HISTORY AND PHYSICAL PATIENTt MR #: DISCHARGE DATE: ADMISSION DATE: 02/ 04/2003 Job P/T: L LOCATION: PCfT 320D CHIEF COMPLAINT : Mental statue change. HISTORY OF PRESENT ILLNS39: The. patient is a 45 - year - old^,obeae femme :with a history of chronic : ventilatory dependency and steroid d^peadeacy, carbea dioxide retainer,. chronic obstructive pulmor:ary . dicaease , history of diabetes mellitue ;. óa:^in,sulia and oral hyperglycemic .$geá£s, questionable bipolar disorder , hiátá^y"of anxiety and left foot^c+erTEulitis . and anemia - aecretioa : She.is , noted to. have; chaage in with trouble with mental status and wis. referred to the Emergencg Ra^.fi^r eváluation. ° In the Emergency Róáñi ,.; tie patient had a pS. of 7.°2.9^" caY^on.:dioxide ° partial pressure S'S^,^ oxygen - pártial pressure 71; btcárbonates of 40 on 40$ ° _ ° FI02. ° ° ' ° PAST HISTORY : ó F1 . As. aliov$.' ' PAST SIIRGTCA7. HISTÓÁ3C: Thé patient leas a trach^óstbmy• ánd seta by Mouth. MEDICATIONS : Combiden^ ,, Valium, Lasix , prednisoae ;•• Cólace, Protonix, Neuroatin 300 millgré^má p.o. q. am .and Prozac 40 milligrams p?:o, q.d . 1200 p . o. q. at bédtims ;' Glípizida 7.5 milligrams p.:o+ cÍ.d :; Glucophage XS, 2 grams p.o . g. 5 .pm and Lántus insulin 30 units subcutaneous q. at The patient wás also receiving Biaxin and Ceftin at the nursing bedtime . home, it was day 3 of both antibiotics. ALLERGIES : NO KNOWN DRUG ALLERGIES. REVIEW OF SYSTEMS: The patient has a complaint of left foot pain and left She denies any ahortaesa of breath. hip pain . PHYSICAL EXAMINATION: VITAL SIGNS : Temperature Blood pressure 136J7S, pulse 96 and respirations 16. Pupils equal , round, reactive to light 3114 HEENTs __,. Ai%icteric aclerae . accommodation . Normocephalic , átraumát^ c3`amfum: NSCR : noted. Supple., no jugular venous diatantion noted . CHEST : Reveals air entry bilaterally. HEART : Reveals distant " heart sounds . No lymph nodes are Otherwise unremarkable. HISTORY AND PHYSICAL PATIENT: MR #: LOCATION: PCU ABDOMEN : Markedly obese with hyperreaonant bowel sounds . nondiatended. . NonEender, RECTAL: Unable to do a rectal evaluation and evaluate for any coccyx decubitus ulcers at this time. ,. EXTREMITI83 : Leeft foot with a small ulcer whioh has ';a dry .. dressing ón, and complaint of° le-ft hip pai:i on palpation . . Pulses are 2+ bilaterally. . 1" ^ .1. LABORATORY DATAe •':., Her admission laboratory examinatioá^ : revealed WBC . 21, 000, H&F3 , 14.•x/46 á9, xrlatelet count 382 , OOO,.^ ebdium wad 145, potassium 5.3, chloride 4^k,+.' bicarbonates 42, blood urea sütrcigea/ creatinine 35/1.0, glucose 181, ABT,f^1tiT-79/51 . Alkaline phoephatgs'e,1,15. Electrocardiogram.. o. revealed sinus- tgchycardia , otherwise •nonspecifa .¢or..aay ischemia. ChesC:, o' o' x-ray is peadiñg ;, but, possible infiltrate is aostiad on ; the,Emergency Room . 0 note. 0 0 0 ADMITTING DIAGNOSIS: 0 . ' N 1. MSNTAL STATU3 ` CHAATGE. 2.