Wiliam Sepulvado - Medical Summaries€¦ · Web viewMEDICAL CHRONOLOGY - INSTRUCTIONS TO FOLLOW. General Instructions: Brief Summary/Flow of Events: In the beginning of the chronology,

Jane XXX DOB: 09/30/YYYY

MEDICAL CHRONOLOGY - INSTRUCTIONS TO FOLLOW

General Instructions:

Brief Summary/Flow of Events: In the beginning of the chronology, a Brief Summary/Flow of Events outlining the significant medical events is provided which will give a general picture of the focus points in the case

Patient History: Details related to the patient’s past history (medical, surgical, social and family history) present in the medical records

Detailed Medical Chronology: Information captured “as it is” in the medical records without alteration of the meaning. Type of information capture (all details/zoom-out model and relevant details/zoom-in model) is as per the demands of the case which will be elaborated under the ‘Specific Instructions’

Reviewer’s Comments:Comments on contradicting information and misinterpretations in the medical records, illegible handwritten notes, missing records, clarifications needed etc. are given in italics and red font color and will appear as * Reviewer’s Comment

Illegible Dates: Illegible and missing dates are presented as “00/00/0000”(mm/dd/yyyy format)

Illegible Notes: Illegible handwritten notes are left as a blank space “_____” with a note as “Illegible Notes” in the heading of the particular consultation/report.

Specific Instructions:The chronology focuses on care rendered to (Patient Name) in ABC City Health Care from 12/06/YYYY-02/14/YYYY in detail. These include daily nurse assessment, nutrition, skin care and pressure ulcers assessment and management.

02/14/YYYY-11/16/YYYY: These records pertaining to ongoing management for bed sores and heel ulcers in other facilities are captured in brief to assess the medical condition of Mr. Johnson after development of pressure ulcer.

If the name of the provider is not decipherable, snapshot of the same is captured. Events elaborated with time are given in 24 hour format. For occurrence more than one reference, the appropriate reference is given in brown font.

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Brief Summary/Flow of EventsABC City Health Care

12/06/YYYY-01/24/YYYY: Admitted with hypertension, degenerative joint disease, anxiety and depression – On psychoactive medications - Incontinent of bowel and bladder – Daily incontinent

care provided - Extensive assist of 2 for transfer and bed mobility – No skin impairments - Encouraged turning and reposition every two hours – Regular diet with no added salt – Appetite

fair to poor

01/25/YYYY-02/14/YYYY: On 01/25/YYYY assessed with shear in left buttock with small serosanguineous drainage – Cleansed with wound cleanser and Alginate applied – Stage II left

buttock treated with Hydrocolloid – Left buttock ulcer progressed to unstageable – On 02/08/YYYY assessed with elevated WBC (14.6) – On 12/12/YYYY wound noted with foul odor

– IV antibiotics startedOn 01/27/YYYY assessed with 6.5x6 cm ulcer on right heel with no exudate – Treated with dry

dressing followed by Granulex spray and off load heel protectors – Progressed to deep tissue with discoloration – Progression of wound inspite of treatment – Transferred to XYZ Hospital

XYZ Hospital02/14/YYYY-03/21/YYYY: Assessed with unstageable sacral and right heel ulcer – Started on IV antibiotics - Underwent osteoectomy of decubitus ulcer and debridement of left heel ulcer –

Stable condition – Transferred to Health and Rehabilitation Center with per oral Doxycycline and Levaquin for 18 days

Health and Rehabilitation Center03/21/YYYY-04/19/YYYY: Stage IV ulcer in sacrum and stage II ulcer in bilateral heels –

Continued wound care – Completed per oral antibiotics – Discharged to GCMC behavioral unit due to increasing psychosis

Medical Center04/19/YYYY-05/08/YYYY: Admitted to behavioral unit with increasing psychosis and dementia – On 04/23/YYYY underwent excision of eschar in right heel - Sacrum wound did not improve

due to anal incontinence – On 05/02/YYYY underwent left end colostomy with Hartman pouch – Discharged to Nursing Home with long term IV antibiotics and wound care to sacral area

Nursing Home & Medical Center05/08/YYYY-07/15/YYYY: Admitted to Nursing Home with stage III ulcer to right heel and

sacrum – Had weekly visits to Wound Care Clinic – On antibiotic therapy – Completed on 07/01/YYYY

07/18/YYYY-07/22/YYYY: Admitted to Medical Center for debridement of right hip, excision of greater trochanter and placement of wound VAC – Discharged to nursing home

07/25/YYYY-08/20/YYYY: Continued wound care for heel and sacrum with Santyl, Gentamicin – Off load heels – Recommended rotational flap to right hip and debridement to right heel

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08/26/YYYY-08/29/YYYY: Underwent rotational flap to right hip; ostectomy or the right hip and wound VAC placement

09/03/YYYY-09/25/YYYY: Continued wound care – Wound VAC in place – Developed pressure ulcers on medial aspects of knee - Right heel not healing – Recommended amputation

09/30/YYYY-10/03/YYYY: Underwent above knee amputation on 09/30/YYYY followed by antibiotics

11/11/YYYY-11/16/YYYY: Underwent excision of eschar from sacrum and left knee with debridement into the fascia – Recommended Cefepime 1 gram every 12 hours for 10 days*Reviewer’s comments: Further records are not available to assess the status of wound.

Patient History

Past Medical History: Arthritis, hypertension, Degenerative Joint Disease (DJD), depression, osteoarthritis, muscle weakness, Benign Prostatic Hypertrophy (BPH) with urinary obstruction, dementia Alzheimer’s type, anxiety, joint pain-leg, neck pain, vertigo, renal insufficiency, bronchitis

Surgical History: Not known Family History: Non contributory

Social History: He is married twice and has three children. He has never smoked, consumes alcohol occasionally.

Allergy: No known drug allergy

Detailed Chronology

DATE PROVIDER

OCCURRENCE/TREATMENT BATES REF

ABC City Health Care12/06/YYYY Provider/

SignatureNursing admission assessments: (Illegible Notes)Cardiovascular: (Ref: Medical record-- 00145-Medical record-- 00146)Edema in left knee, heart sounds irregularNeurological: Alert to person, behavior cooperative. Vision adequate. Right and left hearing aids.Respiratory: No cough. Right and left breath sounds clearGastrointestinal: Lips moist. Diet regular. Bowel sounds present. Abdomen soft.

Genitourinary: Incontinent. Ostomy: NoMusculoskeletal: Up in chair; partial weight bearing. Poor balance, stands only for short period of time. No extremity abnormalities.

Medical record-- 00355-Medical record-- 00359, Medical record-- 00136-Medical record-- 00140,

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Activity of Daily Living (ADL): Extensive assist for bed mobility and transfer. Unable to walk. Independent in eating.Prior level of functioning: Contractures: NoOriented to room. Call light in reach.

Nurse notes: (Ref Medical record-- 00356)Received patient in room sitting up in mobile wheel chair. Patient is alert and cheerful, speaks about his days in service and his jobs. Skin is warm and dry. He is non-ambulating. Hearing aids in ears. Has knee brace on left knee. Noted 1+ edema in left knee. Various skin moles covering back and lower abdomen. ____ healed skin area on inside of buttock on left. Area pink and dry also on right cheek area

Pain evaluation: Diagnosis related to pain: DJDFrequent pain in right knee joint due to DJD. Pain score of 5-6/10Relieving factors: Positioning, meditation and topical creams.Contributing factors: RepositioningManner of expressing pain: Verbalization, frowning and rubbing

Elopement risk assessments: No verbal expressions to leave facility. No predisposing disease (Alzheimer’s disease, depression, mental illness, substance abuse, expressive language deficits) present.

Fall risk evaluation: 11 (High risk) (Ref Medical record-- 00140)Side rail review: (Ref Medical record-- 00136-Medical record-- 00137)Side rails are indicated and serve as enabler to promote independence.

Abnormal Involuntary Movement Scale (AIMS) (Ref Medical record-- 00138)Facial and oral movements:Muscles of facial expression, lips and peri-oral area, jaw and tongue: Minimal/normalUpper and lower extremity movements: MildTrunk movements: Minimal/normalIncapacitation due to abnormal movements: NoneCurrent problems with teeth: No

Skin assessments: (Ref Medical record-- 00066)Skin intact. No bruises, skin tear, abrasions or rashes. No previously identified areas. Nails cleaned and trimmed.

Braden score: 18 (Mild risk) (Ref Medical record-- 00432)Additional risk factors: Cognitive impairment, urinary or fecal incontinence and nutrition& hydration deficits.

Medical record-- 00145-Medical record-- 00146, Medical record-- 00066, Medical record-- 00432

12/06/YYYY Provider/Signature

Nurse assessments:Resident admitted today with hypertension, DJD and BPH. Has a knee brace on left knee. He can stand but can’t walk. He is incontinent of bowel and bladder. He is regular diet. Assisting with ADL this evening and tolerating.

Medical record-- 00171

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Emotional status: Alert and anxious.Genitourinary: Yellow color urine. Incontinence.Musculoskeletal: Balance and gait unsteady. Bed/chair bound. Bed mobility and transfer extensive assist.Sensory: Speech clear; hearing and vision adequate.Skin: No problemsNervous system: Abnormal/absent movement in right and left lower extremityDiet: Feeding selfDigestive: Bowel movements atleast every 3 days. Incontinent bowelCognitive status: Disoriented to place. Moderately impaired for decisions. Making self understood: Usually understood – Difficulty finding words or finishing thoughts.

Services: Restorative services.12/06/YYYY Provider/

SignaturePlan of care:Problems: Extensive assist with bed mobility, with transfers, toileting, dressing and grooming, supervision assist with locomotion. Total assists with showers. Staff believe resident capable of increased independence with some ADLs.

Approaches: Encourage and monitor independence. Place call light within reach and answer promptly. Shower and shave three times weekly. Mouth care daily. Assist in turning every 2 hours. Apply preventive care if needed. Pressure relieving mattresses. Dress resident appropriately, encourage family to bring clothes. Assist with ambulation or assist to move about facility. Encourage independence. Assist with bed pan or toileting as needed. Give incontinent care every 2 hours and as needed.

Nutrition plan of care:Weight 214 lbs. BMI 27.47Problem: Potential weight loss. Related to: Cannot feed self, mouth problems (missing teeth), medications, lab values, chronic disease (hypertension, DJD, BPH)Diet: Regular. No Added Salt (NAS)

Approaches: Provide diet as ordered. Offer preferred foods upon availability. Extensive meal assistance. Provide medications and supplements as ordered. Referral to Dentist, speech and Registered Dietician (RD). Monthly weights or as indicated. Oral care

Medication: Anti-anxiety medication Buspar, anti-depression medication Paxil.

Incontinence care: Hand washing before and after of care. Have call light within easy reach. Provide perineal care daily and as needed. Encourage fluids. Observe for complaints of burning, frequency, noting color, amount of odor of urine. Notify physician as needed. Observe for incontinent

Medical record-- 00147-Medical record-- 00157, Medical record-- 00163, Medical record-- 00165-Medical record-- 00167

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episodes at regular and frequent intervals and as needed. Review and observe medication influences. Observe resident for worsening mental or functional status. Refer to therapy services as indicated.

Pain plan of care: Positioning or support and music. Administer analgesics as ordered. Notify physician if interventions are not effective. Observe for verbal and non verbal signs of pain. Medicate prior to treatment and therapy.

Dysfunctional mobility: Encourage to participate in mobility tasks, assistive device training, strengthening, gait or wheelchair mobility training, skilled PT interventions, safety awareness, balance or neuromuscular re-education and restore nursing program. ADL retraining, cognitive retraining, ADL retraining, skilled OT intervention

Pressure ulcer plan of care: (Ref Medical record-- 00163)Apply pressure reduction mattresses to bed, pressure reduction cushion to wheelchair, reposition in chair frequently for comfort and pressure reduction, turn and reposition while in bed, provide incontinence care after each incontinence episode, complete a full body check weekly and document, monitor labs as ordered.

Transfer plan of care: Encourage resident to obtain assistance for transfers, provide gait belt. Provide mechanical lift for transfers: Sit to stand, to/from toilet, chair and bed. Referral to physical, occupational and restorative nursing services. Observe potential patterns of falls to identify possible causes.

*Reviewer’s comments: The medications administered and treatment provided from 12/07/YYYY-02/14/YYYY is tabulated below separately for ease of reference.


Nurse assessments:Resident awake, alert and oriented to self. Slight swelling on left knee due to Degenerative Joint Disease (DJD). Ambulates with motorized wheelchair. Tolerated morning shower well. Will continue to monitor.

Emotional status: Alert and confused.Genitourinary: Yellow color urine. Incontinence.Musculoskeletal: Weakness. Bed mobility limited assist and transfer extensive assist.Sensory: Speech clear; hearing and vision adequate.Skin: No problemsNervous system: Abnormal/absent movement in left lower extremityCardiovascular: Edema in left kneeDiet: Feeding self; dining own roomDigestive: Bowel movements atleast every 3 days. Incontinent bowelCognitive status: Short term memory problems.Making self understood: Understood.

Services: Teaching and restorative services.


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Nutritional assessments:Weight 214.6; BMI 27.6Diet history: Breakfast, lunch and dinner goodNo pressure ulcer. No edema.Dentition: Missing/poor condition. Feeding independent. No labs available.



Bowel and bladder training evaluation:Incontinent bladder. Voiding pattern: Uses urinalIncontinent bowel. No impaction, no constipation. No discomfort voiced.Fluids preferred: Water and juice. Eating habits: Adequate



Nurse assessments: (Illegible Notes)Receives skilled nurse care. Assisted with ADL care with extensive assist. Incontinent of bowel _____; non-ambulatory but stands with assist for short period of time. Skin warm and dry to touch. No complaints voiced of physical discomfort. No acute distress. No adverse reactions to medicines.

Emotional status: Anxious, confused, depressed and restless.Musculoskeletal: Non ambulatory. Supervision; locomotion per motorized wheelchair. Weakness. Bed mobility and transfer extensive assist. Total care.Skin: Weekly skin checks; encouraged to turn and reposition every 2 hours. Skin dry.Nervous system: Abnormal/absent movement in left and right lower extremity. Weak grasps in left upper extremity.Diet: Feeding self; dining own room. Extensive assist with dressing and groomingDigestive: Bowel movements atleast every 3 days. Incontinent bowel. CKD every two hours and _____Cognitive status: Disoriented to place and time. Psychoactive medications required. Anti-anxiety and anti-depression

Services: Teaching and restorative services.

Medical record-- 00174-Medical record-- 00175


Nurse assessments:Resident awake and alert and oriented to times two. Extensive assist needed with ADLs. Commode needs to be fixed in morning. Resident up in motorized wheelchair yelling at staff to take him to toilet. Toileted at this time; wheelchair hit toilet base and broke. Resident continues to yell at staff. Re-directed although ineffective. Will continue to monitor.

Emotional status: Alert and confused.Musculoskeletal: Bed/chair bound. Bed mobility and transfer extensive assist. Total care.Skin: Poor turgor.Diet: Feeding self; dining own room. Extensive assist with dressing and groomingDigestive: Bowel movements atleast every 3 days. Incontinent bowel. Cognitive status: Disoriented to place and time. Severely impaired for decision.


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Services: Comfort measures and restorative services.*Reviewer’s comments: The progress notes from 12/10/YYYY-12/11/YYYY are not available for review.


Skin assessments: Skin intact. No bruises, skin tear, abrasions or rashes. No previously identified areas. Nails cleaned and trimmed.



Nurse notes:Resident transferred from station 2 to station 3. Adjusting to room and environment requires re-direction. Resident appears confused; continent of bowel and bladder. No complaints at this time. Will continue to monitor. Assisted to bed. Partial weight bearing to both legs. Uses urinal to void. Call light within reach.

Braden score (20) (Mild risk) (Ref Medical record-- 00432)

Medical record-- 00238, Medical record-- 00432


Nutritional assessments: (Illegible Notes)Estimated needs: Calories 2400; protein 78-98 grams per Kg and fluids

. _____good appetite and stable weight. Resident fluid large _____._____ resident encouraged to ask snacks if hungry, he agreed.


12/13/YYYY

Xxx Flores

Psychiatry notes:Signs and symptoms: Resident referred following admission to nursing home due to behavioral concerns and adjustment difficulties. Patient observed and reported as agitated and having verbal outbursts with staff. Hygiene is good; speech is pressured, with egocentric-type thinking. He makes statements alluding to the needs and necessitating one on one care, with consistent debate/arguing with staff. He is easily agitated and angered

Attention/cognition/thought content/sensory/memory impairment is present.

Mild depression is present. Verbal outbursts in a negative complaining form with consistent demands and complaints of staff

Psychotic/delusional thinking: Inflated sense of self, delusions questionable.

Other mental health conditions/signs: History of anxiety and depression.Current psychotropic medications: Buspar, Paxil and Donepezil

Recommendations: Patient seems to be having some adjustment difficulties related to his care and the setting in the nursing home; he presents as very demanding and has high expectations of the staff. Boundaries are loose and he is observed and reported as flirtatious with female staff especially younger ones. It is advisable that all staff especially females be vigilant and consistent in maintaining boundaries and be clear about expectations and appropriate language and behaviors. As it relates to outbursts, it would benefit to move patent out of main areas to assist in dc-escalating him, providing clear, supportive yet brief statements. Assist patient with adjustment by to other male residents and encourage daily activities. Continue to provide patient with opportunities for him to


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separate from staff and integrate with residents.Prognosis is guarded.


Nurse notes:Resting comfortably in bed. Medicated for complaints of pain with pain medicines Norco. Repositioned with head of bed elevated for comfort. Re-directed due to yelling. Will continue to monitor.



