Preview
FILED
10/12/2023 12:19 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. 1167! 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 5
Physical Therapy
PT Evaluation & Plan of Treatment
Provider: Brookhaven Nursing and Certification Period: 12/12/2019 - 1/12/2020
NPI 1639468473 Physical Therapy
{[denafeationinvormaton
Patient:
Payer:
FONTENOT, LINDA
Managed Care Part A - PDPM (MGA) ~~ ‘Start of Gare: 222018
MR 3947
| certify the need for these medically necessary services furnished under this plan of treatment while under my care from
12/12/2019 through 1/12/2020.
Physician Signature Not Requi
Physician Signature: : 5
Ketan PATEL NPE 1003814148 Date:
[initial Assessment / Current Level of Function & Underlying Impairments
Patient Referral and History
Current Referral Reason for Referral / Current liness: Patient referred to PT due to decline in strength, static balance, pain, dynamic
balance, coordination, ability to move without pain, functional mobility and functional ambulation.
Hx/Complexities PMHix: Schizophrenia, bipolar, dementia, dysphagia
Medical Precautions / Contraindications: Fall risk, Aspiration, Mechanical soft diet and Swallow precautions in place.
Directives / Code Status Full Code
Respiratory Status = WEL
Medications Medications Impacting Condition Treatment: See medical chart fr full ist of medications
Prior Therapy Did Patient Receive Therapy Previously? = Yes
Location = Hospital
Date(s) of Service: 11/14/19-12/11/19
Prior Tx Outcome: Pt seen for swallowing function in hospital. Pt de'd on MS consistency
Prior Living Prior Living Environment = Patient lived with family member, friends, or others,
Assistance / Support Provided = AM Asst | CA\PM Asst | CA
Prior Cognitive Assistance = Unknow-info not curently available in med chart (Pt is @ poor historian)
Prior Living Description: Pt states that she lived with her daughter. Patient isa poor historian.
Prior Equipment Equipment Prior to Onset: Unknown,
Transition/OC Transition/Discharge Pian = Other (to be determined)
Prior Level(s) of PLOF: Bed Mobilly= M!; Transfers = MI; Level Surfaces = Mil (unknown); Stairs = DNT; Community Mobily = DNT;
Function Patient is a poor historian and unable to state her prior level_of function
Fall Risk Assessment
Historyof Falls Has Palient fallen in past year? = No
Steadiness. ‘Does Patient feel unsteady when standing? = Yes; Does Patient feel unsteady when walking? = Yes
Fear of Falling ‘Does Patient worry about faling? = Yes
Tests and Timed Up and Go = Not Tested
Measures
Musculoskeletal System Assessment
LEROM RLE ROM = Impaired; LE ROM impaired
RLE ROM Right Hip = Impaired: Knee = Impaired; Ankle = Impaired
LLE ROM Left Hip = Impaired; Knee = Impaired; Ankle = Impaired
RLE Strength RLE Strength = Impaired
LLE Strength LLE Strength = Impaired
RLE Strength Hip = Impaired; Knee = Impaired; Ankle = Impaired
LLE Strength Hip = Impaired; Knee = Impaired; Ankle = impaired
Contracture Functional Limitations Present dit Contracture = No
Page
2 of 4
BROOKHAVEN 000281
Physical Therapy
PT Evaluation & Plan of Treatment
Provider: Brookhaven Nursing and Centitication Period: 12/12/2019 - 1/12/2020
NPI: 1639468473 Physical Therapy
[Identification information
Patie
Payer
FONTENOT, LINDA
Managed Care Part A - PDPM (MGA)
oor “Start
of Care: TaN 2018
MRI 3047 es —
[tar assesement Gurren! Lovel
of Function & Undriying inpalrmonts
‘Other System/Condition Assessment
‘Cardiovascular CardioPulmonary System = Functional for age and condilion|
Integumentary Is skilled therapy needed to adaress wounds? = No (Nursing to address surgical site)
Neuromuscular Neuromuscular System = Functional for age and condition
Pain Pain = No pain present, per patient verbal and nonverbal communication
Cognitive-Communicative Assessment
Instructions Follows Directions = Total Dependence
Cognition Orfented To = Orientation x 0; Safety Awareness = Impaired
Functional Mobility Assessment
‘Bad Mobility Bed Mobility iax (A)
Transfers ‘Transfers = Max (A)
Gait Level Surfaces = DNT; Uneven Surfaces = ONT
Stairs Stairs = ONT
Other Ambulation ‘Community Wobil = DNT
‘Additional Abilities/impairments/Needs
Coordination (Gross Motor Coordinalion = impaired
Sensation ‘Sensation / Sensory Processing = Intact,
“Assessment Summary
Ci al Clinical Impressions: Presents with overall weakness and impaired functional mobility.
Impressions
Reason for Reason for Skilled Services: Skilled PT services are warranted lo minimize falls, increase LE ROM and strength, increase:
‘Therapy independence with gat, increase functional activity tolerance, increase coordination, increase awareness of environmental
hazards, improve dynamic balance, evalu eed for assistive device and enhance rehab potential in order to enhance
patient's quality of life by improving ability to decrease level of assistance from caregivers, prepare for / initiate ambulation
‘and perform functional mobilty with reduced riskof falls.
Level of Skiled Services: The recommended level of skilled therapy services is required due to the following complexities
‘and comorbidities that impact treatment: Concomittant cognition deficits, Complicated medical history, Multiple diagnoses,
‘Multiple medications, Need for durable medical equipment for condition and Unstable psychiatric history
Risk Factors Risk Factors: Due to the documented physical impairments and associaled functional deficits, without skilled therapeutic
intervention, the patient is at risk fo: falls and further dectine in function.
Wound Analysis
‘Complications ‘Complications Associated with Wound(s): nla; taples on abdomen
Evaluation Summary
‘Components History/Personal Faclors/Comorbidilies = A history of present problem w/1-2 personal factors andlor comorbidities that
impact the plan of care
# of Body Structures/Functions/Limitations = An examination of 1 - 2 body structures and functions, activity limitations
andlor participation restrictions using standardized tests
Clinical Presentation = Stable and/or uncomplicated characteristics
Clinical Decision Making = Low Compleaity (using standardized patient assessment instrument and/or measurable
assessment of functional outcome)
Page
3 of 4
BROOKHAVEN 000282
Physical Therapy
PT Evaluation & Plan of Treatment.
