Preview
FILED
10/12/2023 12:14 PM
FELICIA PITRE
DISTRICT CLERK
DALLAS CO., TEXAS
Rosa Delacerda DEPUTY,
CAUSE NO. DC-21-08674
FRANTEISHA FONTENOT; DARREN IN THE DISTRICT COURT
KING; MARVIN PRIDE and YALONDA
WRIGHT, EACH INDIVIDUALLY AND
ON BEHALF OF THE ESTATE OF LINDA
FONTENOT WILLIAMS, DECEASED,
VS. 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 4
3/15/2021 Medicare Shift Documention (Dynasty)
Shortness of Breath (Dyspnea) "
2a. ‘On exertion u
2b. Atrest. "
‘Abnormal lung sounds u
Cough present "
5. Cyanosis 1
6. Does resident use oxygen? If yes, note rate in next question. a
1 No
2. Yes
7. Oxygen at what rate? "
Z
8. Oxygen via: a
9. Respiratory Services provided. 4
10. Trachenstamy Gare provided "
41. Notable changes in respiratory function. "
Cardiovascular 1 Pulse regular rate and rhythm "
2. Peripheral pulses palpable "
3. Capillary refil. 4
a, <3 sec - Normal
b. > 3sec <5 sec- Slugish
c. > 5 sec - Abnormal
4. EDEMA
Aa. Edema present "
4b. Location "
4c. Pitting "
0. None
1+ Mild pitting, slight indentation, no perceptable swelling of the leg
2+, Moderate pitting, indentation subsides rapidly
3+, Deep pitting, indentation remains for a short time, leg looks swollen
4 Very deep pitting, indentation lasts a long time, leg is very swollen
5. Episodes of chest pain "
6. Notable changes to cardiovascular status. "
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IKHAVEN 000177
3/15/2021 Medicare Shift Documention (Dynasty)
Neurological/Sensory/Communication 1. PERRLA w
{; 2. Decreased grasp “
| 3. Decreased movement R
4. Vertigo "
Syncope "
Dizziness "
Tremors 4
Adequate hearing W
Wears hearing aid "
10. Adequate vision 4
1 Wears glasses u
12. Clear and appropriate speech. "
13. Notable changes to neurological/sensory or communication status. "
Pain 41. VERBAL PAIN DESCRIPTION
ta. Resident verbalizes presence of pain. 8
4b. Scale out of 10 4
1 2: 3. 4 5. 6. 7. 8. 9. 10.
1c, Location u
4d. Notes "
2. NON-VERBAL INDICATOR PAIN
2a, Resident demonstrates non-verbal signs of pain. "
2b. Describe uw
Medication/Orders 1. ORDERS
fa. Lab orders received "
1b. Medication orders received. "
1c. Treatment orders received. “
4d, Notes 4
2. MEDICATIONS
2a, \V Medication "
2b. Treat Infection 4
2c. IM Medication n
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SROOKHAVEN 00017!
3/15/2021 Medicare Shift Documention (Dynasty)
2d. IV Fluids "
2e. Note any adverse affects to medications. "
3. Notes on medications and treatments. 4
Skilled Services 4. Therapy / Rehabilitative Services
ta. Physical Therapy "
4b. Occupational Therapy "
1c. Speech Therapy "
2. DAILY SKILLED SERVICES PROVIDED
2a, Evaluation and update of Care plan u
2b. Observation/Assessment of resident's condition 4
Teaching and Training
2c. (ex, post-op care, medication, pain mgnmt) Describe in Notes (2d) u
3. ADDITIONAL DIRECT SKILLED NURSING SERVICES
3a. Dialysis "
3b. Tube Feeding 4
3c. Restorative Nursing Services u
3d. Post-surgical services "
3e. Diabetic monitoring u
4. Skilled Progress Notes & it
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BROOKHAVEN 000179
3/15/2021 Medicare Shift Documention (Dynasty)
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SROOKHAVEN 000180
3/15/2021 Activity Interview for Daily and Activity Preferences (3.0) (Dynasty)
{ Searci
Activity Interview for Daily and Activity Preferences (3.0) (Dynasty)
Resider FONTENOT, LINDA (3947)
Description Admission
Date: 12/14/2019 15:24
Section Status: Signed
Lock Date: 1/4/2020 18:40
Cancel
ins. INSTRUCTIONS Attempt to interview all residents able to communicate. It resident Is unable to complete, ullurpl lu Lummplete interview
with family member or significant other. 8
a. Should interview for Daily and Activity Preferences be Conducted? - Attempt to interview ail residents able to
communicate, MDS uv
0. No
1. Yes
- Not assessed
A Interview for 1, How important is it to you to choose what clothes to wear? MDS 4
Daily
Preferences. 1 Very important
2. Somewhat important
3. Not very important
4. Not important at ail
5. Important, but can't do or no choice
9. No response or non-responsive
a Not assessed
2. How important is it to you to take care of your personal belongings or things? MDS
1 Very important
2. ‘Somewhat important
3. Not very important
Not important at all
Important, but can't do or no choice
No response or non-responsive
- Not assessed
3. How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? MDS
1 Very important
2. ‘Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
- Not assessed
4, How important is it to you to have snacks available between meals? MDS H
1 Very important
carcri . SHS e TENA g-nH11D! 40 Morbid obesity
Most Recent Height u
Height: 66.0 (Inches) Date: 12/12/2019 14:55
Method: Lying down
Altered food or fluid consistency? "
2. Automatic If any of the following are checked, skip Section III. Start an interim plan
Referrals to
RDN/NDTRILDN: of care for the patient/resident per the Care Pathways and refer to the
nutrition consultant (RDN/LDN/NDTR)
1, Check any items that apply. "