Nurse notes:Resident lying in bed yelling at this time. Vital signs stable. No acute distress. Stated he is dizzy. Medicated with as needed pain medicines. Refusing meal this morning. Water encouraged and accepted. Yelling and screaming, stated I just want to have someone sit here and talk with me.



Nurse notes:Resident awake at this time screaming to get out of bed, staff went to resident room to assist him out of bed; he refused to get out of bed; staff step out of room. Resident started screaming “Somebody come in here. I am 93 years old and I need someone to stay in here”. No distress noted. Will monitor.



Psychoactive medication evaluation:Diagnosis: Vascular dementia with delirium. Risperdal 0.25 mg for yelling. Medicated with Hydrocodone for pain as needed.


12/18/YYYY X - Associates Of America

Provider/Signature

Visit for knee pain: (Illegible Notes)Admitted from VA medical center. Knee pain, need to go to hospital. Patient known to me from previous nursing home admission with multiple complaints of _____wants to go to VA when I told he needed something. Services to be admitted he said he had contacts in high place that would take care of him.

Functional status: Ambulation assisted with motorized wheelchair. Dependent with ADL. Vision impaired. Hearing minimum difficulty. Mental status alert and oriented.

Chronic medications: APAP, Buspar, Finasteride, Docusate, Donepezil, Furosemide, Aspirin, Hydrochlorothiazide, Meclizine, Paroxetine, KCl, Terazosin, Tramadol, Menthol 10%

Examination: BP 132/70, pulse 74, respiration 18, temperature 97.Awake alert in wheel chairMusculoskeletal: Decreased strength and tone but equal bilaterally. Mobile per electric walker, unable to self transfer – Mobility Assisted Equipment (MAEs)Skin: No lesions, rashes or ulcers. No masses palpated.Psychiatric: Oriented to person, place and time. Reactive, smiling, repeats personal job duties. Poor judgment and loud speech.Otherwise unremarkable.

Assessment and plan:Deconditioning 2/2 degenerative joint disease: Recent recurrence and OT/PT. Continue medicines, monitor signs and symptoms, fall and safety


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precautions and pain management.BPH: Asymptomatic, monitor signs and symptoms continue medicines.Renal insufficiency: Resolved.Hypertension: NormotensiveVertigo: Chronic; monitor signs and symptoms and safetyDementia Alzheimer Type (DAT): Proliferative, monitor. Patient stable, continue medicines, advanced age, wheel chair confined. Requires assist with transfers and ADLs, monitor for safety. Patient with _____ideation. Frequently repeats past ____ at office. Expects staff to answer immediately to his requests. Thinks needs to be in hospital for pain management. Doing better, now that I ordered _____ last week. Don’t know how long patient will accept.

12/18/YYYY

Provider/Signature

Initial psychiatric assessment: (Illegible Notes)Reason for referral: ______dysinhibitionPsychiatric history: Depression and anxiety

Communication abilities: Verbalization clear, vision, hearing and speech within normal limits.Current psychotropic medications: Paxil 40, Buspar 10 thrice daily and ______

Appetite fair, in dining room. Posture and motor activity within normal limits. Energy level moderate. Mental status alert to person. Memory and judgment poor. Thought process illogical. Mood angry, insight and judgment poor. Hallucinations, suicidal and homicidal ideations none.

Summary: Patient with history of depression, anxiety, and dementia was constantly ____ staff is ____ verbally abusing ___ to personal ____ but not situation.

Diagnosis: Vascular dementia with delirium.Recommendations: Risperdal 0.25 mg per oral



Provider/Signature

Nurse notes:Resident at this time yelling for help at this time. Nurse went to resident’s room and observed he is not in any distress. Resident verbalizes take me home, am really in pain. As needed Hydrocodone given at this time, calmly sleeping bed. Will continue to monitor.

Skin assessments: (Ref Medical record-- 00066)Skin intact. No bruises, skin tear, abrasions or rashes. No previously identified areas. Nails cleaned and trimmed.



Nurse assessments:Vital signs: Temperature 97; respiration 18; BP 126/76; pulse 75Mental status: Alert and confused. Short term and long term memory loss.Cognition: Understands information conveyed but has difficulty.Emotional: Sociable, anxious, cooperative and depressed.Pain: Moderate pain daily in back and limbs (extremities).

Medical record-- 00241-Medical record-- 00242, Medical

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Behavior problems: Wanders/gets lost. Lacks awareness on own needs. Yells.Psychoactive medications: Buspar; Paxil for anxiety and depression.Eating habits: Appetite usually poor. Feeds with assistance. Eats in room. Regular diet. Edentulous.Skin turgor: Fair.Sleeps all night. Vision and hearing adequate. Ambulation: Propels self. Transfers with assist of 2. Turn every 2 hours and as needed.

Braden score (20) (Mild risk) (Ref Medical record-- 00432)

record-- 00432


Nurse notes:Resident leaving to go Out Of Phase (OOP) with no problem. Left via wheelchair in personal family vehicle. Retuned from OOP with no problem. Water encouraged at this time and accepted. Medicines given and 100% of meal consumed. Vital signs stable.



Skin assessments: Skin intact. No bruises, skin tear, abrasions or rashes. No previously identified areas. Nails cleaned and trimmed.



Nurse assessments:Braden score (20) (Mild risk)


12/07/YYYY-12/31/YYYY

Multiple providers

Medication administration: Date Medications given

12/24/YYYY-12/31/YYYY

Risperdal 0.25 mg 1 per oral every morning and bedtime.

12/07/YYYY-12/31/YYYY

Buspirone HCL 10 mg per oral thrice daily. Docusate sodium 100 mg 2 capsules per oral daily. Donepezil 10 mg ½ tablets at morning. Finasteride 5 mg tablet per oral daily for urination. Furosemide 40 mg as diuretic. Aspirin 81 mg chewable tablet, Hydrochlorothiazide 25 mg tablet per oral daily. Paroxetine per oral every day for depression, potassium chloride 20 meq, Terazosin 2 mg at bedtime for urination. Hydrocodone as needed for pain.

12/07/YYYY, 12/09/YYYY-12/11/YYYY and 12/15/YYYY

Tramadol 50 mg as needed for pain.



Nurse notes:Seen per psychiatrist. New order noted for increase in Risperdal. Responsible Party (RP) called and made aware. Verbal consent obtained.


12/24/YYYY-01/01/YYYY

Provider/Signature

Psychiatry progress notes: (Illegible Notes)Alert, awake and oriented to person. Thought process scattered. Mood angry or hostile. Speech abnormal ____ loud. Insight and judgment poor. Delusions grandiose. No homicidal ideations or hallucinations. Assessment improved.


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Comments: Less agitated but _____. Recommend Risperdal 0.25 per oral. Will follow patient as indicated.


Skin assessments: Skin intact. No bruises, skin tear, abrasions or rashes. No previously identified areas. Nails cleaned and trimmed. Preventive measures in place.


01/02/YYYY Labs:Normal: WBC (8.8), segs (58.6), creatinine (1.3), BUN (24), glucose (85)Low: RBC (3.8), hemoglobin (11.4), hematocrit (34), potassium (2.5), chloride (94), calcium (8.2), total protein (5.4), albumin (3.1), prealbumin (10.6), AST (10), ALT (6)High: Monocytes (11.1)



Progress notes:Potassium 2.5 at 01/02/YYYY. New order to give KCl 20 mg 1 tablet per oral now and repeat potassium level on 01/04/YYYY


01/04/YYYY Labs: Low: Potassium (2.8)


01/04/YYYY

Xxx Flores

Behavior health visit note:Mood anxious and mood swings. Thought tangential. Behavior: Hyperactive and aimless wandering.

Mental status: Attention/cognition/thought content/sensory/memory impairment present but did not impede exchange.Intervention: Behavior management.



Nurse assessments:Vital signs: Temperature 97.6; respiration 18; BP 132/70; pulse 74Mental status: Alert and confused.Emotional: Sociable, anxious, cooperative and depressed.Pain: Moderate pain in back relieved by pain medications and positional changes.Behavior problems: Wanders/gets lost. Lacks awareness on own needs. Yells.Psychoactive medications: Buspar; Paxil for anxiety and depressionEating habits: Appetite is usually poor. Feeds with assistance. Eats in room. Regular diet. Edentulous.Skin turgor: Fair. Circulatory problems. Sleeps all night. Vision adequate, hearing impaired. Ambulation: Propels self. Transfers with assist of 1. Turn every 2 hours and as needed. Extensive assist.

Labs: (Ref Medical record-- 00251)Low: Potassium (2.7)

Medical record-- 00239-Medical record-- 00240, Medical record-- 00251


Skin assessments: Skin intact. No bruises, skin tear, abrasions or rashes. No previously identified areas. Nails cleaned and trimmed. Preventive measures in place.


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Nutritional progress notes: (Illegible Notes)Re-admit for positive _____ poor to fair _____ very good appetite and weight was very good. Resident encouraged per oral intake per nursing will eat well. NAS regular. Weight 215.6; BMI 27. Weight ____ one month. No edema seen; no labs. ________weight seen and stable. ______all medicines.


01/11/YYYY Not available

Plan of care:Constipation: Lactulose 30cc per oral at bedtime. Patient wants Zinc oxide applied every diaper changed. Encourage fluid intake every hour when awake, rectal checks as needed, monitor bowel movements. If no bowel movements for 3 days administer as needed laxative. Monitor for diarrhea and assess complaints of upset stomach and vomiting.



Nurse assessments:Resident up in wheel chair with no distress noted. No complaints voiced. Wander guard in place. He shouts out incoherently at this time but he appears comfortable in no acute distress.

Emotional status: Alert and confused.Musculoskeletal: Bed/chair bound. Bed mobility and transfer total care.Skin: No problemsDiet: Feeding self; dining own room. Extensive assist with dressing and groomingDigestive: Bowel movements atleast every 3 days. Incontinent bowel. Cognitive status: Disoriented to place and time. Severely impaired for decision. Psychoactive medications required.



Nurse assessments: (Illegible Notes)Resident resting quietly in bed. 1:1 assist required with ADLs. No attempts to elope. Incontinent bowel. Incontinent care given. Wander guard in place. Water encouraged and accepted. Dr. her. Orders for Depakote ____

Emotional status: Alert and confused.Skin: No problemsDiet: Feeding self; dining own room.Cognitive status: Disoriented to place and time. Severely impaired for decision. Psychoactive medications required. Behavior issues.

Services: Comfort measures and restorative services.



Provider/Signature

Nurse assessments:Continue PT/OT/ST with no problems noted. 1:1 assist for ADL and 2:1 for transfer total. Initial dose of Depakote given and as needed pain medications given for back/leg pain. Incontinent care given. Fluids offered and accepted

Emotional status: Alert and confused. Vitals: Temperature 97.6; pulse 74; respiration 18; BP 134/60Skin: No problemsDiet: Feeding self; dining own room.


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Cognitive status: Disoriented to place and time. Severely impaired for decision. Psychoactive medications required. Behavior issues.Services: Comfort measures and restorative services.

Skin assessments: (Ref Medical record-- 00068)Skin intact. No bruises, skin tear, abrasions or rashes. No previously identified areas. Nails cleaned and trimmed. Preventive measures in place.


Nurse assessments:Resident having outburst of yelling. Writer tried to redirect resident to explain he was just changed and trays were on the floor. Write checked resident and resident was clean. Writer left the room and resident was yelling again saying he didn’t care he needed help and to be changed now. He called police and stated that he was mistreated and not taken care of. After trays were picked up; diaper was changed and cleaned. Will continue to monitor.

Emotional status: Alert and confused. Vitals: Temperature 97.6; pulse 70; respiration 18; BP 120/70Skin: No problemsCognitive status: Disoriented to place and time. Severely impaired for decision. Psychoactive medications required. Behavior issues.




Nurse notes:Resident transferred to VA Emergency Room (ER) accompanied by son.*Reviewer’s comments: The nurse notes pertaining to reason to visit for ER is not available for review.Skin intact. Resident returned to facility. BP 136/87; heart rate 89; respiration 16, temperature 97.7. Skin intact. No issues noted upon head to toe assessment.



Nurse assessments:Resident complains of distress. Respiration even and unlabored. Resident yelling very loudly. Behavior not easily altered. Total care provided with ADL and incontinent care of bowel movements, uses urinal to urinate. No complains of pain or distress. No behavior problems. Will continue to monitor.

Emotional status: Alert. Vitals: Temperature 97.3; pulse 74; respiration 18; BP 132/74Skin: No problemsPain treatment: Yes



12/06/YYYY-01/22/YYYY

Provider/Signature

Physical therapy records: (Illegible Notes)Initial evaluation:Prior level of function: As per family member, patient lives on one storey house with ramp entering home. Received 24 hour care from niece. Used to ambulate around the house using rotator walker/cane until after fall 3

Medical record-- 00255-Medical record--

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years ago. Patient decline in walking after fall incidence. Will walk only 2-4 steps during transfer’s _____electric wheelchair since then, uses electric wheelchair primarily for mobility. No community mobility noted. Enjoys watching football and talking with friends. Baseline cognition; alert & oriented to person and place

Reason for referral: Referred by MD to skilled PT services for evaluation on decline in function.

Assessment: Minimum assistance for bed mobility, maximum assistance with bed to chair and sit to stand transfers. Independent with wheelchair mobility.Cognitive status: Oriented to place and person. Pain of 7-8 present. Worsen during transitional transfer on left knee.Gait: Unable to fully wait bear on left knee secondary to pain on left knee. Limping gait with 2 maximum assist.Balance: Sitting, static and dynamic fair; standing static and dynamic poor secondary to painWheelchair positioning: Edema on left knee. Trunk core strength grossly graded 3-/5 and tends to lean backward and unstable when sitting, out of bed with fair on balance. Manual Muscle Testing (MMT) and Range Of Motion (ROM) to right knee secondary pain and increased when/during movement.

Treatment diagnosis: Muscle weakness, joint painMedical diagnosis: Osteoarthritis

Treatment plan: Therapeutic exercises, therapeutic activity, gait training, neuro-muscular re-education, wheelchair management, caregiver education or training, discharge planning and diathermy to left knee to reduce pain and increase left motor control.Frequency: 5 times per week

Underwent therapy on 12/06/YYYY, 12/13/YYYY, 12/18/YYYY, 12/19/YYYY, 12/20/YYYY, 12/23/YYYY, 12/26/YYYY, 12/27/YYYY, 12/30/YYYY, 12/31/YYYY, 01/03/YYYY, 01/04/YYYY, 01/07/YYYY, 01/11/YYYY and 01/22/YYYY

Status at end of therapy program: Required maximum assistance for all mobility, patient is non ambulatory at this time. Uses power chair for mobility

Assessment: Maximum assistance for bed mobility, bed to chair and sit to stand transfers. Independent with wheelchair mobility.

Discharge summary: Patient has met maximum potential at this time. No further skilled services recommended at this time. Discharged at this time.

00268


Skin assessments: Skin intact: No.

Medical record--

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Previously identified areas: Yes.No bruises, skin tear, abrasions or rashes.Nails cleaned and trimmed. Preventive measures in place.

00069

12/06/YYYY-01/24/YYYY Provider/

Signature

Speech therapy records:Initial evaluation:Prior level of function: Patient was able to communicate verbally. Enjoyed watching football and talking with friends. Consumed regular diet with thin liquids. Does not have a history of swallowing issues. Presented with aided hearing and wears hearing aids in both ears. Presented with decreased short term memory. He demonstrated appropriate expressive and reduced receptive communication.

Assessment: Receptive communication functional. Sequencing, word finding and topic relevancy moderate. Sentence completion, verbal organization and conversations functional. Speech intelligibility functional. Orientation, safety awareness, functional recall or memory, task maintenance is moderate-severe. Decision making and problem solving is moderate. Food consistency regular and liquids thin. Oral phase and velo-pharyngeal phase functional. Mini mental state exam score 15 – Moderate.

Treatment diagnosis: Symbolic dysfunctionTreatment plan: Speech, language communication and cognitive skills. Frequency: 5 times per week.

Underwent treatment on 12/06/YYYY-12/13/YYYY, 12/27/YYYY, 01/10/YYYY, 01/03/YYYY, 01/17/YYYYStatus at end of therapy: Requires verbal and visual prompts consistently to employ safety precautions. Also requires visual and verbal aid to increase orientation.

Assessment: Mild to moderate sequencing, word finding and topic relevancy. Orientation to self, time and place, safety awareness, functional recall and task maintenance moderate. Decision making and problem solving mild to moderate.

Discharge summary: Goal met. Patient able to orient using verbal and visual prompts and facility. Moderate to maximum prompts given. Visual and verbal prompts. Requires moderate prompts to consistently employ precautions. Patient wears wander guard in order to ____patient’s safety.



Nurse assessments: (Illegible Notes)Resident clean and dressed for pass with family. Placed in wheelchair to take out to vehicle waiting infront of building. Voiced no complaints of pain or discomfort although his head was touching roof of van knees were close to dash board and feet were pressed hard to floor board. Son helped to turn and reposition resident in seat to help with comfort. Resident returned. Resident assisted with meals at this time. Bilateral heels noted with redness. ____heel protector applied. Spoon fed meal 75% consumed.


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100% of fluids consumed. Resident noted with redness to buttocks, Zinc oxide applied per RCS with incontinent care given at this time.