^HISTORY OF CHROÑIC OBSTRUCTIVE FULMONARY DI3EF3$ WITH . CARBON DIOXIDE PARTIAL PRE3SLTRÉ ^QF : 85. PLAN :. The patient now neurologically is stable, will go ahead and continue ventilatory support and monitor arterial :blood geese . We will q. 6 hours. also treat her with Zosyn 3.3 75 grams intraveaous .piggybaek Obtain - blood cultures , +^ ^- get a left foot x-ray sad left hip x-ray We c6311 continue her current to rule out any fractures or osteomyelitis . medication and hold potassium secondary to elevated potassium on admisaian . We will repeat her SMA7 sad CBC in the morning and reevaluate the patient after this is done. Will continue Lasix at this time and the •patient will be isolated for history of methicillia resistant Staphylococcus aureus , VRE, añd C-difficile. DP/ab -^:-tT2-f B4-f2003- -8-x39 ^ T= 02/OS /2D03 7sá.9 A cc: PAGE 2 RIIN DATES 08/02/06 RUN TZl^^ 1758 Summary Discharge Report ••we++ar :• ww wr:wer ^ we ^ weDI8C8AEGE BDlMARY - DO NOT bESTRDY^wwrrww • wwww ^ wwwwe + e+w.www áays. Date Tlme _> =a _> a> 8F SP BF BF 1 80SINOPBIL k 100 BF TCC -_--_-----APR 6 ------__-- .-•------- APR 3 --------'-. Date Time 1710 0655 ^ UNR ^ 0337 Reference Units (4.8-10 . 8) Ous^3 p4s'6 (4.7-6.1 ) ^ (14-18) g/dL (42-52) f (80-94) fL (27-31) p9 (33-37) g/8L (11.5-14.5) k (130-400) mm^3 (7.4-10.4) fL W8C RBC 8GB ACT V .7[ MCBC RDW PLT MFV COMMENT (n) ($) (P) _> _> _> _> _^ _> k k } } 40 LYMPB MACROPSAG 8 NESOT88L2 1 OTHRR (C) _> _> _> v> = _> _> _> sa _> _> APR 5 0515 Reference Units APR 6 0520 '--------APR 7 ------_--1220 0429 AOTOMATSD DIPF RSQUIR83 !0)IFF VERIFICATION. MDZPF TO FOLLOW. At7TOMATBD RIFF RSQIIIR89 4IDIPF VERIFICATION. pIDIFF TO FOLLOW. ADTOMATSD DIPF 1t8QUIR8S MDIFF VERIFICATION. MDIFF TO FOLLOW. f NBUTROPSIL k LYMPRS k MON09 k 80SINOPHIL k SASOPHIL89 ABSOLU173 NSD ^^^^^ as^YS^ t0.9 *L 2.4 0.3 ^;us 64 (42.2-75.2) 4 (2o.s-sl.i) + (1.7-9.3) 4 (0-6) & (0-2) ^ tntn^3 (1.4-5.5) (O.S-0.6 ) pytt^3 (0.0.-0.2) mm^3 (42-75) & (D-3} (20-51) ;P,at ed^:^^_ .... SURGICAL PATHOLOGY REPORT VAME: SURGICAL ^: LOCATION: PCU AGE: 56 SEX : M ROOM : 224-01 DATB COLLECTED : D3/23 / 04 03/23/04 DATE RECEIVED .: ACCT #: MED REC #: SU9MITTING PHYSICIAN: ATTHNDING PHYSICIAN: OTHER PHYSICIAN: Tisaws r A. Liver, NOS - CT GUIDED NEEDLE BIOPSY Cliaical History ,PRS-OPERATIVE DIAGNOSIS : 3 cm: hepa[ Sc lesion POST -OPERATIVE DIAGNOSIS : Rbceas vs Tumor va Infarct OPERATION: CT guided biopsy CLINICAL HISTORY : 56 yo. with hepatic lesion arrera HINAL DIACSiO8I8 + rr sere ^Lr+a.aAlt o3/ 2a/oa 2226> Liver (CT-guided needle core biapey): - Chronic hepatic abscess , organising. - No tumor eeen. - No amoeba or other parasites eeen. - No viral inclusion seen. - No granulomata seen. - Levels are examined. CPT Code: 88305 Primary PatholoQlst: Gross Daaeriptioa <LAB.BAH 03 / 23/04 2131> Specimen ie received in formalin labeled with the patient's name, CT-guided biopsies and.conaieta of multiple cylindrical cores of taasllahgray and white tissue ranging in length from 0.5 to 0.8 cm, averaging The specimen ie filtered and exitirely submitted ixi X0.1 cm in diameter . one block. Dictated bvr PRINTED : 1016104 FORM APPROVED OMB N0 . D93 -0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES STATEMENT OF OEFICIENGES 1 PROVDERfSIJPPIJERICLIA I ^ 2 AMA-TIPLE CANSTRUCT(ON ^I^^^^Y A. BUILDING 01 • MAIN BUILDNG 01 H.7MNG 7128104 STREET ADDRESS, CrrY, STATE, 21P Gx1E NAME OF PROVIDER OR SUPPLIER SU ATEMENT FDEF tENCiES EACN DEFIGENCY MUST BE PRE E BY FULL K 062 Continued Prom page 5 fi d- At least 30% of the s dnkler heads b PREFIX PROVIDER'S PLAN OF CORRECTION K O62 throw hout the bu(Idin s'A' &'B' exhibited