1, Diagnosis of Malnutrition or Failure to Thrive 2. TFITPNIPPN 3. Dialysis 4, Stages 2-4 pressure
injuries 6. NPO or clear liquid > 3 days
3. Mini Nutritional
Assessment Complete the Mini Nutritional Assessment. If the total score is 11 points
(MNA) or less, start an interim plan of care for the patient/resident per the Care
Pathways and refer to the nutrition consultant (RDN/LDN/NDTR)
4 Mini Nutritional Assessment Score "
1.11 points or less 21244
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BROOKHAVEN 000185
3/15/2021 Nutrition Risk Screen - V2
4. 41. Check item that applys n
1. Not at risk 2. Automatic Referral (Section i!) 3. Referred to RDN/NDTRILDN for MNA score of 11 points
or less
2, Interim Interventions per Care Pathways "
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Fax: ) 85 48
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3/15/2021 Nutrition Risk Screen - V 2
(a | Search
Nutrition Risk Screen - V 2
Resident: FONTENOT, LINDA (3947)
Descriptio! Admission
Date: 12/14/2019 15:24
Section Statu: Signed
Lock Da’ 1/2/2020 15:46
[Previous Sec in| ( Cancel |
1
1. RDN, NDTR, LDN Review ary
Summar} i
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Carrollton, TX 201 sauga, Ontario LAW 9 www21-pec-web-main-
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PCC Facility 10: 9 Toll Free (800) 277-5889 | Cop ight 2021 PointClickCare
Phone: 05) 858-8885 | jolagies Inc. Ai ights ved
Fax 858-2248
ban tate “PEA! ohTune=CRESNI sactioncnde=Cust 28ESOL cient S55HB28E 1"
SQ asaaaal
3/15/2021 Medicare Shift Documention (Dynasty)
a
Search
Medicare Shift Documention (Dynasty)
Resident: FONTENOT, LINDA (3947)
Description 6-2 Shift
Date: 12/14/2019 07:05
Section Status: Signed
Lock Date: 12/14/2019 23:15
[Cancel
32
1 INSTRUCTIONS Document all skilled services provided for resident on
each shift
Vital Signs 4 Most Recent Temperature E #
Temperature: 97.8 (°F) Date: 12/14/2019 07:05
Route: Temporal Artery
Most Recent Pulse E u
Pulse: 80 (bpm) Date: 12/14/2019 07:06,
Pulse Type: Regular
Most Recent Respiration £ 1
Respiration: 18 (Breaths/min) Date: 12/14/2019 07:06
Most Recent Blood Pressure E
Blood Pressure: 99 / 58 (mmHg) Date: 12/14/2019 07:07
Positio tying Warm
Is resident a Diabetic? If yes, note most recent blood sugar below. u
1 No
2. Yes
5a, Most Recent Blood Glucose 4
Blood Glucose: (mg/dL) Date:
Most Recent 02 sats En
2 sats: 94 (%) Date: 42/14/2019 07:0)
Method: Room Air
B. Level of 4a. Sensory and Neurological - check all that apply "
Consiousness/Orientation/Cognition
4 Alert
2. Confused
3 Unresponsive
Lethargic
Slurred Speech
Aphasic
Visual impairment
8. Hearing impairment
2. Resident is oriented to: (Check all that apply) "
1 Time
2. Place
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3/15/2021 Medicare Shift Documention (Dynasty)
3. Person
4, Year
5. N/A
3. Note any changes in Level of Consciousness, Orientation and/or Cognition. If none noted, note
NIA, uw
c. Activities of Daily Living/Functional 1. Does not weight bear H
tatus
2. Unsteady gait requiring supervision u
3. Impaired balance "
4. Weakness "
= Paralysis "
6. Decreased sensation "
Ta. Requires assistance with bed mobility. "
7b. Requires assistance with transfers. 4"
Te. Requires assistance with eating. 4"
7d. Requires assistance with toilet use. "
8. Notable changes in functional ability and/or ADL's. 4
D. Mood and Behaviour 1 Mood and behavior patterns: (Check all that apply) "
1 Persistant anger
2. Unrealistic fears
3. Repetitive concerns
Anxious (non-health related)
Sad/worried facial expressions
Cryingtearful
Withdrawn from interests
Wandering
Verbally abusive
10. Physically abusive
"1 Resistant to care
12, Inappropriate behaviour
13. Negative behaviors not easily altered
14. Confused
15, Talkative
16. Friendly
17. Cooperative
Intact net ee tian ien7ESAI agsassid=8373098retURL=/admin/clienvicp_assessmen vse BESOQLclientid=9, 218
ROO! IAVEN 000189
3/15/2021 Medicare Shift Documention (Dynasty)
18, Happy/smiling
19, Quiet
20. Passive
2 NIA
Ja. No changesto mood and behavior noted. #
4b. Notable changes in mood and behavior a
E. Bladder/Genitourinary er Check if no new observations noted during shift
1. BLADDER FUNCTION
fa, Bladder tunction unchanged. "
4b. incontinent of urine: "
te. Distension noted. 4"
2. ‘Check if resident has an indwelling catheter u
2, CATHETER
2a, Supra-pubic Catheter care provided, "
2b. Foley Catheter care provided. n
2c. Catheter patent, in place and draining. "
3b. Bedpan «
3c. Commode "
3d. Pads/Briefs un
4. OSTOMIES PRESENT
4a. Urostomy "
Ab. Ostomy patent, in place and cleaned. "
5, URINE
5a. Color "
te
5b. Clarity "
5c, Odor "
‘1 u
Notable changes to bladder function. "
F. Bowel/Gastrointestinal 4. BOWEL FUNCTION
fa. Bowel function unchanged u
1b. Incontinent of BM. "
te. Bowel sounds present. "
1d. Diarrhea "
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BROOKHAVEN 000190
3/15/2021 Medicare Shift Documention (Dynasty)
te. Constipation 4
2. OSTOMIES PRESENT
2a. Neostomy uw
2b. Colostomy "
2c. Patent and draining. a
3.6!