Emotional status: Alert and confused. Vitals: Temperature 97.1; pulse 76; respiration 18; BP 132/72Skin: No problemsPain treatment: Yes

Services: Comfort measures and restorative services.01/25/YYYY Provider/

SignatureSkin assessment: (Illegible Notes)Location: Left buttock. Other: ShearDate notified dietary and physician: 01/25/YYYY

Size Characteristics Exudate Wound bed

Pain related to wound

4.6x4.2x0.5

Partial thickness

Small serosanguineous

Red No

Comments: New treatment in progress. Resident returned ____ with new shear. Interventions: Wheelchair cushion, pillows and offload heel protectors.

Treatment record: Clean abrasion on left buttock with wound cleanser, apply Alginate if ____with Hydrocolloid every Tuesday, Thursday and Saturday and as needed. (Ref Medical record-- 00046)


12/06/YYYY-01/25/YYYY

Provider/Signature

Occupational therapy records: (Illegible Notes)Initial evaluation:Prior level of function: According to patient he lived at home with 24 hour care from niece. Required assistance at all aspects of ADL care. Alert and oriented with questionable confusion at times. Patient did not drive. Patient meals prepared by caregiver who also took care of all ADL tasks. Enjoys talking and socializing.

Reason for referral: Received to skilled OT services post hospitalization to assess for decrease in function.Assessment: Minimum assistance with bed mobility, moderate assistance with grooming, transfers and upper body dressing, dependant on feeding, maximum assistance for clothing, lower body dressing, upper and lower body bathing, tub transfers and home management.Cognitive status: Patient able to verbally make needs known. Alert and oriented x 2. With decreased short term memory attempts to compensate with long term memory stories. Displayed poor safety awareness.Pain: NoneSkin integrity: IntactMobility: Patient uses electric wheelchair for mobility throughout the facility.Sensory: Light touch, vision, proprioception, vestibular intact

Treatment diagnosis: Muscle weakness


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Medical diagnosis: Osteoarthritis

Treatment plan: Therapeutic exercises, therapeutic activity, ADL training, neuro-muscular re-education, wheelchair management, cognitive training, care giver education or training, discharge planning and e-stimulation diathermy to left knee, decrease pain and increase balance.

Underwent therapy on 12/12/YYYY, 12/27/YYYY, 01/03/YYYY, 01/04/YYYY, 01/09/YYYY, 01/14/YYYY, 01/15/YYYY, 01/16/YYYY, 01/18/YYYY and 01/22/YYYY

Status at end of therapy program: Patient with fair endurance for functional activities. Patient completes bed mobility with supervision. Patient completes upper body dressing with ______ assistance, lower body dressing with moderate assistance. Patient completes 3/3 hygiene and grooming tasks with minimum assistance with occasionally _____

Assessment: Supervision for mobility, toileting. Moderate assistance for grooming, transfers, clothing & hygiene, lower body bathing, tub transfer and home management. Minimum assistance for lower body dressing and upper body bathing. Contact guard for upper body dressing.

Discharge summary: Patient made consistent progress towards all goals. Patient being discharged for skilled OT services. Discharge recommendation hospital bed and 24 hour supervision


Nurse assessments:Resident was dressed up and cleans for pass with family. Skin assessments done. No problems noted, no bruising. Resident was positioned with foot planted firm, knees bent close to dash and head close to top of van. Resident had no complaints of pain.

Emotional status: Alert and confused. Vitals: Temperature 97.4; pulse 74; respiration 18; BP 130/70Skin: No problemsPain treatment: Yes



Skin assessments:Location: Right heelDate of onset: 01/27/YYYY

Date notified dietary and physician: 01/27/YYYYSize Undermining

/exudateWound bed

Surrounding skin color

Surrounding skin

6.5x6x0

None Red, purple

Dark red or purple

Normal for skin

Comments: No pain related to wound. New treatment in progress. Wheelchair cushion, positioning devices; pillows and heel protectors.


01/27/YYYY Provider/ Nurse notes: Medical

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Signature

Provider/Signature

Resident in bed resting; pillows under ankles and off load heel protectors. On dressing to right heel is place. Resident left heel exhibiting redness. Denies discomfort or distress and none observed.

Writer observed unopened blister (6.5x6 cm) to right heel and reddened area to left heel. Patient afebrile. Vital signs stable. Area not tender to touch. Voice message left on RP phone for notification of change of condition. No swellings noted in legs.

record-- 00192, Medical record-- 00128


Plan of care:Pressure ulcer: Off load heel protectors, air mattresses. Pressure ulcer treatment as ordered. Multivitamin/labs as ordered. Apply dry dressing and change every day and as needed soilage.



Nurse notes:Alert. Vital signs: Temperature 97; pulse 72; respiration 16; BP 128/77Skin condition: Decubitus. Wound sacrum and bilateral hips.

Resident clean dressed. Treatment done per order by treatment nurse. Dry and intact. No new skin tears or bruises or areas noted on assessment. Resident has been sitting up in wheelchair this evening. He had been with family earlier this afternoon. He is now transferred back to bed with assistance of two. Resident quickly goes to sleep after settling in bed.

Spoke with RP with D.O.N. present concerning about resident taking multiple trips OOP of facility and prolonged exposure to moisture and injury to bilateral heels. RP stated “we had business at bank today my brother keeps taking money out of his account”. RP was reminded that resident had an MD appointment pending for wound care.



Provider/Signature

Skin assessment:Location: Left buttock. Stage IIDate notified dietary and physician: 01/29/YYYY

Size Surrounding skin

Exudate Wound bed


6x6x0.5 Normal Small serous exudate

Red No

Comments: New treatment in progress. Interventions: Wheelchair cushion, pillows and offload heel protectors.

Location: Left testicle with denuded skin (Ref Medical record-- 00078)Date notified dietary and physician: 01/29/YYYY



2x1/2 cm

Intact None Red No

Comments: New treatment in progress. Interventions: Wheelchair cushion, pillows and offload heel protectors.

Medical record-- 00074, Medical record-- 00078, Medical record-- 00046, Medical record-- 00129

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Treatment: Cleanse denuded site on left testicle with wound cleanser, apply Medseptic topically everyday and as needed soilage. (Ref Medical record-- 00046)

Things that make this problem worse: (Ref Medical record-- 00129)Prolonged sitting.Other things that have occurred with this problems: Frequent OOP


Plan of care: (Illegible Notes)Non pressure ulcer skin impairment: Observe skin weekly and document findings. Document observation of any non-pressure skin impairments. Observe for safety needs for transfer. Geri-sleeves as indicated. Wound care as ordered. Refer to RD or therapy services. Cleanse site with wound cleanser, apply ____ topically everyday and as needed.

Pressure ulcers: Measure and stage wound weekly using pressure ulcer healing assessment form. Air mattresses. Off load heel protectors. Multivitamin or labs and analgesics as needed. Cleanse site with wound cleanser, apply Hydrocolloid and change every 2 hours and as needed.



Provider/Signature

Nurse notes: (Illegible Notes)Incontinent care done as needed. Skin tears in buttock ______. Treatment done per order. Dressing dry and intact. No complaints of pain or distress. Resting with family this afternoon. He refused to be changed (diaper) and is now resting quietly in bed. Appetite fair in supper and medicines taken.

Skin assessments: (Ref Medical record-- 00069)Skin intact: No. Pressure ulcer in heel.Previously identified areas: Yes.No bruises, skin tear, abrasions or rashes.Nails cleaned and trimmed. Preventive measures in place.



Nurse notes:Alert and confused. Vital signs: Temperature 97.6; pulse 70; respiration 18; BP 118/70. Incontinent care as needed. Skin tears to left buttock and left testicle. Dressing per treatment nurse. Zinc oxide barrier cream applied after morning incontinent care. Resident to Hoyer lifts for all transfers. Water encouraged and accepted. Poor appetite noted for evening meal. Ensure offered. 50% consumed. Noted with altered mental status with confused conversation. Turned and repositioned every two hours and as needed, incontinent care every two hours. Treatment per treatment nurse, tolerated well. Dressing dry and intact. No complaints of pain at this time.


01/01/YYYY-01/31/YYYY

Multiple providers

Treatment record:Date Medications given

01/01/YYYY-01/02/YYYY and 01/18/YYYY

Ultram 50 mg for general pain

Medical record-- 00081-Medical record-- 00083, Medical record--

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01/01/YYYY-01/31/YYYY

Hydrocodone 5/325 mg given as needed. Buspar 10 mg thrice daily. Docusate sodium every day. Aricept 10 mg at bedtime. Proscar 5 mg every day. Lasix 40 mg every day. Aspirin 81 mg per oral every day.

01/01/YYYY-01/31/YYYY

Risperdal 0.5 mg given at morning and bedtime. Hydrochlorothiazide 25 mg per oral tablet every day. Potassium chloride 10 meq tablet every day. Terazosin 2 mg capsule at bedtime.

01/04/YYYY-01/06/YYYY

KCl 20 meq tablet per oral every 4 hours x 3 doses

01/25/YYYY-01/31/YYYY

Lexapro 10 mg 1 tablet per oral everyday and Depakote 125 mg I tablet per oral

01/11/YYYY-01/31/YYYY

Lactulose 30 cc at bedtime

01/16/YYYY-01/24/YYYY

Depakote 125 mg per oral twice daily.

01/16/YYYY-01/31/YYYY

Wander guard

01/01/YYYY-01/25/YYYY

Paxil 40 mg tablet

Wound care:Date Wound Care

01/27/YYYY-01/29/YYYY

Cover blister to right heel with non stick dressing everyday and as needed soilage until healed. (Ref Medical record-- 00050)

01/28/YYYY-01/29/YYYY

Cover blister to left heel with dry dressing. Change dressing every day and as needed soilage until healed. (Ref Medical record-- 00050)

01/29/YYYY-01/31/YYYY

Treatment for denuded area on left testicle: Cleanse denuded site with wound cleanser, apply Medseptic topically everyday and as needed soilage. Off load heel protectors every shift/air mattresses to promote wound healing (Ref Medical record-- 00046)

00090-Medical record-- 00094, Medical record-- 00107-Medical record-- 00112, Medical record-- 00049-Medical record-- 00050, Medical record-- 00046

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Cleanse left heel deep tissue injury with wound cleanser apply Granulex spray topically cover with dressing, change every Tuesday, Thursday, Saturday and as needed.

Cleanse shearing on left buttock with wound cleanser; apply alginate if draining cover with Hydrocolloid. Change every Tuesday, Thursday and Saturday and as needed. (Ref Medical record-- 00049)

01/29/YYYY-01/30/YYYY

Cleanse right heel deep tissue injury with wound cleanser, apply alginate AG to open sites, cover with dressing change Tuesday, Thursday and Saturday and as needed.


Nurse notes:Resident resting quietly. Incontinent care given. Dressings intact to buttocks. Zinc oxide barrier cream applied to testicle skin tear. Continue treatment per treatment nurse. Tolerated well. Noted with poor appetite this morning. Accepted Med pass supplement. Hydration encouraged. Turned and repositioned every 2 hours. Incontinent care provided for bowel movement, has use of urinal.



Nurse notes: (Illegible Notes)Resting in bed. Extensive assist for ADL. Incontinent care given. Treatment done per treatment order. Dressing dry and intact. Turn every two hours. No complaints of distress. Noted yelling out. Ativan administered. Medication effective. Extensive assist with bed mobility. Completed 100% of breakfast. Wound care accepted and tolerated. Dressings to wound in place. Off load heel protectors in place. Will continue to monitor.

Resident family expressed concern about resident being sleepy. Writer explained resident behavior from morning and now resident could have been fatigued from all the yelling plus Ativan has side effect of drowsiness. Family expressed that he needs a trapeze when writer explained that resident has snatched _____ from window overnight.



Nurse notes:Resting quietly. Incontinent care given. Dressing dry and intact. Heels pads on. Turned every 2 hours. Complains of feet pain. Vicodin per oral given. Results effective. Vital signs stable. Afebrile. Wound care tolerated with minimal discomfort. Off load heel protectors in place. 100% of breakfast completed. Extensive assist with bed mobility. No transfer occurred. Resident eats with total assistance of staff. Incontinence x 2. Dressings to wound intact. Heel protectors in place.



Skin assessments:Location: Right heelDate notified dietary and physician: 02/03/YYYY

Size Stage Undermining/exudate

Wound bed


Surrounding skin


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6.5x6x0

II None Purple Normal for skin

Normal for skin

Comments: No pain related to wound. RP notified. Wheelchair cushion, positioning devices; pillows and offload heel protectors.


Nurse notes:Incontinent care given. Decubitus to sacrum and heels. Turn every 2 hours. Receives wound care to sacrum and bilateral heels. Heel protectors on. Speech is clear.


02/04/YYYY xxx Flores Mental or behavioral health visit note:Signs and symptoms: Increased dependency in self care. Increased withdrawal or isolation. Mood depressed; despondent, decreased energy and enjoyment. Behavior lethargic.Attention, cognition, thought content/sensory/sensory/memory impairments required extra effort/repeated communications but exchange was satisfactory atleast 75%

Patient in room, in wheelchair, alert but significantly more lethargic than usual, oriented x2. Patient presents as declining medically and cognitively since last visit, He is being evaluated for sudden changes by medical staff. Will continue to assess for feasibility of continue treatment. Decline in medical and cognitive status.



Nurse notes:Resident resting in bed. No complaints of pain. Dressings dry and intact. Incontinent care given. Fluids offered and accepted. Feed resident at all times.



Skin assessments:Location: Left testicle with denuded skin



1.8x1.8 Intact None Red No

Comments: Progress improved. Continue treatment. RP notified. Interventions: Wheelchair cushion, pillows and offload heel protectors.



Skin assessment: (Illegible Notes)Location: Left buttock. UnstageableDate notified dietary and physician: 02/05/YYYY

Size Exudate Wound bed

Surrounding skin


8.6x6.6x___

Small serous exudate. No undermining

Red, yellow

Normal No

Comments: Still has 60% yellow slough noted. Interventions:


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Wheelchair cushion, pillows, offload heel protectors02/06/YYYY Provider/

SignatureNurse notes:Dressing dry and intact to buttocks. Incontinent care given. Turned every two hours. Fluids offered and accepted. Wound treatment done per orders. Noticed resident lethargic. Not eating complete meals. Keep resident hydrated. No signs of pain.



Nurse notes:Dressing dry and intact on buttocks. Turned every two hours. Incontinent care given as needed. Resident screaming and yelling. Unable to state needs. When asked what is wrong, resident states “I don’t know”. Vicodin 5/325mg and Ativan 0.5 mg per oral given. Signs and symptoms of pain and agitation. Medicines effective. Turned every two hours. Dressings dry and intact. Must be fed all meals. Seems to be very lethargic. Encourage fluids and monitor.



Wound consult for sacral wound:Patient seen at family request regarding sacral wound and health. Resident in long term care with multiple co-morbidities. Patient has been depressed, not eating, missing his family. Speaks of moving him closer to Wharton with possible home care. There are social and legal issues that are being addressed.

Review of systems: Buttock hurts. Positive leg pain. Positive weakness, increased depression. Pain level 3-4 buttocks.

Examination: Weight 215.6; previous weight 215.4Vital signs: BP 120/66, pulse 72, respiration 18, temperature 97.6Oriented to person. Lying in bed. Flat affect

Labs reviewed.

Assessment and plan: Hypokalemia, repeat lab. Prerenal azotemia: Repeat labs. Protein malnutrition. Repeat labs, weight stable. Pain management: Chronic controlled with Fentanyl. Monitor. Patient stable. Anemia improved. Labs drawn.



Nutritional progress notes: (Illegible Notes)Pureed diet, thin liquids, Lasix. Weight 215.6 ______



Nurse notes:Resident resting quietly. Turned and repositioned every two hours. Dressing dry and intact. Incontinent care as needed. Wound treatment provided every day per treatment nurse. Wound care tolerated.


02/08/YYYY Labs:Low: Potassium (3), chloride (92), calcium (7.8), RBC (3.42), hemoglobin (10.2), hematocrit (30.8), lymphocytes (9), albumin (2.3), prealbumin (3.4)High: Total carbon-dioxide (34), BUN (42), WBC (14.6), platelet count


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(472), absolute neutrophil (12.7), segs (85)02/09/YYYY Provider/

Signature

Provider/Signature

Nurse notes:Vital signs stable. He is afebrile. Fluids encouraged and accepted. Tolerated wound care with no discomfort. Meal fed and completed 100%. Incontinence x2. Ativan administered due to yelling. Non effective. Continued to yell. No complaints of pain and none observed. Dressings clean and intact. Wound care given. Encourage fluids. No signs and symptoms of pain.

Medication error or over sedation. Ativan 0.5 mg given at 06.15 hrs and again at 0900 hrs. Difficulty swallowing medications. Vital signs stable. Resident seemed very lethargic or sedated until about 18 hours. Will continue to monitor.

Medical record-- 00215-Medical record-- 00216, Medical record-- 00131-Medical record-- 00132


Speech therapy notes:SLP spoke with RP regarding patient’s meal consumption. Stated that his father consumed 100% of dinner meal. SLP also spoke with RCS and nursing staff regarding patient consumption to gain well rounded adequate picture of per oral intake. Over the past week, SLP has observed patient at varying levels of alertness levels. When patient is fully alert, per oral intake is 50-75%, when patient alertness affected by medication per oral intake reduced by 25-40%. RP expressed that he want medication levels to be noted in SLP report that influence his father’s meal consumption


01/31/YYYY-02/09/YYYY

Tekeisha XX,

Dysphagia, speech and cognitive therapy notes:Reason for referral: Patient was referred by nursing staff due to decreased meal consumption.

Assessments: Intake: All oral intake Diet: Regular textures, thin liquids, Successive swallows;Prior Level Of Function (PLOF): Regular textures, thin liquids, Successive swallows;Weight: No recent weight loss; PLOF: No recent weight loss. Oral phase and pharyngeal phase intact.

