdominal (PEG) ie) fee} . Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids) D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol) = Z. None of the above : oO MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019 Page 32 0f 51 BROOKHAVEN 000051 Resident FONTENOT, LINDA Identifier 3947 Date Dec 15,2019 [Section K Swallowing/Nutritional | Status K0710. Percent Intake by Artificial Route R ite -- Complete KO710 only if Column 1 and/or Column 2 are checked for KO510A and/or KO510B a ———— —— ‘hilea Resident erformed while a resident of this facility and within the last 7 days 2. 3, 3. During Entire 7 Days While a During Entire Performed during the entire last 7 days Resident | 7 Days [| t Enter Codes t A. Proportion of total calories the resident received through parenteral or tube feeding O 1 25% or less 2. 26-50% 3. 51% or more O = 4 B. Average fluid intake per day by IV or tube feeding 1 500 cc/day or less 2. 501 cc/day or more O L Section L | Oral/Dental Status 10200. Dental } Check all that apply A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) B. No natural teeth or tooth fragment(s) (edentulous) . Abnormal mouth tissue (ulcers, masses, oral lesions, including under denture or partial if one is worn) D. Obvious or likely cavity or broken natural teeth — = E. Inflamed or—o bleeding gums or loose natural teeth_ = — F,Mouth or facial pain, discomfort or difficulty with chewing_ — G. Unable to examine = te | Z. None of the above were present MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019 Page 33 of 51 BROOKHAVEN 000052 Resident FONTENOT, LINDA Identifier 3947 Date Dec 15,2019 [Section M | Skin Conditions Report based on highest stage of existing ulcers/i njuries at their worst; do not "reverse" stage M0100. Determination of Pressure Ulcer/Injury Risk —— |} check all that apply — es} A. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device as B. Formal assessment instrument/tool (e.g., Braden, Norton, or other) & C. Clinical assessment O Z. None of the above M0150, Risk of Pressure Ulcers/Injuries Ent Is this resident at k of developing pressure ulcers/injuries? 0. No 1, Tee M0210. Unhealed Pressure Ulcers/Injuries EnterCode | Does this resident have one or more unhealed pressure ulcers/injuries? 0. No —> Skip to M1030, Number of Venous and Arterial Ulcers | i Yes —> Continue to M0300, Current Number of Unhealed Pressure Ulcers/injuries at Each Stage M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage cece A. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues Enter Number 1, Number of Stage 1 pressure injuries /'B. Stage 2: Partial thickness loss of dermis presentingas a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister Enter Number 1. Numberof Stage2 pressure ulcers - If0 > Skip to M0300C, Stage 3 7 2. Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry — —- = —ainteel lc. ‘Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible ut bone, tendon ormuscle isnot exposed, Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling Enter Number 1, Number of Stage 3 pressure ulcers - If0 > Skipto M0300D, Stage 4 2. Number of these Stage3 pressure ulcers that were present upon admission/entry or reentry- enter how many were noted at the time of admission/entry or reentry D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling Enter umber 1, Number of Stage 4 pressure ulcers- If 0 —> Skip to MO300E, Unstageable - Non-removable dressing/device Enter Number 2. Number of these Stage4 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry = cat S = a a a M0300 continued on next page MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019 Page 34 of 51 BROOKHAVEN 000053 Resident FONTENOT, LINDA Identifier 3947 Date Dec 15,2019 [Section NM _| Skinee Conditions _ = tees ee | M0300. Current Number of Unhealed Pressure Uleers/Injuies at Each Stage- Continued = = = jeE. Unstageable- Non-removable dressing/device: Known but not stageable due to non-removable dressing/device Enter Number Number of unstageable pressure ulcers/injuries due to non-removable dressing/device - if0 —» Skip to MO300F, Unstageable - Slough and/or eschar Enter Number 2. Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry - enter how many | were noted at the time of admission/entry or reentry F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Enter Number 1 Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar - If O—> Skip to M0300G, Unstageable - Deep tissue injury Enter Number Number of these unstageable pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry G. Unstageable- Deep tissue injury: Enter Number 1. Number of unstageable pressure injuries presenting as deep tissue injury - If 0 > Skip to M1030, Number of Venous and Arterial Ulcers Enter Number 2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry M1030. Number of Venous and Arterial Ulcers — Enter Number Enter the total number of venous and arterial ulcers present 0 1 40. Other Ulcers, Wounds and Skin Problems cat Check all that apply a | Foot Problems te) | A. Infection | of the foot (e.g., cellulitis, purulent drainage) oO B. Diabetic foot ulcer(s) ai ae a — Oo €. Other open lesion(s) onthe foot : a — = a ——— Other Problems Pr O |p. _ Open lesion(s) other than ulcers, rashes, cuts (e.g, cancer lesion) & |e. “Surgical wound(s) = ao O F. | Burn(s) s) (second ¢or ‘third degree) = O 1G. Skin tear(s) a — O | H. Moisture Associated ‘Skin Damage (MASD) (e.g, incontinence-associated dermatitis [|AD],Perspiration, drainage) a a a —— ‘No None ofof t the Above - es pi —— O |zZ. None of the above were present MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019 Page 35 of 51 BROOKHAVEN 000054 Resident FONTENOT, LINDA identifier 3947 Date Dec 15, 2019 [Section M =— [Skin aConditions M1200. Skin and Ulcer/Injury Treatments Ss — a — cl ck all that apply A. Pressure reducing device for chair B. Pressure reducing device for bed | €. Turning/repositioning program a i — = 5 — are | D. Nutrition or hydration intervention to manage skin problems — E, Pressure ulcer/injury care a F, Surgical wound care G. Application of nonsurgical dressings (with or without topical medications) other than to feet H. Applications of ointments/medications other than to feet 1 Application of dressings to feet (with or without topical medications) Z. None of the above were provided MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019 Page 36 of 51 BROOKHAVEN 000055 3/15/2021 Medicare Shift Documention (Dynasty) J. Neurological/Sensory/Communication 1 PERRLA " Decreased grasp Decreased movement a Vertigo 8 Syncope u Dizziness uw Tremors " Adequate hearing u Wears hearing aid " 10. Adequate vision " 4 Wears glasses " 12. Clear and appropriate speech. K 13. Notable changes to neurological/sensory or communication status. " Pain 4. VERBAL PAIN DESCRIPTION ta. Resident verbalizes presence of pain. " 4b. Scale out of 10 # 1 2, 3. 4 5. 6, 8. 9. 10. 1c. Location 4 1d. Notes " ek pate cement 2. NON-VERBAL INDICATOR PAIN 2a. Resident demonstrates non-verbal signs of pain. " 2b. Describe u Medication/Orders 1. ORDERS ta. Lab orders received " 4b. Medication orders received. " te. Treatment orders received. u 4d. Notes " 2. MEDICATIONS 2a, IV Medication " 2b. Treat Infection 4 2c. IM Medication " https://www21 pointclickcare.com/care/charlmds/mdssection jsp?ESOLassessid=83667 7&retURL=/admin/clienUcp_assessment jsp&ESOL clientid=9. 