Tustin end fined conditions andlor showed accumulation of excessive dust int and/or rime and leces of lactic ba s. The exam les include but are not limited to residents cloth srora a room oMIDe of the maintenance director hone cables room trash chute dischar a room, in the residents rooms and the corridors hallwa on the nursin units. o- Adhesive to es and laces of lasge matedals were noted wre ed around/ fled to ri us s 'nkler I es in the laund foldin roo an Interview at that tim n to ee in the area said that those are the r mn nts of the decorative articles hen ed Burin a birthda a amen ed in that room. f- n were f t e s rinkler i e in the trash chute disch a room in buildin '13'. -The s rlnkler i in venous bcations throw howl the basement area exhibited hea encrustation of the cello slot and were noted rocs rusted underneath the la ers of the slot. The maintenance su eNisor said that the facilit is wnsidenn a Ian to overhaul the old s dnkler i e s stem. h-Electdc and as lines of the washin machines n rlineswere bserved tied u to and hun on the s nnkler ea In 5 location In he m . -The buildin is artial ed with the automatic exGn uishin s stem. A review of the faciti maintenance records and interview with the Director of maintenance and su ervisor of mainten nce could not confirm that the s nnkler i e s stem au es have been tested/calibrated or replaced in the past 5 years. FORM CMS^2567(02A9¡Prehour Vartians Obaokle Event lD: YuRaG2t If continueBon sheet Pape B 0111 PRINTED: 10/6104 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES ENTEe CFRt11(!F. STATEMENT OF DEFICIENCIES ^1 ^^^^ ¡X2 MULTIPLE CONSTRUCTION X7 PROVIDER I3UPPLIER,CW A. BUNAING 01 • MAIN aUILDOJG 01 712 10{ NAME OF PROVIDER OR SlN'PLIER STREET ADDRESS , CfTV, STATE, ZIP CODE 1 (XIj ID NI SUMMARY STATEMENT OF DEFICIENCIES RECEED R 1 PROYIDER' 9 PLAN OF CORRECTIDN IN CROSSREFERENCED E R U (x5) C AEIIDN K 062 K 062 Continued From page 6 2.tr The facll' retards did not indicate that the s rinkler i in Internal obstruction Invest atbn has been conducted N accordance with NFPA 25. T f I n n had no rewllection K the internal ins action of the sprinkler piping had been conducted, in the past 5 A review of the faeili s records at that time revealed that the 5- ar s rinkler s em test report was net available. 71I.2(af (11 KQ64 K 064 NFPA 1 7 IFE SAFETY TAN ^^ Podable fire extin uishers are rovided in all health care occu ancles In accordance with 9.24.1. 79.3.5.6, 9.7.4 . 1, NFPA 70 I This STANDARD is not met as evidenced b This requirement is not Met as evidenced by: Based on observation on 07/22121m4 it was t Toed the the tat I Tied to ens All ortable fire extin ers in The f r installed so that the to of the fire exti wisher is no[ morethan 5feet 60i s ebovet oor This w s found on fi t f five reside on; 'rn the twOdinge A' and '13' , as well as, In the basement area. The findings Include: FORM CM&2587(0299) Pr¢vious Vwaiane 0óadele I Event lD: nRSasr If conlinue9an sAaet Paye 7 of t t PRINtED: Ta6ro4 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES ru STATEMFM OF DEFICIENCIES 1 pR OtaVSUPPUERlCUA IDENTIFICATION NUMBER {x310ATE SURVEY (7(2) MULTIPLE CONSTRUCTION ABUL[NNG 01-MAIN BUILDING 01 8. WING NAME Of PROVxIEROR SUPPLIER Xd ID 7128104 STREET ADDRESS , CRY, STATE, ZIP CODE SUMMARY STATEMENT OF DEFICIENCIES 10 PROYWER'S FLAN OF CORRECTION (EAGN CORRECTOE ACTION SHOULD eE P61 ^iETKT1 I NT K 084 K 064 Continued From page 7 'I• n 7l2272004, itwasotuervedthat rtabla fire extin uishers are installed on the walls on all fhe floors kitchen and basement areas. When measured the facili s maintenance su arvisor Burin the life safe tour the ma on of these fire Dxiin ulshers was mounted on the Is with their o mos ortian at " t ^ above the floor In Ileu of the re ulrad 60 inches. Exam les Include but are not limited to the corcidors on the 1st throw h 5th floors of the buildin s'A" and B% in the North and South staircases, basement areas and in h eical therapy/ occupational therapy section. li-The ortable fire extin uisher5 in the followin bcations in the 'B' buildin were mounted with their t0 ortion at 64 "-70" hi h from floor. on the 5th floor near the trainin toilet near nurse station and near north taircase on the 4th Boor near room 406 in the dinin room near south end north at i on the 2nd floor near the n station and on the first floor near room 106, and In the dining room. i-T e w I un oAabla fire ezfin fishers in he ends of the oorrido In ximi f h se exR doors on fist throw h 5th floors in bu8dln W to moat rtian of the eMin wisher was 5'-9' 5'-t ^', in excess of the re wired 60 inches from the floor. N- One rYaWe fire extin wisher C02 a in the elevator machine room in buildin 'A' was noted stored directly on the floor. LSC 18.3.5.6, 19.3.5.6, NFPA 10, 711.2 (a)(1) FORM CMS^R567(02.09) Prariale VersiOna OOSOIete EwM10: Wap02t If continuelion sheet Paae 8 of 11 9 (Pages 33 to 36) ^- February 8, 2005 THE WITNESS: Is that hQe? Here 1 2 it is. MS. It would be the last 3 3 6 pages. 5 Okay, yes, I love it in front of me now. Q, SY h1R. :That's something that you have airudy reviewed. A. Correct. Q. Yü? A. Yes. Q. Did you make any determination as to whether you disagreed with the three items, A, B and C listed in Paragraph 3 by 6 7 8 9 10 1I 12 13 t4 t5 16 17 l8 19 20 21 22 23 24 25 A. Xes, I agree with those critteisms. Q. Were there also optaions that you have ruched lathe matter? A. Yes. ^ Q. Item Nnmber A, 3A, says the ataadard of care required the phyilelaa to 4 5 6 7 8 9 10 11 12 13 14 complgwith that A. No. Q. Would those opialoas that you have just given methen be fn addition to chase that you have itemized oa Page 2 of the letter in your handwritten aotatioaa coaceraing the traaafusion, the diseont [nuauce of Iategrilia and the fact no c.b .c was taken prior to 2324? A. I think tbat Item C in terms of the surgical rnasult is in addidon to what I have listed is my haadsvrittea notes . llama A and B are basically arore generte references to what I'm referring [o is terms of my 16 17. 18 19 Items 1 , 2 and 3. Q. All right. So Ia terms of Items 3(a) sad 3(b), if we were to talk about your apec[fics in those, we wonld go back to the list, Items I , 2 and 3 oa PAge 2 of the letter, those would be your critieistm of Dr. 21 22 23 24 25 patient's hypotension in a timely fashion . Is that an opinion that you held? ^ A. Yü. Q. Did Dr. _ ataadard of care? 15 20 evaluate the Case of the Page 35 ^ Page 33 I 2 A. Yea. Q. And is addition to those Items 1, 2 sad 3, you said yon would add 3(c) to Page.3ó Page 3d 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Q. And do you believe that Dr. acted in aecordapre with the'ataadard of care fa evaluation of the cause of the patient 's hypotension in s timely fashion ? 