Diagnosis: Dysphagia unspecified. Organic psychotic conditions, cerebral degeneration, Alzheimer’s disease Treatment approaches: Speech and hearing evaluation, oral function therapy, evaluate oral and pharyngeal swallow function. Frequency: 5 times a week for 4 weeks.

Assessment summary:Clinical impressions: Patient would benefit from skilled Speech Therapy (ST) services for dysphagia.Reason for skilled services: Skilled Speech Language Pathologist (SLP) services for dysphagia are warranted to assess/evaluate least restrictive oral justification intake, increase per oral intake, and analyze environmental barriers in order to enhance patients quality of life by improving ability to consume intake in least restrictive environment.


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Recommendations:Intake diet recommendations: Solids puree. Thin liquidsSupervision for oral intake: Occasional supervisionSwallow strategies/positions: To facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake: general swallow techniques/precautions and alternation of liquid/solids.

Comments: On 01/31/YYYY, patient consumed less than 50% of meals. On 02/06/YYYY consumes 25-50% of meals. On 02/09/YYYY patient alert status varies due to patients as needed medications that affect alertness. When patient is alert he is able to consume puree/thin liquid diet.

Discharge status and recommendations:Problem solving mild-moderate. Memory moderate; auditory comprehension functional; verbal expression functional; pragmatic skills functional; reading comprehension functional; motor speech functional; swallowing abilities supervised (A) (Due to poor dentition. Patient food texture downgraded to pureed thin)

Diet recommendations: Solid: Puree. Liquids: Thin liquidsSwallow to facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake: alternation of liquid/solids and general swallow

Supervision for oral intake occasional supervision, close supervision (Supervision level dependent on patient’s alertness during mealtime.)

Discharge recommendations: It is recommended the patient use the following strategies and or maneuvers during oral intake: alternation of liquid/solids and general swallow. Patient positioned upright during meal consumption.


Nurse notes:Alert, confused and lethargic. Yelling at times. Very lethargic. Vital signs stable. Incontinent care given. Fed all meals. Dressing dry and intact. Experienced pain this evening on his knee. Medicated with Tramadol 50 mg as needed for relief. Noted to be restless in bed.



Skin assessments:Location: Right heel

Date notified dietary and physician: 02/03/YYYYSize Stage Underminin

g/exudateWound bed


Surrounding skin


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6.5x6x0

II None Purple Normal for skin

Normal for skin

Comments: No pain related to wound. RP is here and aware of need for further treatment. Wheelchair cushion, positioning devices; pillows and offload heel protectors.


Nurse notes:Dressing dry and intact although wound noted with foul odor. Will follow-up with RN. Spoon fed every meal. Water encouraged and accepted. No complaints of pain or distress. Family visited and left. Pain medicines were given due to resident saying he was in pain. Family stated resident was overmedicated.


02/12/YYYY X - Associates Of America

Provider/Signature

Follow-up wound care visit: (Illegible Notes)Discussion with son regarding plan of care____ will proceed with Long Term Acute Care (LTAC) in their area, if function declines LTAC Hospice recommended.Patient exhibits a chronic unstageable wound on left buttock, increased WBC, decreased prealbumin, decreased appetite, weight stable. Vital signs stable. Afebrile.

Vital signs: BP 122/74; pulse 72; respiration 20; temperature 97.4.Alert in no acute distress but uncomfortable.Musculoskeletal: Bed bound or chair bound. Hands and knees arthritic. Range of motion limited. Strength decreased.Skin: Bilateral deep tissue injury, purple discolored heels. Malodorous unstageable left buttock wound.

Assessment and plan: Left buttock wound unstageable. Continue multivitamin with minerals, Zinc, Med Pass. Start IV fluids, rehydration, potassium replacement and _____. IV antibiotics. No draining wound, _____ culture. Hypokalemia improved. Repeat BMP 02/15/YYYY. _____Increase Aricept to 10 mg every day. Anxiety and depression: ______10 mg every day. Will decrease Ativan to 2.5 every 8 hours, Depakote and Risperdal.



Nurse notes:Turned every two hours. Incontinent care provided. Intervals of yelling out. Treatment by treatment nurse. Air mattress installed today. Right arm midline was inserted. Given Acetaminophen for pain. Consumed 100% of dinner. Resident yelled through shift with no change or effect when pain medications given.



Provider/Signature

Skin assessment: (Illegible Notes)Location: Left buttock. Presents as stage ____Date notified dietary and physician: 02/12/YYYY

Size Exudate/undermining

Wound bed

Surrounding skin


8.6x6.6x unknown

None Black Normal No


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Comments: RP is here and MD is on site and has ___ wound and is presently in conference with MD. Interventions: Air bed, wheelchair cushion, pillows and offload heel protectors.

Skin assessments: (Ref Medical record-- 00079)Location: Left testicle with denuded skin



1.2x1.2 Intact None Red No

Comments: Progress improved. Continue treatment. RP is here and aware of small improvement. Interventions: Wheelchair cushion, pillows and offload heel protectors.

02/12/YYYY

Provider/Signature

Psychiatry progress notes: (Illegible Notes)Diagnosis: Arteriosclerotic dementia.

Findings: Awake, alert and oriented to person. Illogical and tangential. Thought process: Concrete reasoning. Affect labile. Mood angry. Speech loud. Insight and judgment poor. No delusions.

Comments: Still loud. _____. Will follow patient as indicated.



Provider/Signature

Nurse notes: (Illegible Notes)Resident unable to explain why he is yelling. Stated “Do something to help me”. Vicodin per oral given for pain and discomfort. Continue to yell out after pain medicines. Incontinent care given. New order _____ ½ liter normal saline with 40 mg KCl at 60cc/hour; Cefepime 1 gram every 12 hours for 7 days. CBC and BMP on 12/15/YYYY. Air mattresses and ______.

Medicated for pain at 0815 hrs with complaint of pain to sacrum area. IV site to right upper extremity. Dextrose in 5% normal saline in 40mg KCl. Cefepime 1 gram IV every 12 hours with NARN. Treatment done per treatment nurse.

@1330 hrs: Treatment nurse notified RP that wound on left buttock has a change in status and that the wound is seeping with a malodorous discharge today. Dr. Wasserstein had been contacted and he was in process of trying to contact RP to discuss alternative treatment plan as resident was currently on antibiotic therapy and was on air mattresses and was rotated every two hours and then next step would possibly be having resident moved to LTAC for more aggressive treatment. RP then proceeded to yell that this treatment nurse and everyone taking care of resident would have to answer to his lawyer. Treatment nurse stated that we have really good staff, which is trained in taken care the need of elderly. RP’s wife then stated that not all of the staff care that; morning nurse had sedated resident that morning knowing his lawyer was coming to see him and due to his sedation lawyer was unable to have important documents signed. This treatment nurse then explained to RP’s wife that the role of the nursing


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staff is to address the needs of the resident and to evaluate resident’s level of pain and medicate accordingly. RP then asked the resident when the doctor evaluated the wound. RP was reminded of meeting of RP and MD on previous day and that MD had looked at the wound and let RP know that he would begin on antibiotics as RP had cancelled appointment to wound center at VA again.

RP’s wife then asked, when did you change his dressing and treatment nurse explained that when she was on 2 back hall she went from there to end of hall 3 then when RCS were in the room changing resident they noticed a change in wound bed status that it was draining from dressing and had a foul odor so they called this treatment nurse to go to see his wound, treatment nurse then went promptly to see his needs and as she had already stated she called D.O.N. to come see as D.O.N and administrator and were already informed of changes of condition. RP’s wife then told treatment nurse that the only reason RCS were changing resident was because she came into the room and noticed smell and that he had a dirty diaper on and she bet he had not been changed or rotated all day as facility had a nursing shortage. RP’s wife was then told that the facility was not ____ staffed, facility had proper amount of staff as per staffing compliance.

RP’s wife was then told that resident’s diaper was soiled from seepage of wound bed and had no bowel movements or urine present. RP’s wife then stated “So you can’t tell me when he was changed last”. RP’s wife asked charge nurse to answer as treatment nurse had just came to this hall. RP then stated just wait until I call my lawyer. Treatment nurse referred RP to speak with D.O.N.

@2145 hrs: Resident in bed with intervals of yelling. Changed dressing to sacrum area. Wound oozing. Resident pulled out arterial line. No bleeding. Verbal order to reinsert line. Notified pharmacy. Waiting for call back. Will continue antibiotics when midline is re-inserted.

02/13/YYYY XYZ Hospital

Provider/Signature

Pre-admission assessment:Summary of referring facility course: Failed at lower level of care. Wound draining with foul odor.

Psychiatric behavior: No psychosis, no personality disorder.Gastrointestinal: Weight 214.6. Diet purees thin liquids.Specialty bed: Low Air Loss (LAL)Skin: Left buttock unstageable 8.6x6.6 draining with odor. Left heel deep tissue injury 6x6 purple. Right heel deep tissue injury 6.5x6 purple.

Primary reason for LTAC admission: Multiple wounds with infection. Dysphagia. Decreased appetite, chronic pain and deconditioning. IV antibiotics, wound care, possible surgical intervention, speech therapy, dietician consult, low air mattresses, pain management and PT/OT .

Wound care: Deep tissue injury with drainage and odor. Active co-

XYZ Hospital First - 000042-XYZ Hospital First - 000048

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morbid illness: Dementia and dysphagia.

Treatment criteria: Frequent greater than 2x24 hour and or complex dressing changes. Rehabilitation services. Specialized wound care provided by wound care team. Specialty bed that is not available at a lower level care. IV therapy anti-infective. Malnutrition management.


Provider/Signature

Provider/Signature

Nurse notes: (Illegible Notes)@0330 hrs: Resident yelling out continuously. Turned and repositioned. Continued to yell out. Ativan 0.5 mg given for agitation. IV pulled out ____. IV team to reinsert. Vicodin 5/325 1 per oral given. IV team re-contacted regarding reinsertion of IV. Stated “We don’t come out overnight to put in IV, we wait till morning”

@1000 hrs: IV was inserted; resident pulled out before it could be taped; IV nurse tried second time to place it but he pulled it also. Dr. Wasserstein notified and IV discontinued. Antibiotics changed to _____Cefepime 1 gram every 12 hours; 20 meq KCl twice daily per oral.

@1530 hrs: Resident transferred to XYZ


02/01/YYYY-02/14/YYYY

Multiple providers

Treatment record:Date Medications given Wound care

02/01/YYYY-02/14/YYYY

Aspirin 81 mg tablet every morning, Docusate sodium 100 mg capsule every morning for constipation, Divalproex 125 mg tablet. Lactulose 10gram/15 ml. Lexapro 10 mg 1 tablet per oral every day. Furosemide 40 mg as diuretic. Buspirone 10 mg tablet. Klor Con 10 meq per oral every day. Risperdal 0.5 mg 1 per oral at bedtime. Terazosin 2 mg at bedtime. Donepezil HCL 10 mg at bedtime. Hydrocodone as needed. Finasteride 5 mg tablet per oral daily. Hydrochlorothiazide 25 mg every day.

Cleanse shearing on left buttock with wound cleanser; apply alginate if draining cover with Hydrocolloid. Change every Tuesday, Thursday and Saturday and as needed.

Cleanse denuded site on left testicle with wound cleanser, apply Medseptic topically everyday and as needed.

Off load heel protectors, air mattresses to promote wound healing in all three shifts.

02/09/YYYY and 02/14/YYYY

Buspar 10 mg held

02/07/ Med pass thrice daily between


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YYYY-02/10/YYYY 02/13/YYYY-02/14/YYYY

meals.

02/08/YYYY-02/14/YYYY

Multivitamin daily per oral; Vitamin C 500 mg twice daily, Zinc sulphate 220 mg; Med pass 2; 120cc

02/02/YYYY-02/05/YYYY, 02/08/YYYY-02/09/YYYY

Ativan 0.5 mg tablet.

02/01/YYYY-02/09/YYYY

Cleanse right heel deep tissue injury with wound cleanser, apply Alginate AG and cover with dressing change every Tuesday, Thursday and Saturday and as needed.

02/12/0213-02/14/YYYY

Cleanse right and left heel deep tissue injury with wound cleanser apply Granulex spray topically cover with dressing, change every Tuesday, Thursday, Saturday and as needed.


Discharge summary:Admission date: 12/06/YYYY

Provisional diagnosis: Hypertension, knee pain, DAT.Final diagnosis: As above. Pressure ulcer buttocks, hypokalemia

Brief history: 92 year old male admitted from VA for rehabilitation.

Course of treatment: Patient treated symptomatically. Medical management, physical, occupational and speech therapy evaluation and treatment as indicated. Patient with grandiose ideation. Developed pressure ulcer and was sent to VA for evaluation. Had progression of wound inspite of treatment and was sent to Hospital for evaluation and treatment.


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Condition on discharge: Guarded.12/06/YYYY-02/14/YYYY

Other related records:Nursing assessments (Ref Medical record-- 00269-Medical record-- 00270, Medical record-- 00287-Medical record-- 00288, Medical record-- 00326-Medical record-- 00332, Medical record-- 00232-Medical record-- 00235, Medical record-- 00348, Medical record-- 00270, Medical record-- 00314-Medical record-- 00325, Medical record-- 00353-Medical record-- 00354, Medical record-- 00141-Medical record-- 00144, Medical record-- 00363-Medical record-- 00390, Medical record-- 00418-Medical record-- 00421, Medical record-- 00434-Medical record-- 00435, Medical record-- 00246, Medical record-- 00413-Medical record-- 00417, Medical record-- 00422-Medical record-- 00427, Medical record-- 00170, Medical record-- 00335-Medical record-- 00336, Medical record-- 00113-Medical record-- 00122, Medical record-- 00051-Medical record-- 00058, Medical record-- 00125-Medical record-- 00126, Medical record-- 00133-Medical record-- 00134, Medical record-- 00351, Medical record-- 00338, Medical record-- 00428-Medical record-- 00431, TDADS - 000001-TDADS - 000003) plan of care (Ref Medical record-- 00135, Medical record-- 00160-Medical record-- 00161), orders (Ref Medical record-- 00041-Medical record-- 00045, Medical record-- 00033-Medical record-- 00037, Medical record-- 00021-Medical record-- 00022), consent form (Ref Medical record-- 00013-Medical record-- 00017, Medical record-- 00002-Medical record-- 00012), minimum data set (Ref Medical record-- 00360-Medical record-- 00362, Medical record-- 00436-Medical record-- 00469, Medical record-- 00391-Medical record-- 00412)

*Reviewer’s comments: These records are not elaborated as they do not contain significant details pertaining to case. Will be elaborated if required.

XYZ Hospital02/14/YYYY Daryl xx,

M.D.Admission for inpatient care of complex pressure ulcers:Patient with medical history most notable for dementia and chronic renal insufficiency. He is a former veteran who was has been in and out of the Veteran’s Administration Hospitals for various different reasons. He has had unstable dynamic within his family and has had, per report of the eldest son, who I spoke to about the patient’s history, a history of neglect by caretakers and most notably his younger son and another individual who shuffled him from different facilities to different facilities and different homes.

Sometime in the last several months, he developed several pressure sores in his buttock regions, and was not kept clean, according to this eldest son. Currently, the patient has significant foul-smelling discharge from the buttock wound. The patient is currently seen and examined with his son and daughter-in-law at the bedside. Information taken from the son directly as well as notes that accompanied the patient from his Geriatrician and from other information taken from the outside acute care hospital.

Physical examination:Vital signs: Temperature 97.8, blood pressure 97/58, pulse is 64, respiratory rate is 18.


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General: Not in acute distress.HEENT: Anicteric sclerae.Lungs: Clear.Cardiovascular: Tachycardic.Abdomen: Soft, non-tender, non-distended.Extremities: Trace pitting edema. Heel protectors in place.Back: Wound reviewed with the Wound Care team. The patient has a left buttock ulcer with necrotic-appearing material scattered throughout.

Assessment/plan: Complex pressure sores: Antibiotic therapies for suspected left

infected buttock wound. Per Infectious Disease, I will consult specialist to see him here.

Bilateral foot pressure sores with eschar: We will have Podiatry evaluate the patient.

Chronic renal insufficiency: Renal function appears to be within reasonable limits and with mild failure only. We will have Nephrology follow the patient as well, and evaluate for any issues.

Dementia: Continue all supportive care and medicines as needed. Avoid oversedation as much as possible. He has a history of being over sedated with Ativan, is currently on Risperidone.

History of vertigo, on Meclizine as needed.02/14/YYYY Sarfraz x,

M.D..Infectious Disease consultation for sacral wound:Patient who resides in the long-term acute care, now presented outside facility with multiple sacral wounds. The patient was noted to have bilateral lower extremity ulcers. The patient was transferred to this facility at Wharton and the patient was started on IV antibiotics, was asked to be evaluated because of persistent wound healing. The patient was transferred to LTAC facility. The patient was asked to evaluate for antibiotic recommendations and management.

Physical examination:Vital signs: Blood pressure of 120/66, pulse of 72, respiration rate of 18, temperature of 97.6.Extremities: Shows bilateral skin breakdown with heel ulcers along with medial malleolus ulcers.Back examination: The patient has a foul odor, unstageable sacral decubitus ulcer with necrotic tissue noted.Otherwise unremarkable.

Labs: None available at this time. Labs from the previous hospital stay was reviewed

Assessment: Sacral decubitus ulcer, unstageable, likely osteomyelitis. Left lower extremity ulcer. Acute on chronic kidney disease. Dementia. Benign prostatic hypertrophy. Hypertension.