Provider ‘Brookhaven Nursing and Contiication Period: 12/12/2019- 1/12/2020
NPI: 1699468473 Physical Therapy
[fensneationtotormadon
Patient: FONTENOT, LINDA or ere: Tan2n018
Payer: Managed Care Part A - PDPM (MGA)
mi 3947
[LINDA FONTENOT]
T : PT Evaluation & Plan of Treatment
Disciplin
Changes For: 1/9/2020 11:48:39 AM
Diagnosis
Changes: Modified By
Diagnosis added : MEDICAL : [ICD10} 20.9 - Schizophrenia, unspecified joy 1025592,
Diagnosis added : MEDICAL : (ICD10} F31.9- Bipolar disorder, unspecified joy 1025592
Diagnosis added : MEDICAL : [ICD10} J18.9 - Pneumonia, unspecified organism mjoyt025592
Diagnosis added : MEDICAL : {ICD 10} K85.90 - Acute pancreatitis without necrosis or infection, ‘mjoy1025502
unspecified
Diaynusls deleted . MEDICAL . (JCD 10] 110- Exselia (pinay) hypertension ‘joy 1028562
Page 4of 4
BROOKHAVEN 000283
Speech Therapy
‘SLP Evaluation and Plan of Treatment
Provider: Brookhaven Nursing and Certification Period: 12/12/2019 - 1/12/2020
NPI 1939468473, Speech/LanguagelCognitive Therapy Dysphagia Therapy
[encation tntormation
Patient: FONTENOT, LINDA
Payer:
MRN:
Managed Care Part A - PDPM (MGA)
3947
~ ‘Start of Care: 121272019
jagnoses
Type [Code [Description Onset
10 Essential (primary) hypertension 19/94/2019
1x Ra1.841 [Cognitive communication deficit 2122019
Tx Ri3.12 Dyspha ‘orepharynges! phase 12/12/2019
[Plan of Treatment J]
Short-Term Goals. ‘Treatment Approaches May include
#10 Patient will understand yesino questions with 70% accuracy and 35% verbal . ‘Treatment of speech, language, voice, communication
‘cues and 35% visual cues in orderto participate in functional exchanges and/or auditory processing, individual (92507)
‘about daily wantsineeds. (Target: 12/25/2019) . ‘Speech Group Treatment (92508)
#20 Patient will name objects with 60% accuracy during structured language
tasks and 35% Visual Cues and 35% Semantic Cues in order to . Evaluation of speech sound production and language
‘communicate basic wantsineeds. (Target: 12/25/2019) assessment (92523)
#3.0 Patient wil follow 1-step verbal commands with 25% accuracy and 75% ° “Treatment of swallowing dysfunction andlor oral
Verbal Cues and 75% Visual Cues in order to participate in functional function for feeding (92526)
‘exchanges about daily wants/needs and participate in therapeutic and daily e Eyal of oral and pharyngeal swallow function (92610)
tasks. (Target: 12/25/2019)
+#4.0 Patient will exhibit good safety awareness during daily ving tasks with 25% of Frequency: 5 time(s) week
‘opportunities and with 75% Verbal Cues and with 75% Visual Cues to
improve ability to decrease risk for falls, to improve abilty to improve caryover Duration: 30 day(s)
of safety techniques win tasks, 10 improve ability o increase ability fo
Participate in ADLS and to improve ability te promote independence on Cort. Period: 12/12/2019- 1/12/2020,
nursing unit, (Target: 12/25/2019)
#50 Patient will present with functional mastication skils in orderto
‘consume Regular textures 10/10 therapeutic attempts. (Target: 12/25/2019)
#60 In order to safely consume highest level of oral intake, patient will use general
‘swallow techniquesiprecautions, alteration of iquid/salids, alteration
tastes, rate modification, bolus size modifications and no straws and upright
posture during meals and upright posture for>30 mins after meats
‘opporunitesin order to safely swallow without signs/symptomsof dysphagia
and safely consume highest level of oral intake. (Target: 12/25/2019)
‘Long-Term Goals
#1.0 Patient will increase cognitive-communication skis to Mod to improve ability
to communicate basic wantsineeds, decrease risk for falls, follow directions.
for activities and ADL, improve carryover of safely techniques win tasks,
increase ability to participate in ADLs and return to prior level of living. (Target
1112/2020)
#2.0 Patient will improve swallow abilities to Distant Supervision as evidenced
ability to safely and efficiently swallow least restrictive diet with minimal 10
‘absent s/s oral dysphagia, coughing and/or wet vocal quality post swallows in
‘order to safely swallow without signs/symptoms of aspiration, meet primary
nutrition Mydration needs and safely consume highest level of oral intake.
(Target: 1/12/2020)
Caregiver Goals: To return to PLOF
Potential for Achieving Reehab Goals: Patient demonstrates good rehab potential as
evidenced izes to sounds, responsive to noxious / painful stimuli,
recognizes familiar situations/routines and recent onset
Focusof Plan of Treatment = Restoration Compensation
Participation = PatienCaregiver participated in establishing POT
Page
1 of 4
BROOKHAVEN 000284
‘Speech Therapy
‘SLP Evaluation and Plan of Treatment
Provider: Brookhaven Nursing and Certification Period: 12/12/2019 - 1/12/2020
NPI 4630468473 ‘SpeechiLanguage/Cognitive Therapy, Dysphagia Therapy
identification Information
Patient: FONTENOT, LINDA oo ‘Start of Care: T2219
Payer: ‘Managed Care Part A - PDPM (MGA)
MRW: 3987
Original Signature: Electronically signed by Caroline Geiger, SLP TX 108373 12/18/2019 11:58:58 AM CDT
Date
| certify the need for these medically necessary services furnished under this plan of treatment while under my care from
42/12/2019 through 1/12/2020.
Physician Signature Not Required
Physician Signature:
Ketan PATEL NP 1003814146 Date:
Initial Assessment / Current Level of Function & Underlying Impairments _]
Patient Referral and History
Current Referral ‘Reason for Referral / Current iness: Pt is a 65 yo female admitted to the hospital with ‘auule pancreatitis os woll as health
care associatedPI ‘acute respiratory failure, and sepsis. Patient referred to ST due to exacerbation
function, ponaed mation wh sc, isk fo aspraton and ely cng ora ae, Pant tered 1S avo 0
exacerbation of yi ftectly cornmunicae ferences, sity0 in to respondto
|. ablity 'o use compensatory strategies, nicative deficits and safety awareness.
HxiComplexities ear PMH oee bipolar, dementia, dysphagia
Prior Therapy Did Patient Receive Therapy Previously? = Yes
Location = Hospital
Date(s) of Service: 11/14/19-12/11/19
Prior Tx Outcome: Pt seen for swallowing function in hospital. Pt de'd on MS consistency
Previous Tests Prior MBS / FEES / GI/ ENT = Yes (MESS completed during Hepes with limited resuits due to pt fatigue and
limited participation. Recommended minced/moist and thin fiquids}
Prior Living Prior Living Environment = Patient residedin other LTC faciity,
‘Transition/DC ‘TransiiowDischarge Plan = Patient to return to residence at prior LTC site
Prior Level of PLOF: intake/Diet Level = Regular textures, Thin liquids, Successive swallows; Audltory Comprehension = Mod; Reading
Function = DNT; Verbal = Mod: Writien Expression = DNT; Problem Solving = N/A - Not Applicableat
this time; Memory = Marked - Patient altempts to iniiate/participate; Pragmatic Skills = Sev; Swallowing Abilities = Distant
juperision; Self Feeding = Mod (A); Moderate cog-comm impairments
PLOF Source(s) = Caregiver/Statf Medical Record
Chart Review / Patient Interview
Medical Factors Precautions / Contraindications: Fall risk, Aspiration, Mechanical soft diet and Swallow precautions in place,
Directives / Code Status = Full Code
Respiratory Status = WFL
Intake Intake/Diet Level = mechanical soft,Thin liquids, Successive swallows; Intake Method = All oral
Medications Medications Impacting Condiion/Treatment: See medical chart for full ist of medications
Position Position During Eval = WFL w/support wio affecton safstyicommunication
‘Cognitive-Communicative Skills Overview
‘Oral Exam (Oral Motor Structure and Function = Intact
Language Receptive Language Skils Impaired; Expressive Language Skits = impaired
Cognition Cognitive-Communicative Skills = Impaired
Motor Speech Motor Speech Sills = Intact, patient functioning independently, further assessment is not indicated
Page
2 ot 4
BROOKHAVEN 000285
Speech Therapy
Evaluation and Plan of Treatment
Provider Brookhaven Nursing and Certification Period: 12/12/2019 - 1/12/2020
NPI 1630468473, ‘Speech/Language/C ognitive Therapy Dysphagia Therapy
[lentiieaton information
Patient: FONTENOT, LINDA
Payer: Managed Care Part A - POPM (MGA)
ME TazROT9
MRN: 3047
[Initiat a int / Currant Level of Fu & Underlying Iimpai
Roceptive/Expressive Language & Communication Abilities
‘Auditory ‘Auditory Comprehension = Sev, Understands Yes / No Questions = 50% Follows 1- Step Commands = < 25%
Comprehension
Reading Reading Comprehensi = ONT
Comprehension
Verbal Expression Verbal Expression = Sev; Making needs known = 25%; Conversation = < 25%; Functional Speech Characteristics = Non-
Fluent; Naming Objects=
Written Expression Written Expression = DNT.