'A. No. Q. You believe that be violated the standard of can fn that regard? A. Yes. Q. Aad Ilem B says that the standard of care requires A physician to provide appropriate [resimeat for the patient's ^ hypotension Does that ín your opiniotl constitute as accurate statement of the standard of care? A.' Yü. Q. Did Dr. comply with [hat ataadard of care iu applying appropriate treatment for thepatieat's hypotension? A. No. Q. ^ Item 3(c) says that the standard o care requtrü at a m y surg cZT consult be obtained . Does [hat accurately _ _ _ state what you believe to be the applicable ataadard of care? A. Yü. abtafa a timely surgical consult, right? A. Correct. Q. Would you add anything else then to your erificitmi otDr. büidü 1 2 3 4 thosefonritems? 5 A. Yes. 6 Q. What? 7 A. Failure to obta(n the appropriate 8 specialty surgical aroasult . Dr. : is 9 a general surgeon . The appropriate . 10 consultation chould here bees with a vascular I1 aurgeoa since this was a vascular catastrophe. 12 Q• Aaythiag else? 13 A. Yü. The treatment of Dr. 14 should - have included oagoiag bedside 15 evaluation and treatment of the patient nntll 16 such time that she was stable and her 17 conditloa had been resolved in a saHsfaetory 18 ^ maatler, and it appears to me sow from review 19 of [he tes [ imoay of the nurses, as well as 20 71 - -- YBr:: _ actually left the patieat . even though she was 22 still is an unstable aituaaoa in [he 23 iategsive care unit. 24 25' Q. Yonr basis for that you say is the NaRonwide Scheduling lA (Pages 37 to 40) -February 8, 2005 4 $ 6 g^ 37 deposition testimony o[ the nurses and ? A. And the medical records which iúdicate that verbal orders were given which would mean that he was sot on site at tbat time. ^ 4 $ 6 7 8 Q. When you say on site, what do you mean by on site? 7 8 . abdominal ultrasound Stan should Lave been done and should Lave been ordered immediatey 9 10 Il oatt the severe hypatenaton developed requiring pressor support. Q.. When was that? A. 2142 is the fiat entry is the cridttl tare flow sheet that indicates that she blood pressure Is at shock levels. The blood pressure was 58 over 27 ai 2142. Q. So you are saying tbat Dr. ! should have ordered the CT scan at 2142? A. Correct. Q. Why would be do that at 2142? A. Because you Lave a patient in stock and your number one diagnosis is a padent wbo bad as angiogram sad who Las .received sadcoagntants and sad-platelet agents is hemorrhaglcshock and you need to 1. 2 3 9 10 11 12 13 I4 1$ 16 17 18 19 20 21 22 23 24 2$ Page 79 1 2 3 A. Site, ri-t-e, meaning fa the intensive care unit at the patient 's bedside . Q. Well, those are two different lacadoas. Do you mean apecificaóy tight st the patient' s bedside or do you fuses vrithin the urdíae care unit ftaelf, say 50 feet from the. patient In a different room or fn his office or where do yon mno? A. A[ the bedside. ^ Q. And ís it your testimony that you believe -that Dr. should Lave remained at the bedside of this padent from ffie completion of the catheterizatioa procedure until A. Until the patient was stabilized and until the eoadidon wu resolved sad fully evaluated anti treated. 