3a, Nausea "
3b. Vomiting "
3c. Difficulty swallowing. A
4. Notable changes in bowel or GI function. "
Skin/Wound 4. SKIN INTEGRITY.
fa. No new changes to skin integrity noted. "
4b. Notable changes to skin integrity. "
2. WOUND CARE,
2a. Resident has treatable wounds. u
2b. #, type and location (i.e. #1, pressure, left buttock) u
site
2c. Dressing changed as per treatment orders. 8
2d. Dressing change not required. "
2e. Changes were noted to wound. 4
2f. Notable changes to wound. "
Respiratory Within Normal Limits, 4
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BROOKHAVEN 000191
3/15/2021 Medicare Shift Documention (Dynasty)
‘Shortness of Breath (Dyspnea) u
2a. On exertion u
2b. At rest. 4
Abnormal lung sounds uw
Cough present 4
Cyanosis “
Does resident use oxygen? If yes, note rate in next question. n
4. No
2. Yes
Oxygen at what rate? u
2h
Oxygen via: "
‘
Respiratory Services provided. 8
10. Tracheostomy Care provided "
1 Notable changes in respiratory function. n
Cardiovascular Pulse regular rate and rhythm. "
2. Peripheral pulses palpable. u
3. Capillary refi u
a. <3 sec - Normal
b. > 3sec <5 sec - Slugish
c . > 5 sec- Abnormal
4, EDEMA
4a. Edema present "
4b. Location u
4c. Pitting u
0. None
14 Mild pitting, slight indentation, no perceptable swelling of the leg
2+ Moderate pitting, indentation subsides rapidly
3+. Deep pitting, indentation remains for a short time, leg looks swollen
4 Very deep pitting, indentation lasts a long time, leg is very swollen
5. Episodes of chest pain "
6. Notable changes to cardiovascular status. 4
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BROOKHAVEN 000192
3/15/2021 Medicare Shift Documention (Dynasty)
J. Neurotogical/SensoryiCommunication| 1. PERRLA u
2 Decreased grasp "
3. Decreased movement n
A. Vertigo 0
5. Syncope u
Dizziness u
Tremors 4
Adequate hearing uw
Wears hearing aid "
10. Adequate vision #
"1 Wears glasses "
12. Clear and appropriate speech. H
13, Notable changes to neurological/sensory or communication status "
Pain 1. VERBAL PAIN DESCRIPTION
ta. Resident verbalizes presence of pain, 4"
4b. Scale out of 10 "
4 2. 3. 4, 5. 6. 7. 6. 9. 10.