Cognition
General Processes ‘Responsive to Stimulation = < 25%, Responsive to Strategies = < 25%
Problem Solving Problem Solving = N/A - Not Applicable al this time (Unable to accurately assess due to limited verbal expression)
Memory ‘Memory = Marked - Patient attempts to iniiate/patticipate
Pragmatic Skills & Behavior
Pragmatics Pragmatic Skils = Sev
‘Clinical Bedside Assessment of Swallowing
l Abilities ‘Swallowing Abilities = Mild
Intake {Is Patient NPO? = No
Liquids Assessed Liquids / Method Assessed During Eval = Thin/C iquids, Thiv’S
Solids Assesssed Solids Assessed During Eval = Mechanical Soft textures
Self Feeding ‘Self Feeiing = Mod (A)
Oral Prop Phase ‘Oral Prep Phase = Moderate
‘Task Recognition = impaired; Oral Phase initiation = Moderate
Thin Liquids - Cup ‘Thin Liquids - Cup = WFL.
Thin Liquids. ‘Thin Liquids Straw = ClinicalS18. Pharyngsal Phase Impairments characterized by: coughing after the
‘swatlow.; Oral Transit Time = WFL; Swallow Onset Time
Solids-Mech Soft MechanicalSoft = WFL
Esophageal Phase Esophageal: Patient/medical record indicates: No signs/symploms of esophageal dysphagia present.
‘Assessment Summary
Clinical Clinical Impressions: Pt piw severe eaeiaiea oy epiirene Weka
comorahension, deta mares ‘that limit functional communication and ‘participation In therapeutic and
day tasks,
Reason for Reason fr Shiled Serdces: Patient requires sled SLP senices fr cogntnfcommunicalon fo analy communication
‘Therapy abilities, Improve ability to communicate self care and/or medical needs, improve cognitive-inguistic skils, improve
Pr
‘enhance short-term memory, ‘and instructin ‘and instruct in adaptation
‘and decrease adverse behaviors. Skiled SLP services for dysphagia are Warranted lo analyze oralipharyngeal function,
‘estore oral/pheryngeal function, developand instructin
‘motor facitation and train caregivers in cueing hi
Leval of Skilled Services: The recommended evel of skied therapy services is required due to the following complexities
‘and comorbiclies that impact treatment: Level of alertness, Decreased ‘equires frequent
breaks due to medical condition, Difficulty leaning new information, Limitaions in selective attention and Limitations
Jeamning complex information,
Risk Factors Risk Factors: Due to the document ‘and associated functional deficits, without skiled
intervention, the patient is at risk for: falls, decreased abiity to return to prior level of assistance, decreased abilty to retum
Gor fag sensors Soreness pcr tan oR ‘dependency upon caregivers
Page
3 of 4
BROOKHAVEN 000286
Speech Therapy
SLP Evaluation and Plan of Treatment
Provider: Brookhaven Nursing and Certification Period: 12/12/2019 - 1/12/2020
NPL 4639468473 ‘SpeechiLanguage/Cognitve Therapy, Dysphagia Therapy
identification information
Pati rf FONTENOT, LINDA, 12122019
Payer: ‘Managed Care Part A - PDPM (MGA)
MRN: 3047
[initial Assessment / Current Level of Function & Underlying Impairments _]
Recommendations
Further Testing MBS/FEES/ENT/G! Indicated = No|
Further exarr/consult not indicated dit: = Swallow therapy is indicated prior to exam to increase billy to participate with
‘objective testing.
Intake Diet Recs - Solids = Mechanical Soft textures
Diet Recs - Liquids = Thin liquids
Supervision ‘Supension for Oral intake = Close supervision
Strategios Comp Strategies/Positions: To facilitate safety and efficiency, itis fecommended the patient use the folowing strategies
‘and/or maneuvers during oral intake: alternation of liquid/solids, alternation of tastes, bolus size modifications, rate
‘modification, general swallow jons and no siraws upright posture during meals and upright posture for
>30 mins after meals.
Page
4 of 4
BROOKHAVEN 000287
Facility Brookhaven Nursing and Rehab l Pharmacy | OMNICARE OF FORT WORTH | Phyetclan PATEL, KETAN
Allergies Hydralazine
Diet
ESSENTIAL (PRIMARY) HYPERTENSION(I10), ENCOUNTER FOR OTHER SPECIFIED AFTERCARE(Z51.88), PNEUMONIA, UNSPECIFIED ORGANISM(J18.9), PAROXYSMAL ATRIAL FIBRILLATION(48.0), SCHIZOPHRENIA,
Medical Conditions
UNSPECIFIED(F20.8), ELEVATED WHIT BLOOD CELL COUNT, UNSPECIFIED(072.828), BIPOLAR DISORDER, UNSPECIFIED(F31,9), ACUTE PANCREATITIS WITHOUT NECROSIS OR INFECTION, UNSPECIFIED(K85.60),
UNSPECIFIED ABNORMALITIES OF GAIT AND MOBILITY(R26.9), MUSCLE WEAKNESS (GENERALIZED)(M62.81), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE((62.50), COGNTT
COMMUNICATION DEFICIT(R41.841), DYSPHAGIA, OROPHARYNGEAL PHASE(R13.12)
Advance Directive FULL CODE - CPR (discontinued as of 12/17/2018 14:00)
‘Sched for
Sun Mon | Tue Wed | Thu Fr Sot Bun Mon | Tus | Wed Thu Sat Sun Mon | Tue Wed | Thu Fr ‘Sat | Sun | Mon Tue Wed | Thu Fa Sun
Dec 2019
Hours:
2 3 4 5 8 7 8 9 10 " 2 13 4 5 16 7 18 0 20 24 22 23 24 25 28 a 28 29
| 30
IMetoclopramide HC!