Plan and recommendation: We will go ahead and start the patient on Vancomycin and Zosyn, renally dosed at this time. We will go ahead and


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get CBC, BMP. Recommend to get aggressive wound care and possibly surgical evaluation for debridement. Recommend continue with current medical management, possibly increasing nutritional intake for better wound healing. Recommend podiatry evaluation as the patient will need podiatry care because of lower extremity ulcers.

02/15/YYYY Namrata XXXX, M.D.

Nephrology consultation for chronic kidney disease:The patient with a history of peripheral vascular disease, dementia, hypertension, with bedsores, who is now here from his nursing home where apparently he was neglected and overmedicated with Hydrocodone and Ativan because of agitation. The patient has now brought him to XYZ Sugar Land for wound care of his sacral bedsores as well as further therapy.

Physical examination:Vital signs: Blood pressure 100/68, pulse in the 70s, and temperature afebrile. Neck: Supple. No elevated Jugular Venous Distention (JVD).Lungs: Decreased breath sounds bilaterally.Extremities: No peripheral edema.

Laboratory data: Sodium 144, potassium 3.5, BUN 35, creatinine 1.3, albumin 1.8, and hemoglobin 9.3.

Assessment and plan: Elevated BUN/creatinine likely chronic kidney disease 3 from long-term by renal atherosclerosis and hypertension. We will check a renal ultrasound to make sure the patient is not obstructed. Please avoid any Non Steroidal Anti Inflammatory Drugs (NSAIDs) and nephrotoxins, and renally dose all his medications and IV antibiotics for Glomerular Filtrate Rate (GFR) of 45. Hypertension, currently controlled on current medications. Dementia/agitation - nurses only to help the patient bathe and feed. Sacral ulcer infection - on IV antibiotics and wound care.


02/15/YYYY Nicolas ZZZZ, M.D.

Infectious Disease consultation for Leukocytosis:Patient history significant for hypertension, Alzheimer dementia, bedridden status, history of deconditioning, prostate hypertrophy, chronic renal insufficiency, history of vertigo, who appears to be a nursing home resident who was admitted with long-term acute care for a non-healing left ischial foul- smelling decubitus as well as bilateral heel bloody blisters.

Review of systems: The patient is confused, disoriented, complains of difficulty having bowel movements, although according to the nursing staff, he has had 2 bowel movements so far.

Physical exam:Vital signs: He is afebrile. His T-max is 99.1, currently 97.8, blood pressure 97/58, heart rate 61, respiratory rate 18 per minute.Lungs: Clear, although he has poor inspiratory effort. Decreased breath sounds on the bases are noted.Heart: Regular rate and rhythm. S1, S2 present. No tachycardia. There is a 2-3/6 systolic murmur at the left sternal border.Abdomen: Soft, non-distended, non-tender. Bowel sounds are present. No organomegaly.


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He has bilateral heel bloody blisters with dark bloody discoloration, not ruptured yet, right larger than left. He has an unstageable left ischial decubitus with necrotic slough and deep tunneling with seropurulent drainage.Otherwise unremarkable.

Chest X-ray shows hypoinflated lungs with accentuation of pulmonary vasculature, no large size consolidation. Right infrahilar atelectasis and small right effusion is noted.

Medications: Include Terazosin, Lactulose, Divalproex, Risperidone, Temazepam, Magic Cup, Citalopram, Hydrochlorothiazide, Furosemide, Buspirone, Docusate, Aspirin, Finasteride, Vancomycin, Zosyn, Meclizine, Lorazepam, and Tylenol as needed.

Labs: From today, WBC count 10.3 which are improved from previous WBC count of 14 on 10/13. Hemoglobin 9.3, platelet counts 438 with 76% segs. Sodium 144, potassium 3.5, chloride 96, CO2 30, BUN 35, creatinine 1.3. Glucose of 85. ALT 59, AST 48, alkaline phosphatase 86, bilirubin 0.5. Urine culture is pending. No urinalysis available. Blood cultures are in progress.

Impression and plan: Leukocytosis, likely related to left ischial abscess, as the patient has a foul-smelling drainage from the left ischial unstageable wound, with deep tunneling to it. We will recommend CT of the left ischial area. Meanwhile, we will follow up results of blood cultures and urine cultures. Obtain urine analysis. Agree with current antibiotic therapy in the form of Vancomycin and Zosyn. Check Vancomycin trough level before the third dose. Increase Zosyn to 3.375 g IV every 8 hours.

02/15/YYYY Wound assessments: XYZ Hospital First - 000129

02/16/YYYY Azul ZZZ, M.D.

Plastic Surgery consultation for left buttock decubitus ulcer:The patient with a wound greater than 1-month history of left buttock

XYZ Hospital

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wound. Positive pain, positive discharge, positive pressure.

Review of systems: eleven point reviews of systems negative except for weakness, swelling, and non-healing wound.

Physical examination: Pelvic: Left buttock decubitus ulcer with necrotic tissue. No purulence. No crepitus. No fluctuance. Positive surrounding erythema.

Laboratory data: Lab reports and other reports were reviewed.

Assessment and plan: The patient with a left buttock decubitus ulcer. He will undergo an excision and ostectomy of the left buttock ulcer this week in the procedure room. I have discussed this with the patient as well as his son. They are in agreement. I will coordinate this.

First - 000234

02/16/YYYY Majid ZZ, M.D.

Cardiology consultation for hypertension and cardiac management:History reviewed.He has no apparent history of coronary artery disease and no apparent history of CHF, although no recent echo has been done. No reports of any chest pain. The patient was confused when I saw him, but appears to be without any significant distress.

Assessment: Patient with history of hypertension, osteoarthritis, depression, muscle weakness, benign prostatic hypertrophy, anxiety, neck pain, and chronic renal insufficiency who has some pressure sores.

Plan: Continue current medical therapy. Blood pressure is well controlled. I reviewed his medications. He is on Lasix 40 mg daily and Aspirin 81 mg daily. From a cardiovascular standpoint, there is no evidence of renal failure right now and I think we should continue these medications to maintain his current blood pressure.


02/18/YYYY Alpash Z, DPM

Podiatric Medicine and Surgical consultation for ischemic pressure sores in bilateral heels:Patient with significant history of dementia and chronic renal failure. He has been to different facilities and that since then has developed pressure sores in the buttock area as well as the lower extremities in the heels of unknown duration.

Physical examination:Vital signs: T-max is 98 degrees, blood pressure is 102/56, respiratory rate is 60 and pulse is 75.Vascularly: The DP/PT pulses are diminished 1/4 bilaterally. Capillary refill x less than approximately 5 seconds with heat or cold touch and atrophy of the skin. Dermatologic: There are extremely long hypertrophic elongated mycotic dystrophic nails 1 through 5 bilateral. Toes as well as the right heel have large necrotic eschar on the plantar aspect of the heel. It is approximately 4 cm x 4 cm with a central nucleus, which does not have any fluctuant areas. The entire area is extremely hard to touch with non-fluctuant area. The left heel also has a lateral nucleated and well-


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demarcated necrotic eschar, which is approximately 2 cm x 2 cm and hard as well.Musculoskeletal: He has diminished range of motion in ankle joints as well as the hallux of abductovalgus deformity with contracted digits and limited range of motion in the ankle joints and 4/5 muscle strength in all 4 quadrants of the legs. He has very limited dorsiflexion and plantarflexion.Neurologic: Diminished sensation in bilateral lower extremities.

Assessment and plan: Generalized peripheral vascular disease. Has pressure sores in both heels, stable un-stageable to. We will continue dry and keep them off loading and may also require slight debridement of the eschar in the next couple of weeks if there is no improvement in dryness of both feet and eschars of both heels.

02/18/YYYY Wound assessments: XYZ Hospital First - 000128

02/18/YYYY Mathur zzzz, M.D.

CT of pelvis with contrast: Indications: Left ischial stage 4 decubitus and abscess.

Impression: No evidence of osteomyelitis is seen. No definite abscess formation is noted. Decubitus ulcer is seen on the posterior aspect of the left ilium and ischium.

XYZ Hospital First - 000305

02/19/YYYY Wound culture reports:Collected date: 02/15/YYYY

Body site: HipResult: Proteus mirabilis and Enterococcus species present.

Susceptible: Ampicillin and Vancomycin


02/15/YYYY-02/23/YYYY

Jason zzz, APRN

Cumulative Infectious Disease progress notes:Temperature 98-98.6. Blood cultures on 02/14/YYYY shows no growth. Urine and wound culture pending. On Vancomycin and Zosyn for sacral

XYZ Hospital First -

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Sarfraz x, M.D..

decubitus ulcer. Wound care for left lower extremity ulcer. Benign prostatic hypertrophy; acute on chronic kidney disease. Sacral decubitus ulcer thought to be osteomyelitis. Blood cultures negative for one day. Wounds are dressed without drainage. Protein calorie malnutrition; continue nutritional support. Labs on 02/18/YYYY with low albumin (1.7). Bilateral heel ulcers with eschars. On antibiotics and local wound care. Hypertension controlled. On DVT and GI prophylaxis. Blood culture reports on 02/20/YYYY reveals no growth. Wound culture shows gram-positive cocci, gram-negative rods and non-lactose fermenters; culture positive for Proteus mirabilis and Enterococcus. Zosyn discontinued and Ampicillin started. Left lower extremity ulcer with local wound care and antibiotic therapy. WBC on 02/21/YYYY is 11.3 and on 02/22/YYYY is12.5. Mild leukocytosis without fever. Sacral decubitus with possible osteomyelitis with unstageable wound. Continue antibiotics.

000136-XYZ Hospital First - 000146, XYZ Hospital First - 000148-XYZ Hospital First - 000149, XYZ Hospital First - 000152-XYZ Hospital First - 000154

02/21/YYYY-02/23/YYYY

Mustaq zz, M.D.

Cumulative progress notes for bilateral heel pressure ulcers:Blood pressure 91/56. Grade 3/6 systolic murmur noted. No pedal edema. Bilateral heel eschars noted. On Ampicillin and Vancomycin. DVT and GI prophylaxis. On current medication Lasix and Hydrochlorothiazide. Bilateral pedal edema with healed eschars noted on 02/22/YYYY. Blood pressure on lower side, anemia, and dementia and protein-calorie malnutrition. Terazosin discontinued. Bilateral trace pedal edema with foot dressing.

XYZ Hospital First - 000149-XYZ Hospital First - 000152, XYZ Hospital First - 000154-XYZ Hospital First - 000155

02/23/YYYY Azul ZZZ, M.D.

Operative report for excision and ostectomy of decubitus ulcer:Pre and post-operative diagnosis: Decubitus ulcer.Procedure: Excision and ostectomy, decubitus ulcer.

Intraoperative findings: Necrotic skin, subcutaneous tissue, muscle, fat, fascia, and periosteum.Specimen: Decubitus ulcer and pelvic bone.Complications: None.

Disposition: The patient is awake, stable in recovery.


02/27/YYYY Alpash Z, Podiatric Medicine progress notes: XYZ

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M.D. The dressings are clean, dry, and intact on the right heel. The left heel has clean, dry, and intact dressing.Vitals: Temperature is 97.6, BP is 105/82, and respiration rate is 20, pulse rate 68. Extremities: Both feet are cold to touch. The right heel had a huge blood blister on the lateral aspect of the foot that had been debrided and appears to be beefy red in color with granulation tissue and healing quite well; however, the right heel still appears to be very necrotic and hard. There is no fluctuant area. It is well demarcated approximately 4 cm x 4 cm and 0.5 cm thick, and we will treat it conservatively. There is no peri wound cellulitis, exudate, or streaking present.

Assessment and plan: Generalized peripheral vascular disease in both lower extremities. Status post debridement of left lateral heel abscess/blood blister

healing quite well. Continue with local wound care. Stage I ulceration of the right heel quite stable and solid, and we

will continue to monitor and off load. Discussion was carried out with the family in detail especially the

son who wants to get guardianship of his father and place him in a facility and is seeking for newer facility local to Sugar Land and was advised to contact the case manager as well as the social worker to try and help him find a facility in which he will be well taken care of and not run into the pressure sore problems and abuse that he did at the previous facility. He has also expressed an interest in pursuing legal action against the previous facility where his father had been. We will continue to follow.

Hospital First - 000169-XYZ Hospital First - 000170

03/02/YYYY Alpash Z, M.D.

Podiatric Medicine progress notes:Vital signs: T-max of 98.2, blood pressure is 102/80, respiration rate is 20 and pulse rate is 62.Extremities: The dressing on the left foot is clean, dry, and intact. Right foot well secured with heel protectors. Upon examination, generalized peripheral vascular disease, diminished pulses bilateral feet, on left lateral heel, the wound is thoroughly debrided stage II ulceration, is healing quite well. This granulation tissue has very little exudate, very little fibrotic eschar present. The right heel appears to be extremely hard eschar with no exudate, no malodor, and no streaking present in the area. The entire tissue bed is nice and hard and we will leave it.

Assessment and plan: Bilateral lower extremity ulcerations, left heel is stage II whereas right heel is unstageable, however, it is extremely hard and solid on the right lower extremity. We will continue to monitor both the wounds and continue keep the right foot off loading to hopefully have the eschar falls off by itself. We will continue following, the patient currently on antibiotics as well, and continuation of antibiotics of Ampicillin and Vancomycin.


02/24/YYYY-03/20/YYYY

Mustaq zz, M.D.

Cumulative progress notes for pressure ulcers:Bilateral trace pedal edema. Left foot dressing noted. Sacral decubitus ulcer with osteomyelitis. Bilateral heel ulcer with eschar. Continue IV antibiotics and local wound care. Started on wound Vacuum Assisted Closure (VAC) on 03/20/YYYY

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Pdf ref: XYZ Hospital First - 000157-XYZ Hospital First - 000158, XYZ Hospital First - 000169-XYZ Hospital First - 000171, XYZ Hospital First - 000173-XYZ Hospital First - 000178, XYZ Hospital First - 000219-XYZ Hospital First - 000220, XYZ Hospital First - 000221-XYZ Hospital First - 000223, XYZ Hospital First - 000062

02/24/YYYY-03/21/YYYY

Sarfraz x, M.D..

Cumulative Infectious Disease progress notes:Temperature maximum 98.8. Clear to auscultation bilaterally, on 2L nasal cannula. Afebrile. Continue Unasyn and Vancomycin. WBC on 02/25/YYYY is 12.9. Mild leukocytosis. Afebrile. Will follow temperature curve. Will follow CBC. Local wound care. Recommend 14 day and minimal 28 day course of antibiotics. Patient pulled out PICC line on 02/26/YYYY. On Aricept, Risperdal, Citalopram for dementia. Norco for pain management. Chest X-ray on 02/25/YYYY shows pulmonary vascular congestion, pleural effusion, right greater than left. Bed bound status, is on air mattresses. Sacral decubitus ulcer with osteomyelitis. Labs on 02/28/YYYY revealed WBC 9.6. WBC on 03/02/YYYY is 8.9. Continue antibiotics and wound care. Monitor hemoglobin and hematocrit. Vancomycin on hold on 03/05/YYYY due to elevated levels.

The patient’s right heel is still showing necrosis along with left buttock and deep tissue ulcers with slough noted. Leukocytosis back to normal on 03/05/YYYY. Recommended to complete 42 day antibiotic course and aggressive wound management. Right side heel dressed well no drainage. Lasix 20 mg per oral was added. On Vancomycin. Generalized debility and deconditioning. Severe protein calorie malnutrition. Encouraged per oral with nutritional support. On antibiotics and local wound care. Bilateral lower extremity swelling. Leukocytosis resolved. Ampicillin and Vancomycin discontinued. Levaquin per oral and Zyvox started on 03/16/YYYY. Zyvox switched to Doxycycline 100 mg twice daily for 10 days. Chronic bed bound status and chronic anemia. Lower extremity edema. Signs of fluid overload. IV Lasix started. Lasix can be changed to per oral after change to skilled nursing facility. Wound VAC started on 03/20/YYYY. Afebrile. Remains stable. Local debridement and wound care for lower extremity ulcer. Continue with supplemental nutrition. Stable. To transfer to skilled nursing facility.

XYZ Hospital First - 000156-XYZ Hospital First - 000157, XYZ Hospital First - 000160-XYZ Hospital First - 000168, XYZ Hospital First - 000171-XYZ Hospital First - 000172, XYZ Hospital First - 000179-XYZ Hospital First - 000191, XYZ Hospital First - 000193-XYZ Hospital First - 000217, XYZ Hospital First - 000224-

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02/15/YYYY-03/21/YYYY

Namrata XXXX, M.D.

Cumulative Nephrology progress notes:Without peripheral edema. Chronic kidney disease stable at baseline. On 02/18/YYYY ultrasound of kidney revealed 8 mm stone in right kidney. Hypokalemia. Will treat with KCl 20 meq twice daily x 1. Renal failure improved. Creatinine stable at 1.2. Hypernatremia – Encourage to drink 150 ml of water every 4 hours. Hypertension improved. GFR is 58%. Avoid NSAIDs or nephrotoxins. Hypotension. Hydrochlorothiazide 25 mg stopped due to hypotension. Blood pressure 112/60-90/57. Resolving hyponatremia, hypoalbuminemia – started on protein supplements. Acute renal failure resolved.