1c. Location H
4d. Notes u
2. NON-VERBAL INDICATOR PAIN
2a, Resident demonstrates non-verbal signs of pain “
2b. Describe uw
Medication/Orders 4, ORDERS
fa, Lab orders received u
4b. Medication orders received. u
1c. Treatment orders received. "
4d. Notes "
2. MEDICATIONS
2a. IV Medication "
2b. Treat Infection "
2c. IM Medication "
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BROOKHAVEN 000193
3/15/2021 Medicare Shift Documention (Dynasty)
2d. IV Fluids "
2e. Note any adverse affects to medications. "
3. Notes on medications and treatments. "
Skilled Services 1. Therapy / Rehabilitative Services
fa. Physical Therapy "
tb. Occupational Therapy "
te. Speech Therapy 8
2. DAILY SKILLED SERVICES PROVIDED
2a. Evaluation and update of Care plan u
2b. Observation/Assessment of resident's condition a
Teaching and Training
2c, (ex, post-op care, medication, pain mgnmt) Deserihe in Notas (24) u
3. ADDITIONAL DIRECT SKILLED NURSING SERVICES
3a. Dialysis "
3b. Tube Feeding "
3c. Restorative Nursing Services “
3d. Post-surgical services
3e. Diabetic monitoring "
4, Skilled Progress Notes
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hevatntc
en ESAIin
accossit
an -8A7 3sec <5 sec - Slugish
c, > 5 sec - Abnormal
4, EDEMA
4a. Edema present
4b. Location u
4c. Pitting "
0. None
14 Mild pitting, slight indentation, no perceptable swelling of the leg
2+. Moderate pitting, indentation subsides rapidly
3+. Deep pitting, indentation remains for a short time, leg looks swollen
4. Very deep pitting, indentation lasts a long time, leg is very swollen
5. Episodes of chest pain a
6. Notable changes to cardiovascular status. "
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BROOKHAVEN 000204
3/15/2021 Medicare Shift Documention (Dynasty)
J. | Neurological/Sensory/Communication| 1. PERRLA 4
2. Decreased grasp "
3 Decreased movement 4
4. Vertigo n
Syncope a
Dizziness "
Tremors 4
Adequate hearing "
9. Wears hearing aid u
10. Adequate vision 4
" Wears glasses u
12. Clear and appropriate speech. 4
13, Notable changes to neurological/sensory or communication status. "
Pain 4. VERBAL PAIN DESCRIPTION
fa. Resident verbalizes presence of pain. 4
1b. Scale out of 10 Hn
1 2. 3. 4 5. 6. 7 8. 9. 10,
1c. Location "
1d. Notes W
2. NON-VERBAL INDICATOR PAIN
2a. Resident demonstrates non-verbal signs of pain. "
2b. Describe uw
Medication/Orders 4, ORDERS
fa. Lab orders received Ww
1b Medication orders received. K
te. Treatment orders received. "
1d. Notes 4
2. MEDICATIONS
2a, IV Medication 4"
2b. Treat Infection 4
2c. IM Medication “"
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BROO! KH.KHAVEN 000208
3/15/2021 Medicare Shift Documention (Dynasty)
2d. IV Fluids "
2e. Note any adverse affects to medications. "
3. Notes on medications and treatments, "
Skilled Services 1. Therapy / Rehabilitative Services
fa. Physical Therapy uw
‘1b. Occupational Therapy 4"
te. Speech Therapy #
2. DAILY SKILLED SERVICES PROVIDED
2a. Evaluation and update of Care plan u
2b. Observation/Assessment of resident's condition H
Teaching and Training
2c. (cx. post op care, medicatinn, pain mgnmt) Describe in Notes (24) "
3. ADDITIONAL DIRECT SKILLED NURSING SERVICES
3a. 7 "
3b. =\ Feeding 4
3c. Restorative Nursing s "
3d. Post-surgical ser 4
3e jabetic monitori "
Skilled Pr "
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BROOKHAVEN 000206
3/15/2021 Medicare Shift Documention (Dynasty)
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FILED 10/12/2023 12:14 PM FELICIA PITRE DISTRICT CLERK DALLAS CO., TEXAS Rosa Delacerda DEPUTY, CAUSE NO. DC-21-08674 FRANTEISHA FONTENOT; DARREN IN THE DISTRICT COURT KING; MARVIN PRIDE and YALONDA WRIGHT, EACH INDIVIDUALLY AND ON BEHALF OF THE ESTATE OF LINDA FONTENOT WILLIAMS, DECEASED, VS. 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 4 3/15/2021 Medicare Shift Documention (Dynasty) Shortness of Breath (Dyspnea) " 2a. ‘On exertion u 2b. Atrest. " ‘Abnormal lung sounds u Cough present " 5. Cyanosis 1 6. Does resident use oxygen? If yes, note rate in next question. a 1 No 2. Yes 7. Oxygen at what rate? " Z 8. Oxygen via: a 9. Respiratory Services provided. 4 10. Trachenstamy Gare provided " 41. Notable changes in respiratory function. " Cardiovascular 1 Pulse regular rate and rhythm " 2. Peripheral pulses palpable " 3. Capillary refil. 