[Tablet 5 MG
0800 x x x x x x x x x x AT vo x x x x x x x x x x x x
|cive 1 tablet by
[mouth one time a
Ke every other day
INAUSEAVOMITTI
ING for 2 Weeks
[Start Date-
12/12/2019 0800
LIC Date-
112/17/2019 1400
jetoprolol Tartrate BP
rablet 50 MG bas aire sa cama— ores ee _ ab = qo ee ap -4e-b-4-— arches Baie he crabs inhs Na how ef
Ive 1 tablet by Pulse
jouth one time a = ee —— - — =4o5 ee ah -4 -hede=. tema — bg — Sa benaw mbredta ah
related to
SSENTIAL, 0600
|HYPERTENSION
(10) HOLD IF
IBP<110/60;HR<60
tart Date-
12/12/2019 0800
DIC Date-
12/11/2019 1938, $$
Chart Codes / Follow Up Codes Init | Name Signature Init Name ‘Signature Name Signature
[-— Follow Up Codes —— [OBI=Observed Individual Checked By ist
ministered JOBP=Group Observed -
= ‘nafiective Partial
ectve }1=Absent from home Checked By 2nd
Inknown Pwithout meds
H=On Hold By Physician l2=Madication Refused Checked By 3rd
[3=Absent from home with
~ Chart Codes ~—-~ meds MEDICATION ADMINISTRATION
INTO Citedcome ce) (Refer to the last page of 12/1/2019 - 12/31/2019 | FONTENOT, LINDA (3947)
the report for a complete RECORD
ist of chart codes)
|OBA=Group Observed - Al Admit Date vaniote | vos | Unit | station 200 Room |
220 [tocatton |
ms 4a anna ab anean.na ANT EANTENAT HIKINA (2047) Dano: 4 af
BROOKHAVEN 000288
Facility Brookhaven Nursing and Rehab [Pharmacy ]OMNIGARE OF FORT WORTH Physician PATEL, KETAN
‘Allergies Hydralazino
Advance Directive FULL CODE- CPR (dlscontinued ae of 12/17/2019 14:00)
‘Sched for
Sun Mon | Tu | Wed | Thu Fri Sat ‘Sun Mon Tue Wed Thu Ft Sat Sun | Mon Tue Wed Thu Fi sat | sun Mon Tue Wed Thu Fri sun | Men
Dec 2019
Hours:
2 3 4 5 6 a 8 9 10 "1 2 13 14 16 16 7 8 19 20 2 22 23
| 24 28 29 30
fisperiDONE Tablet | 999 x x x x x x x x x x x x x x x x x x x x
j0.5MG LTS AT
[Give1 tablet by
mouth at bedtime
DEPRESSION
Date-
12/11/2019 2000
12/19/2019 1754
DONE Tablet | 999 x x x x x x x x x x x x x
MG ddm | No2 | Noz
1 tabletby
Imouth at bedtime
BIPOLAR
ISORDER
tart Date-
12/13/2019 2000
12/17/2019 1400
Rvastigmine Patch |Remove x x x x
Hour 9.5 1359
MG24HR Removel x x
T v7 x x
4 patch 1950 AT ddm | No2 | Noz
ndermally ‘Apply
bedtime for x Ar | eam | no2| noz x
[DEMENTIA and
lremove per
lschedule
tart Date-
{12/11/2019 2000
DIC Date-
11211772019
Chart Codes / Follow Up Codes Init Name ‘Signature Init |Name Signature Name Signature
[-— Follow Up Codes —~ [OSI-Observec Individual Checked By ist
Jv=Administered JOBP=Group Observed -
t=Inetfective Partial
JE=Ettectve |1=Absent from home Checked
By 2nd
JU=Unknown jwthout mods
IH=On Hold By Physician 12=Medication Refused Checked By 3rd
/3=Absent from home with
|. chart Code: jmeds MEDICATION ADMINISTRATION
{Reter to: pageof RECORD
12/1/2019 - 12/31/2019 | FONTENOT, LINDA (3947)
the report for smpete
list of chart codes)
JOBA=Group Observed - Al
se
Admit Dete | 12/11/2019 vos | Unit | station 200 ] Reom [220 [Location |
EANTEMAT LININA (20471 . Dane: 9
OKHAVEN 000289
Factity Brookhaven Nursing and Rehab Pharmacy Jomnicare OF FORT WORTH Physician PATEL, KETAN
Allergies Hydralazine
Advance Directive [aie onaiaamcnclanan
‘Sched for sun | Mon | Tue | Wed Thu Fit Sot sun | Mon Tue Thu Fa Sat ‘Sun | Mon | Tue Fr ‘Sun
| Mon Tue Wed
| Thu Ft ‘Sun Mon 1
Hours
Dec 2019 1 2 3 4 5 8 7 8 9 10 " 12 3 4 5 16 7 18 19 20 2 23 24 25 | 26 | 27 28 30
|TE/PPD TEST ON light x x * x x ie x x x x
|ADMISSION AND BH
JANNUALLY iF
POSITIVE
]QUESTIONAIRE...
jevery night shift until
12/12/2019 08:00
|-Start Date-
12/11/2019 2200
\Zestril Tablet 5 MG. BP 131/ 1181 89/ 98)
[(Lisinopril)
[Give
1 tablet by
bai fads
— ii 69 63 56 te
Pulse 113 105 59 88
|mouth one time a
[day relatedto
baa T wb ae be fn wee
mf a dir “1%
ESSENTIAL 0800 at | at _[Noz No2
(PRIMARY)
|HYPERTENSION
(110) HOLD IF
IBP<110/60; HR<60
|-Start Date-
}12/12/2019 0800
D/C Date-
{12/17/2019 1400 i
Chart Codes / Follow Up Codes Init | Name Signature init | Name Signature Name Signature
|-— Follow Up Codes —~ [OBI=Observed individual Checked By 1st
| /=Administered JOBP=Group Observed -
lsineffective Partial
JE=Ertectve {1=Absent from home ‘Checked By 2nd
lU=unknown [without meds
'=0n Hold By Physician l2=Medication Refused Checked By 3rd
[2=Absent from home with
|-—- Chart Codes —— meds MEDICATION ADMINISTRATION
Refer to the last page of 12/1/2019 - 12/31/2019 | FONTENOT, LINDA (3947)
the report f complete
list of chart codes)
BAS ‘oup Observed - Al Admit Date tai12019 | DOB ma Unit | station 200 Room [220 [Location |
CANTEMAT. LIRIMA (2047) Dane: 2 nF
BROOKHAVEN 000290
Facility Brookhaven Nursing and Rehab | Pharmacy [OMNICARE OF FORT WORTH [_ Physician PATEL, KETAN
Allergies Hydralazine
Advance Directive FULL CODE - CPR (discontinued asof 12/17/2018 14:00)
‘Sched for
Sun | Mon | Tue Wed | Thu Fri Sot | Sun Mon Wod Thu Fa Mon Tue Wed | Tru | Ft | Sat Mon Tus Wed | Thu Fa | Sat Sun Tw
Dec 2019
Hours
1 2 10 " 2 13 4 15 16 7 8 19 2 23 24 25 28 ar 28 29 30 3
BP x i tau] 1401 89/ x
juocinate Capsule aS enfin SLES 62
UL of ime stdin osm ftee Oh. abn daw =a. ow. ss
124 Hour Sprinkle] x] 113, | 105} x 88
MG oo ota sp — on bees = ee thee as ete dias: wn fom aha --| a
fe 1 capsuleby x ATv fe Noe No2
two times a 0800
relatedto
ESSENTIAL BP x 116 | 1347 88)
--4 on fo-em soles or aah11 8468 Soleae J 4-- athe i es meal —
HYPERTENSION Pulse x 103 a8 88
(110) }--- we we — adhe=: atm om being ie mln anal aaaa asm poet =the saniabe
[Start Date- 1900 x AT | ddm | Noz Noz x ll
12/12/2019 0800
LDIC Date-
12/17/2019 1400
ADMINISTER x x x x
INFLUENZA