Pdf ref: XYZ Hospital First - 000136, XYZ Hospital First - 000141, XYZ Hospital First - 000143, XYZ Hospital First - 000147-XYZ Hospital First - 000148, XYZ Hospital First - 000150-XYZ Hospital First - 000151, XYZ Hospital First - 000155-XYZ Hospital First - 000156, XYZ Hospital First - 000304, XYZ Hospital First - 000158-XYZ Hospital First - 000162, XYZ Hospital First - 000166-XYZ Hospital First - 000169, XYZ Hospital First - 000172-XYZ Hospital First - 000173, XYZ Hospital First - 000179, XYZ Hospital First - 000185-XYZ Hospital First - 000186, XYZ Hospital First - 000188, XYZ Hospital First - 000192, XYZ Hospital First - 000199-XYZ Hospital First - 000200, XYZ Hospital First - 000217, XYZ Hospital First - 000220, XYZ Hospital First - 000224, XYZ Hospital First - 000063, XYZ Hospital First - 000174

03/21/YYYY Mustaq zz, M.D.

Discharge summary:Date of admission: 02/14/YYYY

Discharge condition: Stable.

Disposition: Skilled Nursing Facility.

Discharge diagnoses: Left ischial decubitus ulcer with osteomyelitis. Bilateral heel pressure ulcers with necrosis. Chronic bedbound status. Benign prostatic hypertrophy. Chronic kidney disease. Protein-calorie malnutrition. Systolic murmur, grade 2/6. Hypertension. Osteoarthritis. Anxiety and depression. Dementia.

Consultants on the case Dr. Sarfraz Aly, Infectious Disease. Dr. Azul Jaffer, Plastic Surgeon. Dr. Alpash Z, Podiatry. Dr. Namrata Goel, Nephrology. Dr. Majid Basit, Cardiologist.

Procedures: Status post excision and osteoectomy of decubitus ulcer done by

Dr. Azul Jaffer. (Ref XYZ Hospital First - 000295-XYZ Hospital First - 000297)

Debridement of the left heel decubitus ulcer by Dr. Alpash Z.


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Ultrasound of the kidneys showing 8-mm stone in the right kidney. (Ref XYZ Hospital First - 000304)

CAT scan of the pelvis with contrast, no evidence of osteomyelitis, no definitive abscess. (Ref XYZ Hospital First - 000305)

Bilateral lower extremity venous Doppler negative for DVT. (Ref XYZ Hospital First - 000307)

Brief course of hospital stay: Patient was transferred to XYZ LTAC for continuation of care for complex pressure ulcers. The patient was continued on IV antibiotics and Dr. Sarfraz Aly was consulted. The patient’s antibiotics were managed through the course of hospital stay by Dr. Aly. The patient has completed IV antibiotics and has been started on per oral Doxycycline and Levaquin, which will be continued for 18 more days. The patient has also been evaluated by Dr. Azul Jaffer and by Dr. Alpash Z for the pressure ulcers and the patient underwent debridement as mentioned above. The patient was being followed by Wound Care Team. The patient’s ischial pressure ulcers will be started on wound VAC upon transfer to Skilled Nursing Facility (SNF). The patient had signs of volume overload for which he was being diuresed with resultant hypernatremia. The patient was being followed by Dr. Namrata Goel. The patient is now on Lasix at 40 mg per oral daily.

The patient remains stable and will be discharged to skilled nursing facility. Case managers have been involved in the patient’s discharge planning and disposition and after discussion with the patient’s family members, the patient will be for a skilled nursing placement. As discussed with case manager, Ms. Kern, there is an active APS case in reference to the patient.

Subjective: The patient is drowsy, arousable to verbal stimuli, in no respiratory distress. The patient had received a dose of Ativan this morning. No other acute events noted.

Objective:Vital signs: Blood pressure is 146/69, pulse 75, respiratory rate 20, and temperature 97.General: The patient is drowsy, arousable to verbal stimuli, in no acute distress.Cardiovascular: Regular rate and rhythm. S1 and S2 audible. Grade 2/6 systolic murmur.Lungs: Decreased basilar breath sounds. No wheeze or rhonchi.Abdomen: Obese, soft, and non-tender. Bowel sounds present.Extremities: Bilateral trace pedal edema noted.

Lab studies: Noted. Sodium of 148.Diet: 2 gram sodium heart-healthy diet.Activity as tolerated.

Follow-up: The patient will be under service of Dr. Amer at Skilled Nursing Facility. Upon discharge from SNF, the patient will need to follow-

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up with his primary care physician for follow-up.02/14/YYYY-03/21/YYYY

Other related records:Nursing assessments (Ref XYZ Hospital First - 000065-XYZ Hospital First - 000067, XYZ Hospital First - 000137-XYZ Hospital First - 000140, TDADS - 000001-TDADS - 000003, XYZ Hospital First - 000326-XYZ Hospital First - 000656, XYZ Hospital First - 000810-3097, XYZ Hospital First - 000780-XYZ Hospital First - 000781, XYZ Hospital First - 000791-XYZ Hospital First - 000800, XYZ Hospital First - 000823-XYZ Hospital First - 000826, XYZ Hospital First - 000807-XYZ Hospital First - 000809, XYZ Hospital First - 000657-XYZ Hospital First - 000723), consent (Ref XYZ Hospital First - 000047-XYZ Hospital First - 000055), culture reports (Ref XYZ Hospital First - 000118-XYZ Hospital First - 000121, XYZ Hospital First - 000108-XYZ Hospital First - 000112), labs (Ref XYZ Hospital First - 000113-XYZ Hospital First - 000117, XYZ Hospital First - 000298-XYZ Hospital First - 000302, XYZ Hospital First - 000068-XYZ Hospital First - 000107), medication sheets (Ref XYZ Hospital First - 000782-XYZ Hospital First - 000790, XYZ Hospital First - 000728-XYZ Hospital First - 000779, XYZ Hospital First - 000058-XYZ Hospital First - 000061), occupational therapy records (Ref XYZ Hospital First - 000804-XYZ Hospital First - 000806), orders (Ref XYZ Hospital First - 000240-XYZ Hospital First - 000294, XYZ Hospital First - 000312-XYZ Hospital First - 000314), physical therapy records (Ref XYZ Hospital First - 000801-XYZ Hospital First - 000803), plan of care (Ref XYZ Hospital First - 000315-XYZ Hospital First - 000325), X-ray reports (Ref XYZ Hospital First - 000303, XYZ Hospital First - 000306-XYZ Hospital First - 000311, XYZ Hospital First - 000122, XYZ Hospital First - 000123)


Health and Rehabilitation Center03/21/YYYY Provider/

SignatureAdmission assessment: (Ref 3 - 000009-3 - 000010)Resident arrived to facility, alert and oriented to self with confusion, yelling out. Requesting pain medicines, asked resident where is pain and resident stated “give me my pain medicines”. Norco given. Ulcer to left buttocks with 95% granulation tissue and 5% slough with tunneling at 2o’clock. Right heel with 100% eschar, left heel with 50% granulation and 50% slough. Resident taking clothing off along with oxygen cannula.

Wound Size StageLeft buttock 7x6.5x4.3

Tunneling at 2o’clock at 4 cm

Stage IV

Right heel 6.5x6.5xunable to determine

Unstageable

Left heel 1.5x1xunable to determine

Stage III

Braden score: 14 (Moderate risk) (Ref 12 - 000033)

3 - 000001-3 - 000013

03/25/YYYYProvider/Signature

History and physical:Patient with dementia and chronic kidney disease. Patient was neglected by caregivers and transferred from hospitals and facilities. Developed several pressure sores in buttocks.

1 - 000013

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Physical examination: Chest clear, abdomen soft, non tender. Bilateral heels and left buttock under dressings.

Diagnosis: Complex pressure ulcers with infected left buttock wound. Continue wound care. Complete per oral antibiotics for osteomyelitis. Bilateral foot pressure ulcers with eschar. Continue wound care _____.Chronic kidney disease stable, monitor. Dementia and vertigo; continue medicines.

*Reviewer’s comments: The daily progress notes from 03/22/YYYY-04/01/YYYY are not available for review. The only available progress note is captured below.


Progress notes:No pain. Bilateral upper extremity edema 2+. Bilateral lower extremity heel ulcers and buttock ulcer. Continue wound care, wound VAC and antibiotics. Continue pressure relieving dressings for bilateral foot ulcers. Upper extremity edema secondary to hypoproteinuria; increase Lasix done.

6 - 000020

04/01/YYYYProvider/Signature


Admission diagnosis: Osteomyelitis, muscle weakness, abnormal posture, stiffness of joints and necrosis multiple sites.Final diagnosis: UTI, dehydration, wound heels and dementia.

Hospital course: Discharged to Methodist Sugarland via ambulance.Diagnosis at the time of transfer: Urinary retention with swollen penis and scrotum

1 - 000001, 1 - 000003


Readmission note: (Illegible Notes)Readmission date: 04/02/YYYYPatient with advanced dementia was admitted _____ last week, started to have difficulty urinating. Went to the hospital, was dehydrated _____sent back on IV antibiotics.

Current diagnosis: UTI/urine retention: Improved. Continue IV Rocephin and then per oral antibiotics. Pressure ulcer in left buttock. Continue wound care and per oral antibiotics. Monitor chronic kidney disease. Dementia stable. Vertigo: Continue Meclizine.

Wound Date of onset

Size Discharge Stage

Left buttock

03/21/YYYY 7x6.5x4.3Tunneling 4 cm

Large serosanguineous drainage

Stage IV

Right heel 03/21/YYYY 1x1x0.1 Eschar tissue removed. No discharge

Stage II. Eschar tissue removed.

6 - 000017, 10 - 000021-10 - 000027

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Left heel 03/21/YYYY 2.2x0.9x0.1

Moderate purulent drainage

Stage II

Superior right hip

04/02/YYYY 5x3.4x0.1 No discharge

Stage II

Shearing in right side flank

04/02/YYYY 8x6.5 NA NA

Bottom of left great toe

NA 2.1x2 None Suspected deep tissue injury.

Inferior left hip

04/02/YYYY 4x2 None Stage I

*Reviewer’s comments: The daily progress notes from 04/02/YYYY-04/19/YYYY are not available for review.04/11/YYYY

Provider/Signature

Wound progress notes: (Illegible Notes)Patient afebrile. BP 129/64. Respirations and heart sounds regular. Abdomen soft.

Wound Size Discharge Stage Wound painSacrum 7x5.5x1.1 Undermining 9-

11 o’clock, maximum 6 cm. Large exudate

IV Score 1

Right hip 13x4 Moderate exudate

NA Score 1

Left heel 2x0.7x0.1 NA NA Score 1Right heel 5x4.5 NA NA Score 1

Problem list: Sacrum decubitus: Patient _____ wound VAC. Hip ulcer: Continue with Santyl ____. All other ulcers: Betadine.Orders: Sacrum: Cleanse with saline, apply Santyl and Alginate. Cover with bordered gauze twice daily. Right hip and left heel; apply Santyl and Alginate every day. Other wounds, Betadine

6 - 000023-6 - 000027

04/15/YYYY XYZ Care Physicians

Provider/Signature

Wound evaluation and treatment notes:Stage IV ulcer in sacrum. Right hip 6x6x2. 100% granulation. 11 cm tunneling; 12-3 o’clock undermining 7 cm with serous drainage. Eschar in right hip.

Wound status: Improving.Santyl to right hip. Cleansing solution saline.Secondary dressing: Abdominal pads and gauze 4x4sPressure relief: Air mattresses; follow pressure ulcer prevention.

Plan: Betadine to right heel Will need debridement. Hydrogel to right hip. Right buttock next week.

7 - 000001-7 - 000002

04/19/YYYYProvider/


6 - 000001, 6 - 000007

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SignatureAdmission diagnosis: Osteomyelitis, muscle weakness, abnormal posture and stiffness of joints.

Final diagnosis: Severe dementia, lower extremity and buttocks decubitus ulcer.

Hospital course: Discharged to GCMC via ambulance.Rehabilitation potential: Fair

Diagnosis at the time of discharge: Psychosis, osteomyelitis, pressure ulcer, pain, stiffness of joints, dementia.

Disposition: GCMC behavioral unit03/21/YYYY-04/10/YYYY

Health and Rehabilitation Center

Other related records:Nursing assessments (Ref 11 - 000083, 3 - 000018-3 - 000019, 5 - 000001, 12 - 000033-12 - 000035, 12 - 000071-12 - 000075, 12 - 000066-12 - 000067, 10 - 000005-10 - 000014, 10 - 000029, 6 - 000019, 10 - 000028, 4 - 000001-4 - 000004, 3 - 000014-3 - 000022), consent (Ref 1 - 000004-1 - 000010, 6 - 000008-6 - 000016, 1 - 000014, 6 - 000021-6 - 000022, 11 - 000084, 5 - 000002-5 - 000003, 12 - 000064-12 - 000065), culture reports (Ref 10 - 000031-10 - 000035, 4 - 000005-4 - 000006), labs (Ref 10 - 000030), occupational therapy records (Ref 12 - 000018-12 - 000032), orders (Ref 1 - 000015-10 - 000004, 8 - 000001-9 - 000004, 2 - 000001-2 - 000002), physical therapy records (Ref 12 - 000001-12 - 000017), plan of care (Ref 12 - 000036-12 - 000063), referral report (Ref 12 - 000068-12 - 000070), treatment sheets (Ref 4 - 000007-4 - 000042, 11 - 000001-11 - 000082)


Medical Center04/19/YYYY Damodhar

an z, M.D.Admission for psychotic behavior:The patient was apparently in his usual state of health at the Nursing Home, who was brought to the Emergency Room for potential admission to the Behavior Health Unit (BHU) because he was found to have altered behavior, like taking off his cloths and inappropriate behavior that way. He denies any fever, chills, chest pain, palpitations, nausea, vomiting right now.

Medications: He is on Tramadol for pain; Aricept 10 mg per oral everyday at bedtime for dementia; Citalopram 20 mg per oral daily; Valproic sodium 125 per oral everyday at bedtime for agitation; Aspirin; Lasix 40 mg daily for edema; Robaxin 400 mg per oral as needed for pain; Tylenol; multivitamin; Protonix 40 daily; zinc oxide 220 daily; Colace as needed for constipation; Finasteride 5 mg daily; Lactulose as needed; Levaquin 250 per oral daily for osteomyelitis; Diflucan 100 mg per oral daily for urinary tract infection; Seroquel 100 mg per oral twice daily for psychosis; Norco as needed.

Review of systems: Significant for no fever, no chills, no headache, no eye

Medical Records 02 - 000048- Medical Records 02 - 000050

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pain, no hearing loss, no dental disease, no cough, no chest pain, no diarrhea, dysuria, polyuria, some memory and mood changes, no neck pain. The patient is bedridden and uses a wheelchair for ambulation.

Physical examination:Vital signs: Blood pressure is 126/59; pulse is 68, respirations 18, temperature 96.General: The patient is lying in bed in no apparent distress.Chest: Breath sounds heard. No rales or rhonchi.Extremities: Has some wounds on the ankles, dressing on both ankles.Skin: Also decubitus ulcer around the coccyx.Neurological: The patient is doing good, alert, awake, oriented, and able to follow objects, read fine prints. Pupils equal, round and reactive to light. Responds to light touch. Able to bite down, has gag reflex, able to puff cheeks, able to raise eyebrows, soft palate intact, gag reflex present, able to shrug shoulders, able to stick his tongue out.

Laboratory data: Urine analysis shows ketones of 250 and RBCs of 16-20. Chest X-ray shows mild cardiomegaly and mild vascular congestion. Hemoglobin is 10. Urine Drug Screen (UDS) is positive for opiates. Alcohol level is 1. CMP is significant only for an albumin of 2.0, otherwise everything else is normal.

Assessment and plan: Inappropriate behavior probably secondary to worsening of

psychosis or dementia. Dr. Patel has been consulted. Osteomyelitis, followed by Wound Care Clinic History of chronic kidney disease, right now looks good. The patient wants to be a full code. I will work with Dr. Mehra in further caring for the patient and

consult Dr. Scott for wound care.

04/22/YYYY Ted X, M.D.

General Surgery consultation for pressure ulcers:The patient has been admitted to the Geriatric psyche unit. I have been asked to see him because of decubitus ulcers,

Physical examination: He is somewhat confused

Vital signs essentially normal.Extremities: He does have a left gluteal abscess, grade 3. It is about 7 cm in diameter. It is relatively clean. He has bad a Wound VAC on his in the past but apparently keeps pulling it off. Minimal exudate if any is present in the wound. His left heel in the calcaneal area has a large eschar probably about 4 cm in sine attached to it at its full thickness. Cannot really tell the depth of this wound. It is probably a level IV pressure wound. There is probably osteomyelitis under it. On his right foot, he has a second-degree wound on his heel as well as one or his left great toe. These as mentioned are second degree.


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Impression: He has pressure ulcers on the gluteal area as well as his feet. He possibly has osteomyelitis of the calcaneal area, I guess it is possible in the sacral area as well, but I think it is only in the calcaneal area, He has hypertension. He has psychosis.He has chronic renal disease.

Plan: Begin local treatment with the wounds. With the gluteal wounds, we will place Gentamicin and Santyl as well as Hydrofera blue on the wound. Maybe he will leave that in place. I am just going to wrap the calcaneal area for the time being. I will protect the foot with just Allevyn heel protectors. Bone scan is ordered. We will continue him on his present medicine for the time being. If he has the osteomyelitis he will in my opinion need long term IV antibiotic treatment. The other thing is I will need to take him to the operating room and debride that eschar off of his heel, and finally after his gluteal area is treated for a while I think he would be a candidate for a rotational flap and if that is the case he would actually be a candidate for hyperbaric oxygen treatment.


Procedure report for excision of eschar:Pre and post-operative diagnosis: Inability to void and status post traumatic catheterization attempt. Pressure ulcer to the right calcaneal area.

Procedure: Placement of Foley catheter. Excision of eschar.Complications: None

Medical Records 01 - 000076

*Reviewer’s comments: The daily progress notes from 04/19/YYYY-05/08/YYYY are not available for review. Hence the only available procedure and operative reports are captured below.