4 a, <3 sec - Normal b. > 3sec <5 sec- Slugish c. > 5 sec - Abnormal 4. EDEMA Aa. Edema present " 4b. Location " 4c. Pitting " 0. None 1+ Mild pitting, slight indentation, no perceptable swelling of the leg 2+, Moderate pitting, indentation subsides rapidly 3+, Deep pitting, indentation remains for a short time, leg looks swollen 4 Very deep pitting, indentation lasts a long time, leg is very swollen 5. Episodes of chest pain " 6. Notable changes to cardiovascular status. " hiinesdianau24 nnintelicunare enmirarelchartimdsimdesertion isn?F SOI assessid=8369068relURL=/admin/clienUcp assessment.isp&ESOLclienti IKHAVEN 000177 3/15/2021 Medicare Shift Documention (Dynasty) Neurological/Sensory/Communication 1. PERRLA w {; 2. Decreased grasp “ | 3. Decreased movement R 4. Vertigo " Syncope " Dizziness " Tremors 4 Adequate hearing W Wears hearing aid " 10. Adequate vision 4 1 Wears glasses u 12. Clear and appropriate speech. " 13. Notable changes to neurological/sensory or communication status. " Pain 41. VERBAL PAIN DESCRIPTION ta. Resident verbalizes presence of pain. 8 4b. Scale out of 10 4 1 2: 3. 4 5. 6. 7. 8. 9. 10. 1c, Location u 4d. Notes " 2. NON-VERBAL INDICATOR PAIN 2a, Resident demonstrates non-verbal signs of pain. " 2b. Describe uw Medication/Orders 1. ORDERS fa. Lab orders received " 1b. Medication orders received. " 1c. Treatment orders received. “ 4d, Notes 4 2. MEDICATIONS 2a, \V Medication " 2b. Treat Infection 4 2c. IM Medication n eae 1” 104 maintatinvrare enmicareichartimdsimdssection.iso7ES OLassessid=8369068retURL=/admin/clienvcp_assessment jsp&ESOLclienti 7 6/8 SROOKHAVEN 00017! 3/15/2021 Medicare Shift Documention (Dynasty) 2d. IV Fluids " 2e. Note any adverse affects to medications. " 3. Notes on medications and treatments. 4 Skilled Services 4. Therapy / Rehabilitative Services ta. Physical Therapy " 4b. Occupational Therapy " 1c. Speech Therapy " 2. DAILY SKILLED SERVICES PROVIDED 2a, Evaluation and update of Care plan u 2b. Observation/Assessment of resident's condition 4 Teaching and Training 2c. (ex, post-op care, medication, pain mgnmt) Describe in Notes (2d) u 3. ADDITIONAL DIRECT SKILLED NURSING SERVICES 3a. Dialysis " 3b. Tube Feeding 4 3c. Restorative Nursing Services u 3d. Post-surgical services " 3e. Diabetic monitoring u 4. Skilled Progress Notes & it led Ate oe noth in te ne dd nid % iota ee a oe he | Cancel Click Here to View Quick Entry - Keyboard Navigation Tips httos:/www21 oointclickcare.com/care/chart’mds/mdssection.jsp7ESOLassessid=8369068retURL=/admin/clienUcp_assessment.jsp&ESOLclientid=9 718 BROOKHAVEN 000179 3/15/2021 Medicare Shift Documention (Dynasty) Brookhaven Nursing and Rehab PointClickCare Privacy Policy A 5 5 Cheyenne Drive 5 70 Explorer Drive Customer Support Carrollton, TX 75010-2204 Mississauga, Ontario Law 0C4 Version 4.3.3.9 www21-peo-web-main: Phone: (972) 394-7141 Help Desk: (877) 722-2431 | (905) 817-6167 6c64744de emg?tz PCC Faality 1D: 9 Toll Free: (800) 277-5889 | Copyright 2000-2021 PointClickCare Phone: (905) 858-8885 | Technologies Inc. All rights reserved Fax: (905) 868-2248 hitnc:/ianiaw?41 nnintelirkeare enm/earelchartimdsimdssection isn?FSOl assess j=836906&retURL=/admin/clientico assessment.iso&ESOLclientid=9. 8/8 SROOKHAVEN 000180 3/15/2021 Activity Interview for Daily and Activity Preferences (3.0) (Dynasty) { Searci Activity Interview for Daily and Activity Preferences (3.0) (Dynasty) Resider FONTENOT, LINDA (3947) Description Admission Date: 12/14/2019 15:24 Section Status: Signed Lock Date: 1/4/2020 18:40 Cancel ins. INSTRUCTIONS Attempt to interview all residents able to communicate. It resident Is unable to complete, ullurpl lu Lummplete interview with family member or significant other. 8 a. Should interview for Daily and Activity Preferences be Conducted? - Attempt to interview ail residents able to communicate, MDS uv 0. No 1. Yes - Not assessed A Interview for 1, How important is it to you to choose what clothes to wear? MDS 4 Daily Preferences. 