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FILED 10/12/2023 12:19 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. 1167! 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 5 Physical Therapy PT Evaluation & Plan of Treatment Provider: Brookhaven Nursing and Certification Period: 12/12/2019 - 1/12/2020 NPI 1639468473 Physical Therapy {[denafeationinvormaton Patient: Payer: FONTENOT, LINDA Managed Care Part A - PDPM (MGA) ~~ ‘Start of Gare: 222018 MR 3947 | certify the need for these medically necessary services furnished under this plan of treatment while under my care from 12/12/2019 through 1/12/2020. Physician Signature Not Requi Physician Signature: : 5 Ketan PATEL NPE 1003814148 Date: [initial Assessment / Current Level of Function & Underlying Impairments Patient Referral and History Current Referral Reason for Referral / Current liness: Patient referred to PT due to decline in strength, static balance, pain, dynamic balance, coordination, ability to move without pain, functional mobility and functional ambulation. Hx/Complexities PMHix: Schizophrenia, bipolar, dementia, dysphagia Medical Precautions / Contraindications: Fall risk, Aspiration, Mechanical soft diet and Swallow precautions in place. Directives / Code Status Full Code Respiratory Status = WEL Medications Medications Impacting Condition Treatment: See medical chart fr full ist of medications Prior Therapy Did Patient Receive Therapy Previously? = Yes Location = Hospital Date(s) of Service: 11/14/19-12/11/19 Prior Tx Outcome: Pt seen for swallowing function in hospital. Pt de'd on MS consistency Prior Living Prior Living Environment = Patient lived with family member, friends, or others, Assistance / Support Provided = AM Asst | CA\PM Asst | CA Prior Cognitive Assistance = Unknow-info not curently available in med chart (Pt is @ poor historian) Prior Living Description: Pt states that she lived with her daughter. Patient isa poor historian. Prior Equipment Equipment Prior to Onset: Unknown, Transition/OC Transition/Discharge Pian = Other (to be determined) Prior Level(s) of PLOF: Bed Mobilly= M!; Transfers = MI; Level Surfaces = Mil (unknown); Stairs = DNT; Community Mobily = DNT; Function Patient is a poor historian and unable to state her prior level_of function Fall Risk Assessment Historyof Falls Has Palient fallen in past year? = No Steadiness. ‘Does Patient feel unsteady when standing? = Yes; Does Patient feel unsteady when walking? = Yes Fear of Falling ‘Does Patient worry about faling? = Yes Tests and Timed Up and Go = Not Tested Measures Musculoskeletal System Assessment LEROM RLE ROM = Impaired; LE ROM impaired RLE ROM Right Hip = Impaired: Knee = Impaired; Ankle = Impaired LLE ROM Left Hip = Impaired; Knee = Impaired; Ankle = Impaired RLE Strength RLE Strength = Impaired LLE Strength LLE Strength = Impaired RLE Strength Hip = Impaired; Knee = Impaired; Ankle = Impaired LLE Strength Hip = Impaired; Knee = Impaired; Ankle = impaired Contracture Functional Limitations Present dit Contracture = No Page 2 of 4 BROOKHAVEN 000281 Physical Therapy PT Evaluation & Plan of Treatment Provider: Brookhaven Nursing and Centitication Period: 12/12/2019 - 1/12/2020 NPI: 1639468473 Physical Therapy [Identification information Patie Payer FONTENOT, LINDA Managed Care Part A - PDPM (MGA) oor “Start of Care: TaN 2018 MRI 3047 es — [tar assesement Gurren! Lovel of Function & Undriying inpalrmonts ‘Other System/Condition Assessment ‘Cardiovascular CardioPulmonary System = Functional for age and condilion| Integumentary Is skilled therapy needed to adaress wounds? = No (Nursing to address surgical site) Neuromuscular Neuromuscular System = Functional for age and condition Pain Pain = No pain present, per patient verbal and nonverbal communication Cognitive-Communicative Assessment Instructions Follows Directions = Total Dependence Cognition Orfented To = Orientation x 0; Safety Awareness = Impaired Functional Mobility Assessment ‘Bad Mobility Bed Mobility iax (A) Transfers ‘Transfers = Max (A) Gait Level Surfaces = DNT; Uneven Surfaces = ONT Stairs Stairs = ONT Other Ambulation ‘Community Wobil = DNT ‘Additional Abilities/impairments/Needs Coordination (Gross Motor Coordinalion = impaired Sensation ‘Sensation / Sensory Processing = Intact, “Assessment Summary Ci al Clinical Impressions: Presents with overall weakness and impaired functional mobility. Impressions Reason for Reason for Skilled Services: Skilled PT services are warranted lo minimize falls, increase LE ROM and strength, increase: ‘Therapy independence with gat, increase functional activity tolerance, increase coordination, increase awareness of environmental hazards, improve dynamic balance, evalu eed for assistive device and enhance rehab potential in order to enhance patient's quality of life by improving ability to decrease level of assistance from caregivers, prepare for / initiate ambulation ‘and perform functional mobilty with reduced riskof falls. Level of Skiled Services: The recommended level of skilled therapy services is required due to the following complexities ‘and comorbidities that impact treatment: Concomittant cognition deficits, Complicated medical history, Multiple diagnoses, ‘Multiple medications, Need for durable medical equipment for condition and Unstable psychiatric history Risk Factors Risk Factors: Due to the documented physical impairments and associaled functional deficits, without skilled therapeutic intervention, the patient is at risk fo: falls and further dectine in function. Wound Analysis ‘Complications ‘Complications Associated with Wound(s): nla; taples on abdomen Evaluation Summary ‘Components History/Personal Faclors/Comorbidilies = A history of present problem w/1-2 personal factors andlor comorbidities that impact the plan of care # of Body Structures/Functions/Limitations = An examination of 1 - 2 body structures and functions, activity limitations andlor participation restrictions using standardized tests Clinical Presentation = Stable and/or uncomplicated characteristics Clinical Decision Making = Low Compleaity (using standardized patient assessment instrument and/or measurable assessment of functional outcome) Page 3 of 4 BROOKHAVEN 000282 Physical Therapy PT Evaluation & Plan of Treatment. Provider ‘Brookhaven Nursing and Contiication Period: 12/12/2019- 1/12/2020 NPI: 1699468473 Physical Therapy [fensneationtotormadon Patient: FONTENOT, LINDA or ere: Tan2n018 Payer: Managed Care Part A - PDPM (MGA) mi 3947 [LINDA FONTENOT] T : PT Evaluation & Plan of Treatment Disciplin Changes For: 1/9/2020 11:48:39 AM Diagnosis Changes: Modified By Diagnosis added : MEDICAL : [ICD10} 20.9 - Schizophrenia, unspecified joy 1025592, Diagnosis added : MEDICAL : (ICD10} F31.9- Bipolar disorder, unspecified joy 1025592 Diagnosis added : MEDICAL : [ICD10} J18.9 - Pneumonia, unspecified organism mjoyt025592 Diagnosis