Operative report for left end colostomy with Hartman pouch:Pre and post-operative diagnosis: Anal incontinenceProcedure: Left end colostomy with Hartman pouch

Findings: Numerous severe adhesions were noted in the left lower quadrant. They were taken down with harmonic scalpel.

Complications: None




Final diagnoses:Osteomyelitis of the right heel.Large sacral decubitus.Dementia.Chronic renal disease.

Operations: On 04/20/13 I performed a Port-a-Cath placement for long-term IV antibiotics. On 04/23/13 I placed a Foley catheter in the operating room and also excised an eschar to his right foot and finally on 05/02/13 I did a left in colostomy with a Hartmann pouch.

2 - 000022-2 - 000023

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Complications: None.

Summary: This patient was admitted to the hospital on 04/19/YYYY in the psychiatric unit for increasing psychosis and inability for them to manage him at his nursing home in Sugar Land. He was Nursing Home. He was admitted to our BHU with altered behavior. They treated him there, had him under control. He was also noted to have several medical problems including a large eschar on this right heel as well as a large decubitus on the sacral area. The sacral decubitus had an eschar but this was excised.

Around 04/23/YYYY he was taken to the operating room. He was transferred to my service and became a medical/surgical patient and was taken to the operating room and had a Foley catheter placed under general anesthesia as well as excision of an eschar. The reason the Foley catheter was placed is that the nurses had tried to place it in the BHU and had been unable to pass it and had achieved a great deal of blood. We were able to place a small catheter in the operating room and I did not want to remove it for at least a month because of possible trauma to the urethra. The eschar was excised. He was followed. The following few days a bone scan showed osteomyelitis in the heel and a Port-a-Cath was then placed and he was placed on long-term Vancomycin treatments.

The sacral area would not improve because he was incontinent to stool and after talking with his son, I told him that the best thing for the patient to have was a colostomy so we did an in colostomy to the sigmoid colon and brought it out on his abdomen to keep the anal area clean. Once we did this and he has recovered from that and his colostomy is functioning actually he is really very alert her at time. He does sleep a lot because of his medications but he has been absolutely no problem for us. We are transferring him to Nursing Home where he will receive his IV antibiotic treatment and wound care to the sacral area. I will see him in the wound care clinic for the sacrum as well as the heel. My plan is that once the sacrum clears up to do a rotational flap on the back and after doing that we will probably need to do hyperbaric oxygen treatment to him for a while until it gets well and then he should be able to function must better.

Nursing Home05/08/YYYY Provider/

SignatureAdmission nursing assessment: (Illegible Notes)Admitted per stretcher from GCMC. Colostomy left abdomen; Foley catheter. Decubitus to hip and heel. Skin tears to lower extremity _______ MRSA of wounds. Alert and oriented.

8 - 000091-8 - 000092

05/13/YYYY Kim XX, NP-C

History and physical:Long term nursing home resident- Admitted to Place after hospitalization for increasing psychosis - he was managed and controlled in Wharton behavioral unit. He also had a large eschar on his right heel and large decubitus on sacral area; excision was performed; on antibiotics for osteomyelitis.

1 - 000027

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Review of systems: Foley catheter pulled by resident last night; voiding per nursing; generalized weakness; large sacral ulcer; right heel debridement / osteomyelitis. History of dementia, cooperative, pleasant. Calm/cooperative.

Examination: Warm and dry skin with poor turgor; port-a-cath to right subclavian, no redness or tenderness; large sacral decubitus; right heel ulcer.Abdomen: Soft, non-tender, no rebound or guarding, bowel sounds x 4; colostomy bag with soft brown stool.Musculoskeletal: Atrophic; moves all extremities with generalized weakness; total care; contractures.Otherwise unremarkable

Assessment and plan:Osteomyelitis: Vancomycin every 36 hours, check Vancomycin peak/trough after every third dose; Levaquin 250 mg, lab pendingSacral ulcer right heel ulcer: Seen by wound care, wound VAC to sacral ulcer - resident pulled off last night - resident refusing to have it replaced - nursing to notify son/wound care MD, continue loss air loss mattressBPH: Foley catheter - resident pulled out last night, nursing reports resident is voiding without difficulty; continue Tolterodine, Finasteride, Phenazopyridine - will discontinue PhenazopyridineDementia with behavior: Continue Seroquel, Namenda, Depakote and DonepezilPain: Continue Robaxin, Tramadol, Tylenol; and Norco as needed,Edema: Continue Lasix 40 mg, monitor BMIFollow-up plan reviewed


Wound assessments:Wound Size Stage Discharge Peri wound

Right heel 5x4x0.3 III Medium serosanguineous drainage. No tunneling or undermining. Slough present. 67/100% necrosis present. No undermining present

Tender on palpation. Dry/ scaly

Sacrum 3.5x3x0.2

III Medium serosanguineous drainage. Tunneling present at 12 o’clock. 1-33% necrosis seen.

Localized edema. Tender on palpation.

5 - 000095-5 - 000096

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Dressings:Sacrum: Gentamicin/black foam VAC/bridge to hip 3 times per week. Right heel: Gentamicin/ Santyl/4x4 Allevyn ____ heel protectors_____3 times per week.


Visit for osteomyelitis of right heel and left sacral ulcer:History reviewed.He is now at Nursing Home receiving those antibiotics. He also had a large decubitus on his sacral area that had been treated with a rotational flap in January, which had failed. He had stool all over his area on his sacral area, and to help facilitate the healing I performed a colostomy on him to divert the stool away from this area. He has been discharged from the hospital. He is at . He is receiving his IV antibiotics. He is receiving wound care to his sacrum as well as his heel. He presents to us today for follow-up.

Physical examination:Vital signs: Blood pressure was 86/54. Pulse was 60/regular. Respirations were 18. His temperature is 97.4. Weight is 170 pounds. He is 62 inches tall.Extremities: No clubbing, cyanosis or edema. There was a pressure ulcer on his right heel with eschar present on the heel. It measured 5 cm in diameter. I excised the eschar with a 15-blade. There was some bleeding noted. In looking at his gluteal area, there was a gluteal open wound with some tunneling noted. The measurements on the wound were 5 cm x 3 cm x 0.2 cm. There is also tunneling noted at 12:00, and it extends 4 cm in the wound. The wound actually looks very clean.Otherwise unremarkable.

Admitting diagnoses: Pressure ulcer to his right heel. Pressure ulcer to his sacrum. Acute osteomyelitis of his right calcaneus. Psychosis, unspecified. Dementia. Anxiety disorder. Depressive disorder. Benign prostatic hypertrophy. Chronic respiratory failure.

Plan: Keep his wounds clean, and do wound care with Gentamicin and Santyl. We will continue his IV antibiotics for his osteomyelitis. I was thinking we might want to do a rotational flap on his sacrum, but it has improved so much since I discharged him from the hospital, I really think this thing will heal on its own. I am concerned about his heel, and we will instruct the nurses at the nursing home that this has got to be off loaded. We will continue with his psychiatric medicines, and I will see him again next week.


*Reviewer’s comments: Only the details pertaining to wound progress and treatment are captured from 05/15/YYYY-11/16/YYYY.

05/23/YYYY-07/15/YYYY

Ted X, M.D.

Wound care progress notes:05/23/YYYY: The left sacral area looks great. There is no debridement that is done in this area. It appears to be about half the size as it was. It is treated with Gentamicin, black foam and a bridge to protect it.The right heel is evaluated. There is a lot of exudate on that. I have used a scalpel to debride an excessive amount of devitalized tissue, exudate, fibrin,

Medical Records 01 - 000021- Medical Records 01 - 000031,

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skin, subcutaneous and some viable tissue. We did have some bleeding, 0.2 cc that was controlled with pressure. The size of the wound at the end is 5.2 cm by 4.2 cm by 0.5.Plan: Continue his IV antibiotics and wound care. He will keep off of his sacrum as well as his hip and he will keep those off loaded. He will return to see us in one week.

05/29/YYYY: The left sacral area looks great. There is no debridement that is done. The wound VAC is replaced. The right heel is evaluated. There is still a lot of exudate and eschar on it. Some of the areas I debrided with a scalpel last week showed some granulation tissue. It is very tender and I am just going to place a great deal of Santyl and Gentamicin on this wound, hoping to soften it up and debride it chemically. This area is dressed with Santyl and Gentamicin, 4x4s and Allevyn. Finally the area on the right hip is evaluated. It does have a VRE present. We have debrided the wound sharply and removed a great deal of eschar. The measurements on the right hip are 6.2 cm x 10.5 cm and probably 0.3 cm deep. He tolerated this well. There is minimal bleeding that was encountered. It was extended down through the subcutaneous tissue in some areas. We dressed this with Santyl and Gentamicin ointment as well as 4x4s and Mepilex. He was then transported back to his nursing home.

06/04/YYYY: The sacral area continues to look good. No debridement is done in that area. He has pulled his wound VAC off and we have simply redressed the wound today with Gentamicin, Santyl, and a Mepilex cover. The right heel is evaluated. There is a tremendous amount of eschar and exudate on it. Attempted debridement of this area but he is extremely tender and combative today so therefore we stopped doing that. Gentamicin and Santyl were also placed on this area and the wound was again covered with 4x4s and Allevyn heel foam and Kerlix. Finally the area on the right sacrum was evaluated. VRE is present. I tried to debride it and it is also very tender and has a lot of eschar. We placed Gentamicin and Santyl on this one with 4x4s and Hypafix dressing. He was then discharged and transported back to his nursing home.

06/11/YYYY: Looking at the sacral area, the wound is dramatically improved. ‘The measurements of the wound show that the length is 2 cm, the width is 1 cm, and the depth is 0.3 cm. It is clean. I do not think we can keep a wound VAC on it and it is covered with Santyl, Gentamicin and Hydrofera blue. The area is then covered with Hypafix. The right heel is then evaluated. There is a great deal of necrotic tissue noted on the heel. We have debrided this sharply with a 15 blade. There does not seem to be quite as much necrotic tissue as the last time. We covered the wound with Gentamicin and Santyl then covered the right heel with contact layer, 4x4s, Allevyn foam dressing and Kerlix. The measurements of the heel are 5cm x 4cmx 0.5cm. Finally the right hip was evaluated. There was necrotic tissue noted on it. This wound is debrided sharply with a 15 blade debriding most of the eschar off. We debrided it down into muscle in a couple of areas. Hemostasis was obtained with pressure. Santyl was used on this wound as


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well as Gentamicin, barrier drape, 4x4s as well as Hypafix dressing. The patient tolerated dissection well without any major complaints. Its measurements were 4.5cm x 8.5cm 1.2cm.

06/25/YYYY: Looking at the sacral area, the wound continues to improve. The measurements of the wound show that the length is 1.2 cm, the width is 0.5 cm, and the depth is 0.2 cm. It is clean. I do not think we can keep a wound VAC on it and it is covered with Santyl, Gentamicin and Hydrofera blue. The area is then covered with Hypafix. The right heel is then evaluated. There is a great deal of necrotic tissue noted on the heel. We have debrided this sharply with a 15 blade. There does not seem to be quite as much necrotic tissue as the last time. We covered the wound with Gentamicin and Santyl then covered the right heel with contact layer, 4x4s, Allevyn foam dressing and Kerlix. The measurements of the heel are 5cm x 4cmx 0.4cm. Finally the right hip was evaluated. There was necrotic tissue noted on it. This wound is debrided sharply with a 15 blade debriding most of the eschar off. We debrided it down into muscle in a couple of areas. Hemostasis was obtained with pressure. Santyl was used on this wound as well as Gentamicin, barrier drape, 4x4s as well as Hypafix dressing. The patient tolerated dissection well without any major complaints. Its measurements were 4.5cm x 8.5cm 1.2cm.Plan: Continue his IV antibiotics and wound care. He will keep off of his sacrum as well as his hip and he will keep those off loaded. He will return to see us in one week.

07/02/YYYY: Looking at the sacral area, the wound continues to improve. The measurements of the wound show that the length is 1.2 cm, the width is 0.5 cm, and the depth is 0.2 cm. It is clean. It is covered with Santyl, Gentamicin and Hydrofera blue. The area is then covered with Hypafix. The right heel is then evaluated. The necrotic tissue much less, it is again debrided -sharply with a 15 blade. There does not seem to be quite as much necrotic tissue as the last time. We covered tie wound with Gentamicin and Santyl then covered the right heel with contact layer, 4x4s, Allevyn foam dressing and Kerlix. The measurements of the heel are 5cm x 4cmx 0.4cm. Finally the right hip was evaluated. It looked much better and no debridement was done. Santyl was used on this wound as well as Gentamicin, barrier drape, 4x4s as well as Hypafix dressing. Its measurements were 4.7cm x 8.7cm 1.5cm.Plan: Keep his wounds clean; offload him off of the pressure sites as much as possible. He will continue using Gentamicin and Santyl. We will see him again next week.

07/08/YYYY: Sacral area: The wound continues to improve. It is almost healed. The measurements of the wound show that the length is 0.5 cm, the width is 0.2 cm, and the depth is 0.1 cm. It is clean. It is covered with Border foam. The right heel is then evaluated. The necrotic tissue much less. It is again debrided -sharply with a 15 blade. There does not seem to be quite as much necrotic tissue as the last time. We covered the wound with Santyl then covered the right heel with Hydrofera blue, 4x4s, Allevyn

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foam dressing and Kerlix. The measurements of the heel are 4cm x 4cmx 0.4cm. Finally the right hip was evaluated. It has deteriorated. Santyl Hydrofera blue, 4x4’s, ABD tape were used on this wound. Its measurements were 4.5cm x 8.0cm 1.0cm.

07/15/YYYY: His bone scan is negative for osteomyelitis of hip. The sacral wound continues to improve. It is healed. It is covered with Border foam. The right heel is then evaluated. The necrotic tissue much less. It is however larger than before. It is again debrided -sharply with a 15 blade. There does not seem to be quite as much necrotic tissue as the last time. We covered the wound with Santyl then covered the right heel with 4x4s, Allevyn foam dressing and Kerlix. The measurements of the heel are 5.3cm x 4.2cmx 0.5cm. Finally the right hip was evaluated. It has deteriorated. Santyl Hydrofera blue, 4x4’s, ABD tape were used on this wound. Its measurements were 5.5cm x 8.0cm 3.0cm. There is a great deal of eschar in the wound. I am going to take him to surgery to further debride it and to place a wound VAC. I have scheduled him for surgery this Thursday. I will place a wound VAC on right hip after excision.

06/03/YYYY-07/15/YYYY

Kim XX, NP-C

Cumulative progress notes:Continue Vancomycin every 36 hours for osteomyelitis. Right heel ulcer improved. On Seroquel, Namenda, Depakote and Donepezil. Continue Foley. Pain management. Hypokalemia. 40 meq KCl given. Vancomycin completed on 07/01/YYYY. Wound care done as ordered.

1 - 000035-1 - 000041

Medical Center07/18/YYYY Ted X,

M.D.Admission for hip wound debridement:History reviewed.Decubitus ulcer on right hip deteriorated in the past month. He is being admitted for debridement and wound VAC placement.

Diagnosis: Pressure ulcer to the right hip. Pressure ulcer to the right heel. Acute osteomyelitis of his right calcaneus. Psychosis, unspecified. Dementia. Anxiety disorder. Depressive disorder. Benign prostatic hypertrophy.



Discharge summary:Date of admission: 07/18/YYYY

Admitting and discharge diagnosis: Decubitus ulcer right hip-stage 4; Osteomyelitis of the right heel; Decubitus ulcer of the left sacral area.

Secondary diagnosis: Urinary tract infection.

Procedure: Debridement of right hip; Excision of greater trochanter; Wound VAC placement.

Consultation: None.

Hospital course: He underwent excision of the decubitus with excision of


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the greater trochanter. The wound was closed with a wound VAC. During the hospitalization he was noted to have a Urinary Tract Infection (UTI). Treatment was begun with Vancomycin. Cultures were taken and have grown out E. coli and Proteus mirabilis. Both were sensitive to Doxycycline. He will continue treatment with Doxycycline at the nursing home. He is discharged with the wound VAC in place. It will need to be changed Monday, Wednesday and Friday.

Condition: Stable.Patient disposition: Nursing home.Discharge medication(s): Doxycycline 100mg twice daily. Continue upon Discharge: Wound care therapy. Discharge instructions given to the nursing home.Patient was instructed to follow-up with physician: Ted C Scott MD, Friday. Patient had no IV access in place at time of discharge.

Nursing Home07/25/YYYY-08/19/YYYY

Kim XX, NP-C

Cumulative progress notes:Readmitted after hospitalization from hospital. Better appetite. Assist with all meals. Med pass thrice daily. Monitor. Start Narco for right surgical wound. On Doxycycline and Levaquin for osteomyelitis. Concern regarding oversedation due to pain medication. On Tylenol, Narco and Tramadol for pain control. Wound VAC biweekly replaced by Wound clinic. Hematuria on 08/12/YYYY. Check urine analysis – MRSA of right heel. Bactrim, Cefepime, Amikacin for 14 days.

1 - 000042-1 - 000051

07/25/YYYY-08/20/YYYY

Ted X, M.D.

Wound progress notes:07/25/YYYY: The sacral wound is healed. It is covered with Border foam. The right heel is then evaluated. The necrotic tissue much less. It is however larger than before and is wet. We covered the wound with Santyl, Gentamicin, Aquacel, 4x4’s, Allevyn, Kerlix tape. The measurements of the heel are 6.5cm x 4.5cmx 0.4cm. Finally the right hip was evaluated. It has deteriorated. The wound VAC has been removed. There is exudate within the wound. It is sharply debrided with a scalpel with removal of necrotic tissue. Sutures were removed in the base of the wound. The wound is dressed with Gentamicin Santyl, contact layer, white foam, black foam and wound vac. Its measurements were 7.5cm x 8.0cm 4.5cm.Plan: Keep his wounds clean; offload him off of the pressure sites as much as possible. He will continue using Gentamicin and Santyl. He will continue his wound VAC. He is to keep the wound dry.