68 BROOKHAVEN 000056 3/15/2021 Medicare Shift Documention (Dynasty) 2d. IV Fluids " 2e. Note any adverse affects to medications. “ 3. Notes on medications and treatments. " M. Skilled Services 1. Therapy/ Rehabilitative Services fa. Physical Therapy u 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 a Teaching and Training 2c. (ex. post-op care, medication, pain mgnmt) Describe in Notes (2d) " 3. ADDITIONAL DIRECT SKILLED NURSING SERVICES 3a. Dialysis n 3b. Tube Feeding " 3c, Restorative Nursing Services u 3d. Post-surgical services " 3e, Diabetic monitoring " 4. Skilled Progress Notes " | Cancel Click Here to View Quick Entry - Keyboard Navigation Tips httne-/Mmnww?1 nointelickcare.comicare/chart/mds/mdssection jsp?ESOLassessid=836677 &retURL=/admin/clientcp_assessment,jsp&ESOLclientid=9 78 BROOKHAVEN 000057 3/15/2021 Medicare Shift Documention (Dynasty) Brookhaven Nursing and Rehab PointClickCare Privacy Policy 1855 Cheyenne Drive 5670 Explorer Drive Customer Support Carrollton TX 75010-2204 Mississal 1a, Ontario LAW 0 Version 4.3.3.9 www21-per-web-m: Phone: (972) 94-7144 Help Desk: (877) 722-2431 | ( 905} 817-6167 6c84744d09-79kxp PCC Facility 1D: 9 Toll Free: (BOC 89| Copyright 200 1 PointClickCare Phone: ( 858-8885 | Technologies Inc. All rights reserved Fax: (905) 858-2248 httos://www21 pointclickcare.com/care/chartmds/mdssection.isp?7ESOLassessi 836677 &retURL=/admin/clienvicp_assessment.jsp&ESOLclientid=9. 88 BROOKHAVEN 000058 HISTORY AND PHYSICIAL Date: May 17, 2021 Brookhaven Nursing and Rehab Facility# Time: 15:39:14 CT Progress Notes User: Pamela McGee Page #1 Resident Name: LINDA FONTENOT (3947) Location: - Admission Date: 12/11/2019 Medical Record #: 3947 Gender: F Date of Birth: Phy: jan: PATEL, KETAN Pharmacy: OMNICARE OF FORT WORTH Allergies: Hydralazine Diagnoses: PNEUMONIA, UNSPECIFIED ORGANISM, PAROXYSMAL ATRIAL FIBRILLATION, SCHIZOPHRENIA, UNSPECIFIED, ELEVATED WHITE BLOOD CELL COUNT, UNSPECIFIED, UNSPECIFIED ABNORMALITIES OF GAIT AND MOBILITY, MUSCLE WEAKNESS (GENERALIZED), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE, COGNITIVE COMMUNICATION DEFICIT, DYSPHAGIA, OROPHARYNGEAL PHASE, ESSENTIAL (PRIMARY) HYPERTENSION, ENCOUNTER FOR OTHER SPECIFIED AFTERCARE, BIPOLAR DISORDER, UNSPECIFIED, ACUTE PANCREATITIS WITHOUT NECROSIS OR INFECTION, UNSPECIFIED Effective Date: 12/12/2019 15:54 Type: Physician's History and Physical Note Te: History ani 3 Physical Exam: HPI: 66 years years old female adm to hospital with abdominal pain. She was diagnosed with gall stone pancreatitis and a large 25cm retroperitoneal mass. She underwent resection of mass by Dr Gogel. Pt is now adm to snf. she remains confused. pt denies any n or v no fever no chills no abdominal pain Past Medical History anemia schizophrenia anxiety depression Past Surgical History as above Family History: Non-contributory Social History: Lives - @ home Smoking no ETOH no Drugs no BROOKHAVEN 000060 Date: May 17, 2021 Brookhaven Nursing and Rehab Facility # Time: 39:14 CT Progress Notes User: Pamela McGee Page #2 Resident Name: LINDA FONTENOT (3947) Location: - Admission Date: 12/11/2019 Allergies: Medication List: As per EMR / Reviewed Review of Systems: 4. 1. Constitutional symptoms Yes: Generalized weakness 1. 2. Eyes Yes: No: Vision problem, Blurry vision, Red eye 1. 3. Ears, Nose, Mouth & Throat Yes: No: Hearing Loss, vertigo, sore throat, ear discharge 1. 4. Respiratory Yes: No: SOB, Cough, Blood in sputum 1. 5. Cardiovascular Yes: No: Chest Pain, Palpitation, Exertional SOB, 1. 