1 Very important 2. Somewhat important 3. Not very important 4. Not important at ail 5. Important, but can't do or no choice 9. No response or non-responsive a Not assessed 2. How important is it to you to take care of your personal belongings or things? MDS 1 Very important 2. ‘Somewhat important 3. Not very important Not important at all Important, but can't do or no choice No response or non-responsive - Not assessed 3. How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? MDS 1 Very important 2. ‘Somewhat important 3. Not very important 4. Not important at all 5. Important, but can't do or no choice 9. No response or non-responsive - Not assessed 4, How important is it to you to have snacks available between meals? MDS H 1 Very important carcri . SHS e TENA g-nH11D! 40 Morbid obesity Most Recent Height u Height: 66.0 (Inches) Date: 12/12/2019 14:55 Method: Lying down Altered food or fluid consistency? " 2. Automatic If any of the following are checked, skip Section III. Start an interim plan Referrals to RDN/NDTRILDN: of care for the patient/resident per the Care Pathways and refer to the nutrition consultant (RDN/LDN/NDTR) 1, Check any items that apply. " 1, Diagnosis of Malnutrition or Failure to Thrive 2. TFITPNIPPN 3. Dialysis 4, Stages 2-4 pressure injuries 6. NPO or clear liquid > 3 days 3. Mini Nutritional Assessment Complete the Mini Nutritional Assessment. If the total score is 11 points (MNA) or less, start an interim plan of care for the patient/resident per the Care Pathways and refer to the nutrition consultant (RDN/LDN/NDTR) 4 Mini Nutritional Assessment Score " 1.11 points or less 21244 hittps:/mww21 pointolickcare m/care/chartimds/mdssection jsp?ESOL tab Type=C&ESOL sectioncode=Cust_1&ESOLclientid=955882&ESOLassessi 112 BROOKHAVEN 000185 3/15/2021 Nutrition Risk Screen - V2 4. 41. Check item that applys n 1. Not at risk 2. Automatic Referral (Section i!) 3. Referred to RDN/NDTRILDN for MNA score of 11 points or less 2, Interim Interventions per Care Pathways " {Cancel} (Next Section Click Here to View Quick Entry - Keyboard Navigation Tips Brookhaven Nursing and Rehab PointClickCare Privacy Policy 1855 Cheyenne Drive 5570 Expl er Drive Customer Support Carroliton, TX 75010-2201 Missi ga. sti Ww OC4 Version 4.3.3.9 www21-pec-web-main- Pr e: (972) 394-7141 Hel (8 905} 81 76167 606 Ad 9-4kv42 PCC acility 1D 9 Free ‘B0C pyright 2 10-2021 kCar Phone 905)85 888: 5}5 | hnologie: Inc All ngh Fax: ) 85 48 i T SrRententunacCRESO! cartinnendasCust 1&ESOL gp EAN i862? 3/15/2021 Nutrition Risk Screen - V 2 (a | Search Nutrition Risk Screen - V 2 Resident: FONTENOT, LINDA (3947) Descriptio! Admission Date: 12/14/2019 15:24 Section Statu: Signed Lock Da’ 1/2/2020 15:46 [Previous Sec in| ( Cancel | 1 1. RDN, NDTR, LDN Review ary Summar} i aa = | Previous Section | | Cancel | Click Here to View Quick Entry - Keyboard Navigation Tips Brookhaven Nursing and Rehab PointClickCare Privacy Policy Cheyenne Drive 0 Explorer Drive Customer Support Carrollton, TX 201 sauga, Ontario LAW 9 www21-pec-web-main- Phone: (972) 394-7141 Hel jesk: (B77) 722-2431 817-6167 dde9. KXBW PCC Facility 10: 9 Toll Free (800) 277-5889 | Cop ight 2021 PointClickCare Phone: 05) 858-8885 | jolagies Inc. Ai ights ved Fax 858-2248 ban tate “PEA! ohTune=CRESNI sactioncnde=Cust 28ESOL cient S55HB28E 1" SQ asaaaal 3/15/2021 Medicare Shift Documention (Dynasty) a Search Medicare Shift Documention (Dynasty) Resident: FONTENOT, LINDA (3947) Description 6-2 Shift Date: 12/14/2019 07:05 Section Status: Signed Lock Date: 12/14/2019 23:15 [Cancel 32 1 INSTRUCTIONS Document all skilled services provided for resident on each shift Vital Signs 4 Most Recent Temperature E # Temperature: 97.8 (°F) Date: 12/14/2019 07:05 Route: Temporal Artery Most Recent Pulse E u Pulse: 80 (bpm) Date: 12/14/2019 07:06, Pulse Type: Regular Most Recent Respiration £ 1 Respiration: 18 (Breaths/min) Date: 12/14/2019 07:06 Most Recent Blood Pressure E Blood Pressure: 99 / 58 (mmHg) Date: 12/14/2019 07:07 Positio tying Warm Is resident a Diabetic? If yes, note most recent blood sugar below. u 1 No 2. Yes 5a, Most Recent Blood Glucose 4 Blood Glucose: (mg/dL) Date: Most Recent 02 sats En 2 sats: 94 (%) Date: 42/14/2019 07:0) Method: Room Air B. Level of 4a. Sensory and Neurological - check all that apply " Consiousness/Orientation/Cognition 4 Alert 2. Confused 3 Unresponsive Lethargic Slurred Speech Aphasic Visual impairment 8. Hearing impairment 2. Resident is oriented to: (Check all that apply) " 1 Time 2. Place ite ma RADEON aennnei “O87 2NGReo IDI slarimininiention ascpesa BRAT SORMeYti ces eg V8 3/15/2021 Medicare Shift Documention (Dynasty) 3. Person 4, Year 5. N/A 3. Note any changes in Level of Consciousness, Orientation and/or Cognition. If none noted, note NIA, uw c. Activities of Daily Living/Functional 1. Does not weight bear H tatus 2. Unsteady gait requiring supervision u 3. Impaired balance " 4. Weakness " = Paralysis " 6. Decreased sensation " Ta. Requires assistance with bed mobility. " 7b. Requires assistance with transfers. 