07/29/YYYY: The right heel is evaluated. The necrotic tissue much worse. It is larger than before and is wet. We covered the wound with Santyl, Gentamicin, Aquacel, 4x4s, Allevyn, Kerlix tape. The measurements of the heel are 8.0cm x 6cmx 0.4cm. Finally the right hip was evaluated. It has improved. The wound VAC has been removed. The wound is dressed with Gentamicin, Santyl, contact layer, white foam, black foam and wound vac. Its measurements were 10.5cm x 8.5cm 4.0cm.Post-operative diagnosis: Non healing surgical wound. Pressure ulcer to left hip and right heel, osteomyelitis of right calcaneus.


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08/06/YYYY: The right heel is then evaluated. The necrotic tissue much worse. It is larger than before and is wet. I debrided eschar, devitalized tissue subcutaneous tissue and skin. Bleeding was controlled with pressure. We lost 0.5cc of blood. We covered the wound with Santyl, Gentamicin, Aquacel, 4x4’s, Allevyn, Kerlix, and tape. The measurements of the heel are 6.0cm x 6cmx 0.4cm. Finally the right hip was evaluated. It has improved. The wound VAC has been removed. The wound is dressed with Gentamicin, Santyl, contact layer, white foam, black foam and wound vac. Its measurements were 10.0cm x 7.0cm x 6.0cm.Plan: Keep his wounds clean; offload him off of the pressure sites as much as possible. He will continue using Gentamicin and Santyl. He will continue his wound VAC. He is to keep the wound dry. We have talked again with concerning the need to offload his heel.

08/13/YYYY: The right heel is then evaluated. The necrotic tissue much worse. It is larger than before and is wet. I think that this wound needs surgical debridernent and a wound VAC. We covered the wound with Santyl, Gentamicin, Aquacel, 4x4’s, Allevyn, Kerlix tape. The measurements of the heel are 6.0cm x 6cm x 0.4cm. Finally the right hip was evaluated. The wound is dressed with Gentamicin, Santyl, contact layer, white foam, black foam and wound vac. Its measurements were 10.0cm x 7.0cm x 6.0cm. I think that this wound is ready for a rotational flap.

08/20/YYYY: The sacral wound is healed. It is covered with Border foam. The right heel is then evaluated. The necrotic tissue much worse. It is larger than before and is wet. I think that this wound needs surgical debridement and a wound VAC. We covered the wound with Santyl, Gentamicin, Aquacel, 4x4’s, Allevyn, Kerlix tape. The measurements of the heel are 7.5cm x 5.5cmx 0.5cm. We sharply debrided the heel, removing eschar, fibrin, subcutaneous tissue and some skin. There was 0.3cc of blood loss. Finally the right hip was evaluated. The wound is dressed with Gentamicin, Santyl, contact layer, white foam, black foam and wound vac. Its measurements were 9.0cm x 6.0cm x 6.0cm. I think that this wound is ready for a rotational flap.Plan: Keep his wounds clean; offload him off of the pressure sites as much as possible. He will continue using Gentamicin and Santyl. He will continue his wound VAC. He is to keep the wound dry. We have talked again with concerning the need to offload his heel. I have talked to his son concerning surgery. We will schedule him for a rotational flap next week. At a different time I will debride his heel and place a wound VAC on it.


M.D.Admission for rotational flap on right hip and debridement of right heel:Admitting diagnoses: Decubitus ulcer of the right hip. Decubitus ulcer to the right heel. Acute osteomyelitis of his right calcaneus- treated. Psychosis, unspecified. Dementia. Anxiety disorder. Depressive disorder. Benign prostatic hypertrophy. Chronic respiratory failure.

2 - 000013-2 - 000014

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Plan: He is scheduled for a rotation flap to the right hip tomorrow. I will place his wound VAC over the flap. I will also debride his right heel.


Operative report for rotational flap to right hip and debridement of right heel:Pre and post-operative diagnoses: Chronic decubitus ulcer to the right hip. Chronic decubitus ulcer to the right heel.

Procedure: Rotational flap to the right hip. Excision of the greater trochanter of the right hip. Placement of a wound VAC. Debridement of his right heel.

Complications: None



Discharge summary:Admitting and discharge diagnosis: Chronic decubitus ulcer right hip. Secondary diagnosis: Decubitus ulcer right heel.

Procedure: Rotational flap to right hip; Ostectomy or the right hip; Wound VAC placement to incision.

Consultation: None.

Hospital course: Rotational flap was performed on 27th of August. A wound VAC was placed at the time of surgery and wound be continued until next week.Condition: Stable at discharge.Disposition: To nursing home.

Discharge medications: Seroquel, Potassium chloride, Norco, Omeprazole, Multivitamin, Namenda, Hydrochlorothiazide, Med pass, Tramadol, Tamsulosin hydrochloride, Tylenol, Vitamin C, Zinc sulphate, Ativan, Haloperidol, Aspirin, Aricept, Detrol LA, Depakote, Colace, Celexa, Finasteride, Doxycycline.Vancomycin 1000mg IV daily for 10 days. Check troughs and creatinine after each third dose. Continue the wound VAC and dressing changes on the heel.

Discharge instructions: Use port to infuse IV Vancomycin in the nursing home; Diet as tolerated; Bed rest; Keep wound VAC in place and keep pressure at 75mm of Hg. Wound care to heel three times weekly; Appointment at the wound clinic Tuesday 3rd September for wound VAC change; Continue pre hospitalization medications. Patient was instructed to follow-up with physician: Ted C Scott, M.D., 3 Sept YYYY.



Ted X, M.D.

Wound progress notes:09/03/YYYY: The right heel is then evaluated. The necrotic tissue much worse. It is larger than before and is wet. We covered the wound with Santyl, Gentamicin, Aquacel, 4x4’s, Allevyn, Kerlix tape. The measurements of the heel are 8.2cm x 6.0cm x 0.8cm. We sharply debrided

Medical Records 01 - 000056- Medical Records 01 -

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the heel, removing eschar, fibrin, subcutaneous tissue and some skin. There was 0.2cc of blood loss. Finally the right hip was evaluated. It has improved. The wound VAC was changed. The incision is healing. Some staples were removed. There is no necrotic tissue present. The wound VAC is replaced.Plan: Keep his wounds clean; offload him off of the pressure sites as much as possible. He will continue using Gentamicin and Santyl. He will continue his wound VAC. He is to keep the wound dry. We have talked again with concerning the need to offload his heel. I am going to talk to his son concerning a Below Knee Amputation (BKA). He is beginning to develop another ulcer on the foot. It is painful. It is not healing. I want to wait until the hip is better.

09/16/YYYY: The right heel is then evaluated. The necrotic tissue is better. It is covered with Santyl, Gentamicin, Aquacel, 4x4’s, Allevyn, Kerlix, tape. The measurements of the heel are 7.0cm x 5.0cm x 0.7cm. Finally the right hip was evaluated. It has improved. The wound VAC was changed. The incision is healing. There is a small area in the corner of the flap that is draining serous fluid. The wound VAC is replaced to remove any excess fluid. There are now pressure ulcers on the knees medially. The right one measures 4cm x 2.5cm x 0.3cm. The left one measures 2cm x 1.5cm. X 0.3cm. They are dressed with Santyl, 4x4’s and Kerlix.

000060


M.D.Admission for urosepsis and multiple decubitus ulcer:He is a patient of mine that I am following in the wound clinic for multiple pressure ulcers. He was transferred here to the Emergency Room for hypotension and was evaluated there. His initial blood pressure on admission to this Emergency Room was 90 systolic. He was evaluated. A urine evaluation showed numerous white cells and red cells and bacteria as well as leukocyte esterase at 500. He was therefore admitted with urosepsis. He is under care with me for evaluation of his ulcers.

Physical examination:Vital signs: My evaluation this morning shows him to be stable. His blood pressure is 133/54 at 7 am; temperature 97.1, pulse 68 and respirations are 18. His oxygen saturations 100%.Extremities: Rotational flap on the right hip with a dressing in place. He does have pressure ulcers on his knees as well as a large one on his right heel and a smaller one that is evaluated.

Impression: Urosepsis. Psychosis. Multiple decubitus ulcers.Plan: Treat his urosepsis and he was placed on Piperacillin (unsure dose) and Vancomycin 1 gram every day. I will continue his psychotic medicines and we will continue wound care.



Discharge summary:Date of admission: 09/17/20 13.

Admitting diagnosis: Sepsis secondary to urinary tract infection. Urinary

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tract infection secondary to chronic indwelling foley catheterDischarge diagnosis: Urosepsis.

Secondary diagnosis: Decubitus ulcers; bilateral inner knee pressure ulcers stage 3; Right heel pressure ulcer stage 4; Right foot pressure ulcer stage 4; Dementia; Schizophrenia; Anemia.

Procedure: None.Consultation: None.

Hospital course: He was placed on Piperacillin and responded immediately to therapy. He was treated for three days with IV antibiotics and then transferred back to his nursing home on oral antibiotics. Cultures were pending at the time of discharge.

Condition: Stable; disposition to nursing home.Discharge instructions: Cipro 500 mg twice daily. Resume diet. Resume wound care. To Wound Care center on Monday.

Records 01 - 000055


Kim XX, NP-C

Cumulative progress notes:MRSA of right heel. Vancomycin/Amikacin per Dr. Scott. Status posts right heel debridement and right hip flap. Right heel not healing. Possible amputation planned. Wound care by Wound Care clinic.

1 - 000052-1 - 000059


M.D.Admission for above knee amputation of right leg:He was transferred here to the have an Above Knee Amputation (AKA) of his right leg. We have been treating an ulcer on the right heel for several months. He developed osteomyelitis in the heel and was treated with a six weeks course of Vancomycin. The heel has not healed. He has developed other pressure ulcers on the foot and has now developed pressure ulcers between his knees. He is in constant pain with his heel. I have talked with his son concerning an amputation of the right foot. We are both in agreement that we need to proceed with an AKA amputation of the right leg.

Physical examination:Vital signs: His blood pressure is 133/54, temperature 97.1, pulse 68 and respirations are 18. His oxygen saturation is 100%.Extremities: Rotational flap on the right hip with a dressing in place. He does have pressure ulcers on his knees as well as a large one on his right heel and a smaller one on the lateral foot.

Impression: Non healing ulcers of the right leg. Pressure ulcers of the right heel and foot. Pressure ulcers of the medial knees. Dementia. Psychosis.

Plan: He is admitted for an AKA of the right leg.



Operative report for above knee amputation:Pre and post-operative diagnosis: Rest pain right leg with chronic open

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wounds and osteomyelitis of the calcaneus.

Procedure: Above-the-knee amputation.

Complications: None.

000061



Admitting and discharge diagnosis: Chronic open wounds to the right leg; Arteriosclerotic Vascular Disease (ASVD) with rest pain of the right leg.

Secondary diagnosis: Schizophrenia.Procedure: AKA of the right leg.Consultation: None.

Hospital course: He was admitted on 09/30/013 and underwent an AKA. He was followed with IV antibiotics. His postoperative course was uneventful. He is discharged today to be followed in wound clinic.Condition: Stable.Patient disposition: Nursing home.Continue upon discharge: Physical therapy. Diet: Regular; Activity: bed rest; Appointment at the wound clinic tomorrow.

2 - 000017


Ted X, M.D.

Cumulative wound progress notes:Wound Care was given on 10/07/YYYY, 10/15/YYYY, 10/22/YYYY, 10/29/YYYY and 11/05/YYYYThe sacral wound is healed. It is covered with bordered foam. The AKA is evaluated. The wound is healthy. The left knee is evaluated. Necrotic eschar is excised with a scalpel. I removed necrotic tissue, eschar, fibrin, skin and subcutaneous tissue. The coccyx is evaluated. Most of the area is just erythema. No debridement was done here. The right hip was dressed with Silvasorb, Hydrofera blue and foam dressing. The left knee and foot were dressed with Santyl 4x4’s foam dressing and pillows between knees at all times, The coccyx was dressed with Silvasorb, foam dressing and OL. The AKA was not dressed.Plan: Keep his wounds clean; offload him off of the pressure sites as much as possible. He will continue using Gentamicin and Santyl. He will continue his wound vac. He is to keep the wound dry. We have talked again with concerning the need to offload his heel. I think we must take him to operating room to clean up his wounds.


05/10/YYYY-10/30/YYYY

Nursing Home

Medical Center

Other related records:Plan of care (Ref 13 - 000019-13 - 000020, 3 - 000026-4 - 000027, 13 - 000050-13 - 000058, 13 - 000073-13 - 000080, 13 - 000062-13 - 000068, 13 - 000015-13 - 000018), nurse notes (Ref 1 - 000016-1 - 000018, 1 - 000029, 11 - 000017, 1 - 000060-1 - 000061, 1 - 000033, 1 - 000019-1 - 000026, 13 - 000049, 13 - 000069, 10 - 000015-10 - 000020, 1 - 000035), occupational therapy notes (Ref 13 - 000053-13 - 000054, 13 - 000001-13 - 000011), physical therapy records (Ref 13 - 000059-13 - 000061), speech therapy notes

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(Ref 13 - 000045-13 - 000048, 13 - 000021-13 - 000044, 13 - 000070-13 - 000072), orders (Ref 5 - 000103-6 - 000004, 6 - 000011-6 - 000051, 5 - 000093-5 - 000094, 2 - 000019, 6 - 000073-7 - 000031, 6 - 000060-6 - 000071, 2 - 000020-2 - 000021), nursing assessments (Ref 10 - 000001-10 - 000048, 13 - 000081-13 - 000106, 14 - 000023-14 - 000028, 8 - 000093-9 - 000050, 1 - 000028, 2 - 000024, 2 - 000030-2 - 000032, Medical Records 02 - 000011- Medical Records 02 - 000043, 6 - 000007-6 - 000010, 10 - 000049-11 - 000016, 13 - 000110-13 - 000117, 11 - 000018-11 - 000075, 9 - 000051-9 - 000059, 6 - 000052-6 - 000059, 11 - 000076, 11 - 000077-11 - 000094, 14 - 000003-14 - 000022, 6 - 000072, 11 - 000095-12 - 000005, 12 - 000006-12 - 000049, 12 - 000050-12 - 000057, 14 - 000029-14 - 000040, 8 - 000001-8 - 000080, 5 - 000096-5 - 000102), treatment sheets (Ref 4 - 000031-5 - 000092, 8 - 000081-8 - 000089), labs (Ref 14 - 000043-14 - 000095, 15 - 000099-15 - 000113, 14 - 000097, 14 - 000099-14 - 000101, 14 - 000102-15 - 000046, 15 - 000051-15 - 000098), minimum data set (Ref 2 - 000033-3 - 000025), culture reports (Ref 14 - 000041-14 - 000042, 14 - 000098), X-ray reports (Ref 14 - 000096, 15 - 000047)



M.D.Admission for debridement of sacrum and knee:He is a patient of mine that I am following in the wound clinic for multiple pressure ulcers. He was transferred here to the have revision of a pressure ulcer of the coccyx and left knee as well as placement of a suprapubic tube for urinary incontinence and recurrent UTI’s.

Physical examination:Vital signs: His blood pressure is 133/54, temperature 97.1, pulse 68 and respirations are 18. His oxygen saturations are 100%.Extremities: AKA on the right. Large sacral decubitus stage 4. Pressure ulcer on the left knee medially.Neurologic: His motor and sensory function is intact. His level of consciousness changes.

Impression: Non healing ulcers of the right leg. Pressure ulcers of the right heel and foot. Pressure ulcers of the medial knees. Dementia. Psychosis.

Plan: He is admitted for debridement of his sacrum and knee. He is volume depleted and anemic. Fluid is given as well as blood prior to surgery.



Operative report for excision of eschar from sacrum and debridement of left knee:Pre and post-operative diagnosis: Full thickness eschar to sacrum and left knee.

Procedure: Excision of eschar from sacrum and left knee with debridement into the fascia.

Complications: None




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Final diagnoses: Pressure ulcer to the sacrum. Pressure ulcer to the left knee. Dementia. Psychosis. Acute urinary tract infection.

Operations: Debridement of ulcers with placement of wound VAC.

Narrative summary: Patient is resident of Nursing Home who has been a patient of mine for several months because of multiple pressure ulcers, was transferred here for revision of a pressure ulcer on his coccyx as well as his left knee. He had these ulcers for several weeks, and they had become progressively worse, primarily because of a urinary incontinence. When he was transferred here, he was begun on Vancomycin for possible urinary tract infection. The urine was cultured. His wounds were debrided, and a wound VAC was placed. Foley catheter was placed and left in place, primarily because of urinary incontinence with contamination of the sacral area. I was going to put in a suprapubic tube to help divert his urine because he was having problems pulling out the Foley catheters before.

However, we elected to have him wear pajamas that tried to hide the tubing so he could not pull them out. Urine cultures did grow out Enterococcus, which is sensitive to Cefepime, and his antibiotics were changed to Cefepime. His wound VAC was changed prior to discharge, and we did have his own wound VAC that we could use. We transferred him back to for care there. I would be following him in the Wound Care Clinic. He would continue his home medications plus the Cefepime 1 gram every 12 hours for 10 days.

000070

*Reviewer’s comments: Further records are not available to assess the status of wound.

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