6. Gastrointestinal Yes No: Loss of appetite, Abdominal Pain, N, V 1. 7. Genitourinary Yes: No: Dysuria, Hematuria, Urinary incontinence 1. 8. Musculoskeletal Yes: No: Muscle pain, joint pain 1. 9. Integumentary (Skin and/or Breast) BROOKHAVEN 000061 Date: May 17, 2021 Brookhaven Nursing and Rehab Facility # Time: 314 CT Progress Notes User: Pamela McGee Page #3 Resident Name: LINDA FONTENOT (3947) Location: - Admission Date: 12/11/2019 Yes: No: Rash, Skin lesions, Itching 1. 10. Neurological Yes No: Headahce, Dizziness, speech problem 4. 11. Psychiatric Yes: No: Anxiety, Depression, Sleep problem 1. 12. Hematologic/Lymphatic Yes: No: Anemia, Bleeding disorder, bruising PHYSICAL EXAMINATION: GENERAL: NAD VITAL SIGNS: Reviewd. Afebrile. Stable HEENT: Atraumatic and Normocephalic head. No ear or nasal discharge nated. Oral mucosa is moist. NECK: Supple. No carotid bruits. No lymphadenopathy or thyromegaly. LUNGS: Clear to auscultation. no use of accessory muscles of respiration. no wheezing HEART: Regular rate and rhythm without murmur. ABDOMEN: Large midline surgical wound - dressed. Soft, non-tender, and non-distended Positive bowel sounds. No hepatosplenomegaly was noted. EXTREMITIES: No edema. No cyanosis. Normal ROM to joints NEUROLOGIC: AAO x 3 PSYCHIATRIC: NAD Labs: Reviewed X-rays: Reviewed Other measures: Pt is non- smoker (CPT II 1036F) Med list reviewed. D/w team. Monthly meds ordered / reconciled and signed. Documented in the chart. (G 8427) Advanced Directives ( CPT II 1023F - 1024F) Assessment and Plan: 1. Gallstone pancreatitis - s/p cholecystectomy BROOKHAVEN 000062 Date: lay 17, 2021 Brookhaven Nursing and Rehab Facitity # Time: 39:14 CT Progress Notes User: Pamela McGee Page #4 Resident Name: LINDA FONTENOT (3947) Location: - Admission Date: 12/11/2019 Large Retroperitoneal Mass - s/p Resection by Dr Gogel - awaiting biopsy results C diff colitis - resolved Acute respiratory failure and Pneumonia - improved Severe PCM Schizophrenia Bipolar disorder AKI Debility Admission labs requested Home meds / Hospital orders will be resumed physical therapy, occupational therapy and speech therapy evaluation fall precautions aspiration precautions Monitor weight. Nutrition consult as needed Optimize oral hydration / nutrition Monitor for weight loss and intervene as needed off loading and wound care precautions as needed Keep follow up with specialist as recommended comprehensive poc reviewed / signed Author: Ketan Patel - MD [e-SIGNED] BROOKHAVEN 000063 3/48/2021 Neurological Checklist (Dynasty) x] Search Neurological Checklist (Dynasty) Re: FONTENOT, LINDA (3947) Descriptio Neuro-checks Dat 12/12/2019 10:47 Section Statu: Signed Lock Date: 12/12/2019 11:17 { Cancel | A VITAL SIGNS 1 Most Recont Tomperature Eu Temperature: 98.3 (°F) Date: 12/12/2019 10:1 Route: ‘Temporal Artery Most Recent Pulse E 4 Pulse: 89 (bpm) Date: 12/12/2019 10:16 Pulse Type: Regular Most Recent Respiration E A Respiration: 20 (Breaths/min) Date: 12/12/2019 10:16 Most Recent Blood Pressure E 1 Blood Pressure: 130 / 76 (mmHg) Date: 12/12/2019 10:16 Position: Sitting Varm B. ORIENTATION 4 Person 4 0. Yes 1..No Place " 0. Yes 1..No Time " 0. Yes 1.No Situation " 0. Yes 1..No Notes 4 ¢. Loc Alert " 0. Yes 1..No Non-rousable " Lethargic u Drowsy n Stuporus. " Confused 7. . Other/Notes. n o. PUPILS 4 Equal u 0. Yes 4.No 2. Pupil Size and Reaction 2a. Left Reactive to Light H https:/www21 pointclickcare.com/care/chart/mds/mdssection jsp?ESOLassessid=836461 &retURL=/admin/clienvcp_assessmentjsp&ESOLclientid=9. 