4" Te. Requires assistance with eating. 4" 7d. Requires assistance with toilet use. " 8. Notable changes in functional ability and/or ADL's. 4 D. Mood and Behaviour 1 Mood and behavior patterns: (Check all that apply) " 1 Persistant anger 2. Unrealistic fears 3. Repetitive concerns Anxious (non-health related) Sad/worried facial expressions Cryingtearful Withdrawn from interests Wandering Verbally abusive 10. Physically abusive "1 Resistant to care 12, Inappropriate behaviour 13. Negative behaviors not easily altered 14. Confused 15, Talkative 16. Friendly 17. Cooperative Intact net ee tian ien7ESAI agsassid=8373098retURL=/admin/clienvicp_assessmen vse BESOQLclientid=9, 218 ROO! IAVEN 000189 3/15/2021 Medicare Shift Documention (Dynasty) 18, Happy/smiling 19, Quiet 20. Passive 2 NIA Ja. No changesto mood and behavior noted. # 4b. Notable changes in mood and behavior a E. Bladder/Genitourinary er Check if no new observations noted during shift 1. BLADDER FUNCTION fa, Bladder tunction unchanged. " 4b. incontinent of urine: " te. Distension noted. 4" 2. ‘Check if resident has an indwelling catheter u 2, CATHETER 2a, Supra-pubic Catheter care provided, " 2b. Foley Catheter care provided. n 2c. Catheter patent, in place and draining. " 3b. Bedpan « 3c. Commode " 3d. Pads/Briefs un 4. OSTOMIES PRESENT 4a. Urostomy " Ab. Ostomy patent, in place and cleaned. " 5, URINE 5a. Color " te 5b. Clarity " 5c, Odor " ‘1 u Notable changes to bladder function. " F. Bowel/Gastrointestinal 4. BOWEL FUNCTION fa. Bowel function unchanged u 1b. Incontinent of BM. " te. Bowel sounds present. " 1d. Diarrhea " https:/ww21 pointclickcare.com/care/chartimds/mdssection jsp?7ESOLassessid=8373098retURL=/admin/clien/cp_assessment,jsp&ESOLclientid=! 3/8 BROOKHAVEN 000190 3/15/2021 Medicare Shift Documention (Dynasty) te. Constipation 4 2. OSTOMIES PRESENT 2a. Neostomy uw 2b. Colostomy " 2c. Patent and draining. a 3.6! 3a, Nausea " 3b. Vomiting " 3c. Difficulty swallowing. A 4. Notable changes in bowel or GI function. " Skin/Wound 4. SKIN INTEGRITY. fa. No new changes to skin integrity noted. " 4b. Notable changes to skin integrity. " 2. WOUND CARE, 2a. Resident has treatable wounds. u 2b. #, type and location (i.e. #1, pressure, left buttock) u site 2c. Dressing changed as per treatment orders. 8 2d. Dressing change not required. " 2e. Changes were noted to wound. 4 2f. Notable changes to wound. " Respiratory Within Normal Limits, 4 nen tate nat lendaben tons mndECO id= 827 20ORratl IRI =larminiclienticn assessment isn&FSOL clientid=9 al BROOKHAVEN 000191 3/15/2021 Medicare Shift Documention (Dynasty) ‘Shortness of Breath (Dyspnea) u 2a. On exertion u 2b. At rest. 4 Abnormal lung sounds uw Cough present 4 Cyanosis “ Does resident use oxygen? If yes, note rate in next question. n 4. No 2. Yes Oxygen at what rate? u 2h Oxygen via: " ‘ Respiratory Services provided. 8 10. Tracheostomy Care provided " 1 Notable changes in respiratory function. n Cardiovascular Pulse regular rate and rhythm. " 2. Peripheral pulses palpable. u 3. Capillary refi u a. <3 sec - Normal b. > 3sec <5 sec - Slugish c . > 5 sec- Abnormal 4, EDEMA 4a. Edema present " 4b. Location u 4c. Pitting u 0. None 14 Mild pitting, slight indentation, no perceptable swelling of the leg 2+ Moderate pitting, indentation subsides rapidly 3+. Deep pitting, indentation remains for a short time, leg looks swollen 4 Very deep pitting, indentation lasts a long time, leg is very swollen 5. Episodes of chest pain " 6. Notable changes to cardiovascular status. 4 https:/Avww21 .pointclickcare.com/care/chart/mds/mdssection jsp?ESOLassessid=837309&retURI =/admin/clientcp_assessment.jsp&ESOl clientid=9. 5/8 BROOKHAVEN 000192 3/15/2021 Medicare Shift Documention (Dynasty) J. Neurotogical/SensoryiCommunication| 1. PERRLA u 2 Decreased grasp " 3. Decreased movement n A. Vertigo 0 5. Syncope u Dizziness u Tremors 4 Adequate hearing uw Wears hearing aid " 10. Adequate vision # "1 Wears glasses " 12. Clear and appropriate speech. H 13, Notable changes to neurological/sensory or communication status " Pain 1. VERBAL PAIN DESCRIPTION ta. Resident verbalizes presence of pain, 4" 4b. Scale out of 10 " 4 2. 