added : MEDICAL : {ICD 10} K85.90 - Acute pancreatitis without necrosis or infection, ‘mjoy1025502 unspecified Diaynusls deleted . MEDICAL . (JCD 10] 110- Exselia (pinay) hypertension ‘joy 1028562 Page 4of 4 BROOKHAVEN 000283 Speech Therapy ‘SLP Evaluation and Plan of Treatment Provider: Brookhaven Nursing and Certification Period: 12/12/2019 - 1/12/2020 NPI 1939468473, Speech/LanguagelCognitive Therapy Dysphagia Therapy [encation tntormation Patient: FONTENOT, LINDA Payer: MRN: Managed Care Part A - PDPM (MGA) 3947 ~ ‘Start of Care: 121272019 jagnoses Type [Code [Description Onset 10 Essential (primary) hypertension 19/94/2019 1x Ra1.841 [Cognitive communication deficit 2122019 Tx Ri3.12 Dyspha ‘orepharynges! phase 12/12/2019 [Plan of Treatment J] Short-Term Goals. ‘Treatment Approaches May include #10 Patient will understand yesino questions with 70% accuracy and 35% verbal . ‘Treatment of speech, language, voice, communication ‘cues and 35% visual cues in orderto participate in functional exchanges and/or auditory processing, individual (92507) ‘about daily wantsineeds. (Target: 12/25/2019) . ‘Speech Group Treatment (92508) #20 Patient will name objects with 60% accuracy during structured language tasks and 35% Visual Cues and 35% Semantic Cues in order to . Evaluation of speech sound production and language ‘communicate basic wantsineeds. (Target: 12/25/2019) assessment (92523) #3.0 Patient wil follow 1-step verbal commands with 25% accuracy and 75% ° “Treatment of swallowing dysfunction andlor oral Verbal Cues and 75% Visual Cues in order to participate in functional function for feeding (92526) ‘exchanges about daily wants/needs and participate in therapeutic and daily e Eyal of oral and pharyngeal swallow function (92610) tasks. (Target: 12/25/2019) +#4.0 Patient will exhibit good safety awareness during daily ving tasks with 25% of Frequency: 5 time(s) week ‘opportunities and with 75% Verbal Cues and with 75% Visual Cues to improve ability to decrease risk for falls, to improve abilty to improve caryover Duration: 30 day(s) of safety techniques win tasks, 10 improve ability o increase ability fo Participate in ADLS and to improve ability te promote independence on Cort. Period: 12/12/2019- 1/12/2020, nursing unit, (Target: 12/25/2019) #50 Patient will present with functional mastication skils in orderto ‘consume Regular textures 10/10 therapeutic attempts. (Target: 12/25/2019) #60 In order to safely consume highest level of oral intake, patient will use general ‘swallow techniquesiprecautions, alteration of iquid/salids, alteration tastes, rate modification, bolus size modifications and no straws and upright posture during meals and upright posture for>30 mins after meats ‘opporunitesin order to safely swallow without signs/symptomsof dysphagia and safely consume highest level of oral intake. (Target: 12/25/2019) ‘Long-Term Goals #1.0 Patient will increase cognitive-communication skis to Mod to improve ability to communicate basic wantsineeds, decrease risk for falls, follow directions. for activities and ADL, improve carryover of safely techniques win tasks, increase ability to participate in ADLs and return to prior level of living. (Target 1112/2020) #2.0 Patient will improve swallow abilities to Distant Supervision as evidenced ability to safely and efficiently swallow least restrictive diet with minimal 10 ‘absent s/s oral dysphagia, coughing and/or wet vocal quality post swallows in ‘order to safely swallow without signs/symptoms of aspiration, meet primary nutrition Mydration needs and safely consume highest level of oral intake. (Target: 1/12/2020) Caregiver Goals: To return to PLOF Potential for Achieving Reehab Goals: Patient demonstrates good rehab potential as evidenced izes to sounds, responsive to noxious / painful stimuli, recognizes familiar situations/routines and recent onset Focusof Plan of Treatment = Restoration Compensation Participation = PatienCaregiver participated in establishing POT Page 1 of 4 BROOKHAVEN 000284 ‘Speech Therapy ‘SLP Evaluation and Plan of Treatment Provider: Brookhaven Nursing and Certification Period: 12/12/2019 - 1/12/2020 NPI 4630468473 ‘SpeechiLanguage/Cognitive Therapy, Dysphagia Therapy identification Information Patient: FONTENOT, LINDA oo ‘Start of Care: T2219 Payer: ‘Managed Care Part A - PDPM (MGA) MRW: 3987 Original Signature: Electronically signed by Caroline Geiger, SLP TX 108373 12/18/2019 11:58:58 AM CDT Date | certify the need for these medically necessary services furnished under this plan of treatment while under my care from 42/12/2019 through 1/12/2020. Physician Signature Not Required Physician Signature: Ketan PATEL NP 1003814146 Date: Initial Assessment / Current Level of Function & Underlying Impairments _] Patient Referral and History Current Referral ‘Reason for Referral / Current iness: Pt is a 65 yo female admitted to the hospital with ‘auule pancreatitis os woll as health care associatedPI ‘acute respiratory failure, and sepsis. Patient referred to ST due to exacerbation function, ponaed mation wh sc, isk fo aspraton and ely cng ora ae, Pant tered 1S avo 0 exacerbation of yi ftectly cornmunicae ferences, sity0 in to respondto |. ablity 'o use compensatory strategies, nicative deficits and safety awareness. HxiComplexities ear PMH oee bipolar, dementia, dysphagia Prior Therapy Did Patient Receive Therapy Previously? = Yes Location = Hospital Date(s) of Service: 11/14/19-12/11/19 Prior Tx Outcome: Pt seen for swallowing function in hospital. Pt de'd on MS consistency Previous Tests Prior MBS / FEES / GI/ ENT = Yes (MESS completed during Hepes with limited resuits due to pt fatigue and limited participation. Recommended minced/moist and thin fiquids} Prior Living Prior Living Environment = Patient residedin other LTC faciity, ‘Transition/DC ‘TransiiowDischarge Plan = Patient to return to residence at prior LTC site Prior Level of PLOF: intake/Diet Level = Regular textures, Thin liquids, Successive swallows; Audltory Comprehension = Mod; Reading Function = DNT; Verbal = Mod: Writien Expression = DNT; Problem Solving = N/A - Not Applicableat this time; Memory = Marked - Patient altempts to iniiate/participate; Pragmatic