113 BROOKHAVEN 000064 3/15/2021 Neurological Checklist (Dynasty) 0. Yes 4.No 2b. Left Pupil Size 4 4mm. 2mm. 3mm. 4mm 5mm. 6mm, 7mm 8mm. ‘9mm, 10mm. 2c. ight Reactive to Light " 0. Yes 4.No 2d, Right Pupil Size " 1mm, 2mm. 3mm. 4mm. 5mm. 6mm. 7mm 8mm. ‘mm. 10mm. 3. Can follow finger with eyes? 4 0. Yes 4.No 4. Notes uw —, RESPONSES dl . Responds to simple commands? # 0. Yes 1,.No 2 . Verbalizes appropriately’? " 0. Yes 1.NO 2. Unable ly deternine/does not verbalize 3. . Notes " F. PAIN 4, Verbal expression of pain? " 0. Yes 4. No 2. Unable to determine/does not verbalize 4a. Pain (Score out of 10) " 4 2. 3. 4 5. 6. 7 8. 9. 10. 2. Grimaces, withdraws, shows non-verbal signs of pain? " 0. Yes 1. No 3. Notes " G, EXTREMETIES 1 . Movement and sensation intact in right arm? " 0. Yes 1..No 2. NIA 2. . Movement and sensation intact in left arm? 4" 0. Yes 4.No 2. N/A 3. . Movement and sensation intact in right leg? " 0. Yes 4..No 2.N/A 4. | Movement and sensation intact in left leg? " 0. Yes 4.No 2..N/A 5. }. Notes: " H. COMMENTS 4 Cancel Click Here to View Quick Entry - Keyboard Navigation Tips hitos://www21 pointclickcare.com/care/charmds/mdssection.isp?ESOLassessid=83646 1 &retURL=/admin/clienticp_assessment jsp&ESOLclientid=9. 23 FROOKHAVEN 000065 3/15/2021 Neurological Checklist (Dynasty) Brookhaven Nursing and Rehab PointClickCare Privacy Policy 1855 Cheyenne Drive 5570 Explorer Driv Customer Support arroltton. TX 40-2201 Mississauga, Ont rio LAW on 4.3.3.9 ww2t-p web-main Pr (972) 394-7141 Help Desk: (677) 2434 05) 81 BATA c PCC Fazility ID: 9 Toll Free: 600) 277-! 5889 | ‘opyright 200 2 021 PointClickCare Phone: ) 858-8885 | Technologies ino, Ail rights reserved ax: { 5)8 2248 https://www21 pointclickcare.com/care/chartmds/mdssection jsp?ESOLassessid=836461 &retURL=/admin/clienticp_assessment jsp&ESOLclientid=9. 3/3, BROOKHAVEN 000066 3/15/2021 Neurological Checklist (Dynasty) tt | Search Neurological Checklist (Dynasty) Resident: FONTENOT, LINDA (3947) Description: Neuro-checks Date: 12/12/2019 06:45 Section Status: Signed 7 Lock Date: 12/12/2019 11:15 | Cancel A. VITAL SIGNS 1 Most Recent Temperature Eu Temperature: 97.6 (°F) Date; 12/12/2019 06:30 Route: ‘Temporal Artery Most Recent Pulse E " Pulse: 76 (bpm) Date: 12/12/2019 06:31 Pulse Type: Regular Most Recent Respiration € 1 Respiration: 18 (Breaths/min) Date: 12/12/2019 06:30 Most Recent Blood Pressure E u Blood Pressure: 118 / 70 (mmHg) Date: 12/12/2019 06:30 Position: si 9 Warm B. ORIENTATION 1 Person 4 0. Yes No Place " 0. Yes No Time " 0. Yes No Situation " 0. Yes No Notes c. Loc Alert 8 0. Yes 1 No. Non-rousable Lethargic uw Drowsy n Stuporus. a Confused 7. . Other/Notes " D. PUPILS 1 Equal H 0. Yes 4..No 2. Pupil Size and Reaction 2a. Left Reactive to Light 4 hitns://www?1 nointclickcare.com/care/chartimdsimdssection .iso?7ESOLassessid=836503&retURL=/admin/clientcp assessment jsp&ESOLclientid=9... 113 SROOKHAVEN 000067 3/15/2021 Neurological Checklist (Dynasty) 0. Yes 1.No. 2b. Left Pupil Size " 4mm: 2mm. 3mm. 4mm. 5mm. 6mm. 7mm. amm. 9mm. 10mm. 2c. Right Reactive to Light 0. Yes 1,No 2d. Right Pupil Size n 4mm. 2mm. 3mm. 4mm. 5mm. 6mm. 7mm. 8mm. 9mm. 40mm. Can follow finger with eyes? " 0. Yes 4.No Notes u —. RESPONSES 4. . Responds to simple commands? 4 0. Yes 1..No 2. . Verbalizes appropriately? " 0. Yes 1.NO 2. Unable to determine/does not verhalize 3. . Notes. 4H F. PAIN 4 Verbal expression of pain? a 0. Yes 1.No 2. Unable to determine/does not verbalize 1a, Pain (Score out of 10) " 4 2. 3. 4. 5. 6. a 8. 9. 10. Grimaces, withdraws, shows non-verbal signs of pain? u 0. Yes 1..No Notes " G, EXTREMETIES 1 |. Movement and sensation intact in right arm? " 0. Yes 1..No 2.N/A . Movement and sensation intact in left arm? " 0. Yes 1. No 2. NIA