3. 4, 5. 6. 7. 6. 9. 10. 1c. Location H 4d. Notes u 2. NON-VERBAL INDICATOR PAIN 2a, Resident demonstrates non-verbal signs of pain “ 2b. Describe uw Medication/Orders 4, ORDERS fa, Lab orders received u 4b. Medication orders received. u 1c. Treatment orders received. " 4d. Notes " 2. MEDICATIONS 2a. IV Medication " 2b. Treat Infection " 2c. IM Medication " https://www21 pointclickcare.com/care/chart/mds/mdssection jsp?ESOLassessid=8373098retURL=/admin/clientiop_assessment jsp&ESOLclientid=9.... 68 BROOKHAVEN 000193 3/15/2021 Medicare Shift Documention (Dynasty) 2d. IV Fluids " 2e. Note any adverse affects to medications. " 3. Notes on medications and treatments. " Skilled Services 1. Therapy / Rehabilitative Services fa. Physical Therapy " tb. Occupational Therapy " te. Speech Therapy 8 2. DAILY SKILLED SERVICES PROVIDED 2a. Evaluation and update of Care plan u 2b. Observation/Assessment of resident's condition a Teaching and Training 2c, (ex, post-op care, medication, pain mgnmt) Deserihe in Notas (24) u 3. ADDITIONAL DIRECT SKILLED NURSING SERVICES 3a. Dialysis " 3b. Tube Feeding " 3c. Restorative Nursing Services “ 3d. Post-surgical services 3e. Diabetic monitoring " 4, Skilled Progress Notes fo pancreatinis a o1e! ste omy of or he aiff or ey ta h on re ws ne bl aned nea, of recaw di noted a zime Ligh ve will inge to m1 sport ui n piace Cancel Click Here to View Quick Entry - Keyboard Navigation Tips hevatntc en ESAIin accossit an -8A7 3sec <5 sec - Slugish c, > 5 sec - Abnormal 4, EDEMA 4a. Edema present 4b. Location u 4c. Pitting " 0. None 14 Mild pitting, slight indentation, no perceptable swelling of the leg 2+. Moderate pitting, indentation subsides rapidly 3+. Deep pitting, indentation remains for a short time, leg looks swollen 4. Very deep pitting, indentation lasts a long time, leg is very swollen 5. Episodes of chest pain a 6. Notable changes to cardiovascular status. " https:/Mwww21 pointclickcare.com/care/chart/mds/mdssection jsp7ESOLassessid=836852&retURL=/admin/clienticp_assessment jsp&ESOLclientid=! 5/8 BROOKHAVEN 000204 3/15/2021 Medicare Shift Documention (Dynasty) J. | Neurological/Sensory/Communication| 1. PERRLA 4 2. Decreased grasp " 3 Decreased movement 4 4. Vertigo n Syncope a Dizziness " Tremors 4 Adequate hearing " 9. Wears hearing aid u 10. Adequate vision 4 " Wears glasses u 12. Clear and appropriate speech. 4 13, Notable changes to neurological/sensory or communication status. " Pain 4. VERBAL PAIN DESCRIPTION fa. Resident verbalizes presence of pain. 4 1b. Scale out of 10 Hn 1 2. 3. 4 5. 6. 7 8. 9. 10, 1c. Location " 1d. Notes W 2. NON-VERBAL INDICATOR PAIN 2a. Resident demonstrates non-verbal signs of pain. " 2b. Describe uw Medication/Orders 4, ORDERS fa. Lab orders received Ww 1b Medication orders received. K te. Treatment orders received. " 1d. Notes 4 2. MEDICATIONS 2a, IV Medication 4" 2b. Treat Infection 4 2c. IM Medication “" [hadttendatendacantinn ien?ESNI assassid=836852&retURL=/adminiclienticp_assessment tjsp&ESOL clientid: BROO! KH.KHAVEN 000208 3/15/2021 Medicare Shift Documention (Dynasty) 2d. IV Fluids " 2e. Note any adverse affects to medications. " 3. Notes on medications and treatments, " Skilled Services 1. Therapy / Rehabilitative Services fa. Physical Therapy uw ‘1b. Occupational Therapy 4" te. Speech Therapy # 2. DAILY SKILLED SERVICES PROVIDED 2a. Evaluation and update of Care plan u 2b. Observation/Assessment of resident's condition H Teaching and Training 2c. (cx. post op care, medicatinn, pain mgnmt) Describe in Notes (24) " 3. ADDITIONAL DIRECT SKILLED NURSING SERVICES 3a. 7 " 3b. =\ Feeding 4 3c. Restorative Nursing s " 3d. Post-surgical ser 4 3e jabetic monitori " Skilled Pr " (Cancel Click Here to View Quick Entry - Keyboard Navigation Tips oe +> somInarainhartimdeimscartinn iso?ESOLassessid=836852&retURL=/admin/clienUcp_asses jsp&ESOLclientid=9 sment 718 BROOKHAVEN 000206 3/15/2021 Medicare Shift Documention (Dynasty) Brookhaven Nursing and Rehab PointClickCare Privacy Policy 1855 Cheyenne Drive 5570 Explorer Drive Customer Support roliton. TX 75010-2204 Mississau Ontario L4 NOC4 Version 4.3.3.9 www21-p jeb-main Phone: (972) 394-7441 Help Desk: (877) 72 90! ) 8 67 6064744d Stsaj PCC Fai lity 1D: & Toll Free: (800) 277-588: Copyright 00: 021 Click