Skills = Sev; Swallowing Abilities = Distant juperision; Self Feeding = Mod (A); Moderate cog-comm impairments PLOF Source(s) = Caregiver/Statf Medical Record Chart Review / Patient Interview Medical Factors Precautions / Contraindications: Fall risk, Aspiration, Mechanical soft diet and Swallow precautions in place, Directives / Code Status = Full Code Respiratory Status = WFL Intake Intake/Diet Level = mechanical soft,Thin liquids, Successive swallows; Intake Method = All oral Medications Medications Impacting Condiion/Treatment: See medical chart for full ist of medications Position Position During Eval = WFL w/support wio affecton safstyicommunication ‘Cognitive-Communicative Skills Overview ‘Oral Exam (Oral Motor Structure and Function = Intact Language Receptive Language Skils Impaired; Expressive Language Skits = impaired Cognition Cognitive-Communicative Skills = Impaired Motor Speech Motor Speech Sills = Intact, patient functioning independently, further assessment is not indicated Page 2 ot 4 BROOKHAVEN 000285 Speech Therapy Evaluation and Plan of Treatment Provider Brookhaven Nursing and Certification Period: 12/12/2019 - 1/12/2020 NPI 1630468473, ‘Speech/Language/C ognitive Therapy Dysphagia Therapy [lentiieaton information Patient: FONTENOT, LINDA Payer: Managed Care Part A - POPM (MGA) ME TazROT9 MRN: 3047 [Initiat a int / Currant Level of Fu & Underlying Iimpai Roceptive/Expressive Language & Communication Abilities ‘Auditory ‘Auditory Comprehension = Sev, Understands Yes / No Questions = 50% Follows 1- Step Commands = < 25% Comprehension Reading Reading Comprehensi = ONT Comprehension Verbal Expression Verbal Expression = Sev; Making needs known = 25%; Conversation = < 25%; Functional Speech Characteristics = Non- Fluent; Naming Objects= Written Expression Written Expression = DNT. Cognition General Processes ‘Responsive to Stimulation = < 25%, Responsive to Strategies = < 25% Problem Solving Problem Solving = N/A - Not Applicable al this time (Unable to accurately assess due to limited verbal expression) Memory ‘Memory = Marked - Patient attempts to iniiate/patticipate Pragmatic Skills & Behavior Pragmatics Pragmatic Skils = Sev ‘Clinical Bedside Assessment of Swallowing l Abilities ‘Swallowing Abilities = Mild Intake {Is Patient NPO? = No Liquids Assessed Liquids / Method Assessed During Eval = Thin/C iquids, Thiv’S Solids Assesssed Solids Assessed During Eval = Mechanical Soft textures Self Feeding ‘Self Feeiing = Mod (A) Oral Prop Phase ‘Oral Prep Phase = Moderate ‘Task Recognition = impaired; Oral Phase initiation = Moderate Thin Liquids - Cup ‘Thin Liquids - Cup = WFL. Thin Liquids. ‘Thin Liquids Straw = ClinicalS18. Pharyngsal Phase Impairments characterized by: coughing after the ‘swatlow.; Oral Transit Time = WFL; Swallow Onset Time Solids-Mech Soft MechanicalSoft = WFL Esophageal Phase Esophageal: Patient/medical record indicates: No signs/symploms of esophageal dysphagia present. ‘Assessment Summary Clinical Clinical Impressions: Pt piw severe eaeiaiea oy epiirene Weka comorahension, deta mares ‘that limit functional communication and ‘participation In therapeutic and day tasks, Reason for Reason fr Shiled Serdces: Patient requires sled SLP senices fr cogntnfcommunicalon fo analy communication ‘Therapy abilities, Improve ability to communicate self care and/or medical needs, improve cognitive-inguistic skils, improve Pr ‘enhance short-term memory, ‘and instructin ‘and instruct in adaptation ‘and decrease adverse behaviors. Skiled SLP services for dysphagia are Warranted lo analyze oralipharyngeal function, ‘estore oral/pheryngeal function, developand instructin ‘motor facitation and train caregivers in cueing hi Leval of Skilled Services: The recommended evel of skied therapy services is required due to the following complexities ‘and comorbiclies that impact treatment: Level of alertness, Decreased ‘equires frequent breaks due to medical condition, Difficulty leaning new information, Limitaions in selective attention and Limitations Jeamning complex information, Risk Factors Risk Factors: Due to the document ‘and associated functional deficits, without skiled intervention, the patient is at risk for: falls, decreased abiity to return to prior level of assistance, decreased abilty to retum Gor fag sensors Soreness pcr tan oR ‘dependency upon caregivers Page 3 of 4 BROOKHAVEN 000286 Speech Therapy SLP Evaluation and Plan of Treatment Provider: Brookhaven Nursing and Certification Period: 12/12/2019 - 1/12/2020 NPL 4639468473 ‘SpeechiLanguage/Cognitve Therapy, Dysphagia Therapy identification information Pati rf FONTENOT, LINDA, 12122019 Payer: ‘Managed Care Part A - PDPM (MGA) MRN: 3047 [initial Assessment / Current Level of Function & Underlying Impairments _] Recommendations Further Testing MBS/FEES/ENT/G! Indicated = No| Further exarr/consult not indicated dit: = Swallow therapy is indicated prior to exam to increase billy to participate with ‘objective testing. Intake Diet Recs - Solids = Mechanical Soft textures Diet Recs - Liquids = Thin liquids Supervision ‘Supension for Oral intake = Close supervision Strategios Comp Strategies/Positions: To facilitate safety and efficiency, itis fecommended the patient use the folowing strategies ‘and/or maneuvers during oral intake: alternation of liquid/solids, alternation of tastes, bolus size modifications, rate ‘modification, general swallow jons and no siraws upright posture during meals and upright posture for >30 mins after meals. Page 4 of 4 BROOKHAVEN 000287 Facility Brookhaven Nursing and Rehab l Pharmacy | OMNICARE OF FORT WORTH | Phyetclan PATEL, KETAN Allergies Hydralazine Diet ESSENTIAL (PRIMARY) HYPERTENSION(I10), ENCOUNTER FOR OTHER SPECIFIED AFTERCARE(Z51.88), PNEUMONIA, UNSPECIFIED ORGANISM(J18.9), PAROXYSMAL ATRIAL FIBRILLATION(48.0), SCHIZOPHRENIA, Medical Conditions UNSPECIFIED(F20.8), ELEVATED WHIT BLOOD CELL COUNT, UNSPECIFIED(072.828), BIPOLAR DISORDER, UNSPECIFIED(F31,9), ACUTE PANCREATITIS WITHOUT NECROSIS OR INFECTION, UNSPECIFIED(K85.60), UNSPECIFIED ABNORMALITIES OF GAIT AND MOBILITY(R26.9), MUSCLE WEAKNESS (GENERALIZED)(M62.81), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE((62.50), COGNTT