12 13 I4 15 16 ^ 17 18 19 20 21 22 23 24 25 ^ Pogo 36 ^ 1 2 3 4 $ 6 7 8 9 10 lI 1Z 13 14 1$ 16 17 18 19 _20 _ 2t 2Z 23 24 2$ Q. Do you have ioformadoo is the depoaidon testimony that tells you witbin ^ [hat dare period, return of the padent to ^ ^ the care unit, cardiac care unit after the catheterization procedure until the padent was taken to the CT scan , between those time periods Low mucó of [hat time Dr.' spent In tht patient 's room? A. No, I don't have that íaformadon . Q. Let's go back for a moment to the affidavit of merit of Dr. ^ that you .said you reviewed sad that yon agree with and I want to look at 3 (s). It says the standard of care required tLe physician to evaluate the tease of the plaindlPa hypotension on Stptember 29, 2002, in a timely fashion, and you have tesdffed you think Dr. ' breached that standard of care, correct? A. _ __Correct. - Q. Tdlmewhatyoubelie4eDr.-_______.. did or did sot do that resulted.in... thebreach of that standard of care .. A. Okay. As I mentioned before, in my handwritten Dotes that we have discussed I indicated the failure to repeat the ab.c, the blood count, to determine if tbere was evidence of bleeding . There was as repeat blood count until two hours later or almost two hours Ister. Aad as far as the evatuadon of the hypotension , a GT scan or 1 2 3 4 $ 6 7 8 9 10 S1 12 13 14 Page 40 identify the source sad location of the hemorrhage and to confirm thae so that appropriate lntervendona could 6e undertaken. Q. Aoytbing else under that 3(e)? We talked about ao repeat blood count , CT, scan wasn't ordered immediately at 2142. A. And I also mentioned, maybe you : didn 't hear nx say it, that as alternative sa a way of diagaoaing the prYSeaee of a retraperitoaeal óemorrhage would be ao abdominal ultrasound. Q. Io lieu of a CT scan? A. In lieu of or in andcipadoo of a CT scan. Ao abdominal ultrasound can be performed a[ We bedside , CI'seaa obviously 1$ - can' t be done at the beds[de, you Lave to ]6 transport thepatient to radiology. 17 I8 Q. In your opinion would an abdominal ultrasound performed st the bedside reflect 19 the existence of a retroperitoneal bleed? 20 ^#. ^]es. -- - -21 22 ___ - ., . ¢ ._ u á retrnperítoneal bleed. had.beea suspected at 2142 or de[ermlaed at 2142, what 23 treatrotoi should have been initlattd at that 24 time? 2$ Nationwide Scheduling üL^MAL WOU^? / PRESSt^yRE SORE FLOW SHEET STAGES: .. Locate and n ber dermai,woúnd! pressure aór^on Tigures.' Assess ánd dboument befoMr e$ch lesion at least every] 7 days and ^ m. Doownen! treálment •plan c^n Tr eatment ' Reoold. ^ ^ ^ i i . Ootwmerd int^rventiorls orb Pat^eM Care Fk>Mr Sheet t,_ fitR ,?ye3^46 078 Q4/26/1447. ^.,^.: c. r arc cc ^ MEU fl At Risk - follow Stage I preverRive measures I Reddened area 11 Btiáter, skin break 111 Skin breák exposing subcutaneous tissue t111fStllé trnrin ^onTlori i rye ^ R, I, II, III, N i 9P pk. plMJred s . aloiyft i s = esehar ^ Slm In GYn ^ eero^+g^ uineous P u^PWU^ ^^ Idar Y ^ yes Nino 111a11rIIA^fMI t] Sulrounáng e=rgne ^ or ska In qn 1 ^^^ y. Yes I ^n. NO 3eds6 mdtrasses¡. (^ ^ ^ _^ E 3 é'r order M. ttAD ceder '• else SlpnaNf9lTIilA lralNCeae 89r ❑ C]UOOOC71 ❑ 05/24/2005