COMMUNICATION DEFICIT(R41.841), DYSPHAGIA, OROPHARYNGEAL PHASE(R13.12) Advance Directive FULL CODE - CPR (discontinued as of 12/17/2018 14:00) ‘Sched for Sun Mon | Tue Wed | Thu Fr Sot Bun Mon | Tus | Wed Thu Sat Sun Mon | Tue Wed | Thu Fr ‘Sat | Sun | Mon Tue Wed | Thu Fa Sun Dec 2019 Hours: 2 3 4 5 8 7 8 9 10 " 2 13 4 5 16 7 18 0 20 24 22 23 24 25 28 a 28 29 | 30 IMetoclopramide HC! [Tablet 5 MG 0800 x x x x x x x x x x AT vo x x x x x x x x x x x x |cive 1 tablet by [mouth one time a Ke every other day INAUSEAVOMITTI ING for 2 Weeks [Start Date- 12/12/2019 0800 LIC Date- 112/17/2019 1400 jetoprolol Tartrate BP rablet 50 MG bas aire sa cama— ores ee _ ab = qo ee ap -4e-b-4-— arches Baie he crabs inhs Na how ef Ive 1 tablet by Pulse jouth one time a = ee —— - — =4o5 ee ah -4 -hede=. tema — bg — Sa benaw mbredta ah related to SSENTIAL, 0600 |HYPERTENSION (10) HOLD IF IBP<110/60;HR<60 tart Date- 12/12/2019 0800 DIC Date- 12/11/2019 1938, $$ Chart Codes / Follow Up Codes Init | Name Signature Init Name ‘Signature Name Signature [-— Follow Up Codes —— [OBI=Observed Individual Checked By ist ministered JOBP=Group Observed - = ‘nafiective Partial ectve }1=Absent from home Checked By 2nd Inknown Pwithout meds H=On Hold By Physician l2=Madication Refused Checked By 3rd [3=Absent from home with ~ Chart Codes ~—-~ meds MEDICATION ADMINISTRATION INTO Citedcome ce) (Refer to the last page of 12/1/2019 - 12/31/2019 | FONTENOT, LINDA (3947) the report for a complete RECORD ist of chart codes) |OBA=Group Observed - Al Admit Date vaniote | vos | Unit | station 200 Room | 220 [tocatton | ms 4a anna ab anean.na ANT EANTENAT HIKINA (2047) Dano: 4 af BROOKHAVEN 000288 Facility Brookhaven Nursing and Rehab [Pharmacy ]OMNIGARE OF FORT WORTH Physician PATEL, KETAN ‘Allergies Hydralazino Advance Directive FULL CODE- CPR (dlscontinued ae of 12/17/2019 14:00) ‘Sched for Sun Mon | Tu | Wed | Thu Fri Sat ‘Sun Mon Tue Wed Thu Ft Sat Sun | Mon Tue Wed Thu Fi sat | sun Mon Tue Wed Thu Fri sun | Men Dec 2019 Hours: 2 3 4 5 6 a 8 9 10 "1 2 13 14 16 16 7 8 19 20 2 22 23 | 24 28 29 30 fisperiDONE Tablet | 999 x x x x x x x x x x x x x x x x x x x x j0.5MG LTS AT [Give1 tablet by mouth at bedtime DEPRESSION Date- 12/11/2019 2000 12/19/2019 1754 DONE Tablet | 999 x x x x x x x x x x x x x MG ddm | No2 | Noz 1 tabletby Imouth at bedtime BIPOLAR ISORDER tart Date- 12/13/2019 2000 12/17/2019 1400 Rvastigmine Patch |Remove x x x x Hour 9.5 1359 MG24HR Removel x x T v7 x x 4 patch 1950 AT ddm | No2 | Noz ndermally ‘Apply bedtime for x Ar | eam | no2| noz x [DEMENTIA and lremove per lschedule tart Date- {12/11/2019 2000 DIC Date- 11211772019 Chart Codes / Follow Up Codes Init Name ‘Signature Init |Name Signature Name Signature [-— Follow Up Codes —~ [OSI-Observec Individual Checked By ist Jv=Administered JOBP=Group Observed - t=Inetfective Partial JE=Ettectve |1=Absent from home Checked By 2nd JU=Unknown jwthout mods IH=On Hold By Physician 12=Medication Refused Checked By 3rd /3=Absent from home with |. chart Code: jmeds MEDICATION ADMINISTRATION {Reter to: pageof RECORD 12/1/2019 - 12/31/2019 | FONTENOT, LINDA (3947) the report for smpete list of chart codes) JOBA=Group Observed - Al se Admit Dete | 12/11/2019 vos | Unit | station 200 ] Reom [220 [Location | EANTEMAT LININA (20471 . Dane: 9 OKHAVEN 000289 Factity Brookhaven Nursing and Rehab Pharmacy Jomnicare OF FORT WORTH Physician PATEL, KETAN Allergies Hydralazine Advance Directive [aie onaiaamcnclanan ‘Sched for sun | Mon | Tue | Wed Thu Fit Sot sun | Mon Tue Thu Fa Sat ‘Sun | Mon | Tue Fr ‘Sun | Mon Tue Wed | Thu Ft ‘Sun Mon 1 Hours Dec 2019 1 2 3 4 5 8 7 8 9 10 " 12 3 4 5 16 7 18 19 20 2 23 24 25 | 26 | 27 28 30 |TE/PPD TEST ON light x x * x x ie x x x x |ADMISSION AND BH JANNUALLY iF POSITIVE ]QUESTIONAIRE... jevery night shift until 12/12/2019 08:00 |-Start Date- 12/11/2019 2200 \Zestril Tablet 5 MG. BP 131/ 1181 89/ 98) [(Lisinopril) [Give 1 tablet by bai fads — ii 69 63 56 te Pulse 113 105 59 88 |mouth one time a [day relatedto baa T wb ae be fn wee mf a dir “1% ESSENTIAL 0800 at | at _[Noz No2 (PRIMARY) |HYPERTENSION (110) HOLD IF IBP<110/60; HR<60 |-Start Date- }12/12/2019 0800 D/C Date- {12/17/2019 1400 i Chart Codes / Follow Up Codes Init | Name Signature init | Name Signature Name Signature |-— Follow Up Codes —~ [OBI=Observed individual Checked By 1st | /=Administered JOBP=Group Observed - lsineffective Partial JE=Ertectve {1=Absent from home ‘Checked By 2nd lU=unknown [without meds '=0n Hold By Physician l2=Medication Refused Checked By 3rd [2=Absent from home with |-—- Chart Codes —— meds MEDICATION ADMINISTRATION Refer to the last page of 12/1/2019 - 12/31/2019 | FONTENOT, LINDA (3947) the report f complete list of chart codes) BAS ‘oup Observed - Al Admit Date tai12019 | DOB ma Unit | station 200 Room [220 [Location | CANTEMAT. LIRIMA (2047) Dane: 2 nF BROOKHAVEN 000290 Facility Brookhaven Nursing and Rehab | Pharmacy [OMNICARE OF FORT WORTH [_ Physician PATEL, KETAN Allergies Hydralazine Advance Directive FULL CODE - CPR (discontinued asof 12/17/2018 14:00) ‘Sched for Sun | Mon | Tue Wed | Thu Fri Sot | Sun Mon Wod Thu Fa Mon Tue Wed | Tru | Ft | Sat Mon Tus Wed | Thu Fa | Sat Sun Tw Dec 2019 Hours 1 2 10 " 2 13 4 15 16 7 8 19 2 23 24 25 28 ar 28 29 30 3 BP x i tau] 1401 89/ x juocinate Capsule aS enfin SLES 62 UL of ime stdin osm ftee Oh. abn daw =a. ow. ss 124 Hour Sprinkle] x] 113, | 105} x 88 MG oo ota sp — on bees = ee thee as ete dias: wn fom aha --| a fe 1 capsuleby x ATv fe Noe No2 two times a 0800 relatedto ESSENTIAL BP x 116 | 1347 88) --4 on fo-em soles or aah11 8468 Soleae J 4-- athe i es meal — HYPERTENSION Pulse x 103 a8 88 (110) }--- we we — adhe=: atm om being ie mln anal aaaa asm poet =the saniabe [Start Date- 1900 x AT | ddm | Noz Noz x ll 12/12/2019 0800 LDIC Date- 12/17/2019 1400 ADMINISTER x x x x INFLUENZA /AGCINE 0.5CC IM PER IMANUFACTURER DIRECTION JANNUALLY IF |CONSENTED AND IS NOT INDICATE 7 19 1400 — = — = Chart Codes / Follow Up Codes Init | Name Signature Init | Name Signature Name Signature [-- Follow Up Codes— [OBI=Observac Inaividual Checked By 1st /=Administered JOBP=Group Observed -