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IN RE: VIOLETTE ROBErTS an Alleged Innapanitated I I Person I I I I IN THE COURT OF COMMON PLEAS OF CUMBERLAND CCUNTY, PENNSYLVANIA ORP~ANS' COURT DIVISION NO. 21-96-148 CITATION WE COMMAND, you that laying aside all business and exnuses whatsoever, you be and appear in your proper person before the Honorable Judges of the Common Pleas Court, orphans I Court Division at a session of the said Court there to be held, for the County of Cumberland to show nause why they should not be appointed emergency guardians of her person for the purpose of nonsenting to the admission of Violette Roberts to Cumberland Crossings Nursing Home, and to show nause why Finannial Trust Servines Company should not be appointed emergenny guardian of her estate, with the emergenny guardianship to be in effent with respect to the guardianship of the person for a period of seventy-two (72) hours from the date of this noures denree and with respect to the guardianship of the estate for a period of thirty (30) days from the date of this nourt's denree. Forty-eight (48) hour notine of hearing on this petition is to be given to Violette Roberts,the alleged innapacitated person, with hearing on the same to be held Feb. 20, 1996 at 2:30 P.M. o'nlock, Room 1, Cumberland County Courthouse, pennsylvania. witness my hand and offinial seal of offine at Carlisle, pennsylvania this 16th day of February, 1996. VIOLETIE ROBERTS, an Alleged Incapacitated Person : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS COURT DIVISION In Re: : NO, 96- Ciyil Tenn PETITION FOR THE APPOINTMENT OF EMERGENCY GUARDIAN OF THE ESTATE AND PERSON IN ACCORDANCE WITH 20 PA. CONS. STAT. ~5513 TO THE HONORABLE, THE JUDGES OF THE SAID COURT: The petition of Claudia Dayis and Gregg Martin respectfully represent that: 1. Petitioners are Claudia Dayis, an adult indiyidual of 2819 Kingsridge, Quincy Illinois, and Gregg Martin, an adult indiyidual of 8000 Steven's Mill Road, Matthews, North Carolina. Petitioners are the daughter and son of the alleged incapacitated person 2. The alleged incapacitated person is Violet Roberts, born on December 4, 1920. She is 75 years of age and resides in an independent liYing cottage at Cumberland Crossings retirement homes, South Middleton Township, Cumberland County, Pennsylvania. Her mailing address is 85 Schimmel Way, Carlisle, Pennsylyania 17013 3. The Petitioners haveinyestigated the alleged incapacitated person's background, and has found the next of kin to be themselyes, her natural daughter and son. The alleged incapacitated person also has two step children, neither of which were adopted by her. 4. The medical condition of the alleged incapacitated person is believed to be delusional paranoia. Petitioners are aware that the alleged incapacitated person has been prescribed medication for her condition and on at least one prior occasion was involuntarily committed to the Carlisle Hospital for treatment of that condition, 5. The alleged incapacitated person now requires skilled care and should now be remoYed from the independentliYing COllage to a nursing facility where she will receive custodial care and regular medication to ayoid irreparable physical deterioration and damage to her health. 6. Petitioners desire to have the alleged incapacitated person admitted to the Cumberland Crossings Nursing Home but the alleged incapacitated person has indicated an unwillingness to voluntarily cooperate in this transfer. The Nursing Home will not admit the alleged incapacitated person without the consent of a legally appointed guardian, 7. Because of the seyerity of her mental condition. the alleged incapacitated person lacks the capacity to makc or communicate any responsible decisions concerning her person or estate and. eyen with the assistance of other persons or services would not be able to participate in the making of any decisions concerning her person. 8. Petitioners are not aware that the alleged incapacitated person signed any powers of attorney or adyanced health care directives or in ;my other way designated anyone to serve as her agent oyer any of her personal affairs or as her surrogate oyer her medical care. or that she designated in writing her wishes with regard to health care. including the use or refusal of life- sustaining ueatment. 9. As the alleged incapacitated person is unable to adequately care for herself. as there are no known powers of attorney or adyanced health care directiyes executed by the incapacitated person. and as petitioners are the alleged incapacitated person's next-of-kin. there are no less reslrictiye alternatiyes ayailable other than the appointment of an emergency guardian. 10. The alleged incapacitated person was not a member of the Armed Services of the United States and is not receiving benefits from the United States Veteran's Administration, 11. The proposed emergency guardians of the person are your Petitioners. The proposed guardians' consents to serye as guardians of the person are attached to the Petition for' Adjudication of Incapacity. filed contemporaneously herewith. 12. The proposed emergency guardians have no interest adyerse to the alleged incapacitated person. 13. No other guardian has been appointed for the person of the alleged incapacitated person. 14. As the alleged incapacitated person has in the past shown an inability to adequately care for herself resulting in her involuntary commitment and as she recently left the area without prior notification to others. possibly being the victim of oyerreaching. there is the need for immediate consent to be given to place her in a nursing home so that her care may be properly supervised. 15. Due to the emergency nature of these circumstances, it is requested that the court waive the requirement that twenty (20) days notice of this proceeding be given to the alleged incapacitated and that instead only forty-eight (48) hours notice be giyen to her along with service of the citation. 16. No other court has ever assumed jurisdiction in any proceeding to detennine the capacity of the alleged incapacitated person. .-~,,"""'-'" . ~.r- In Re: : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS COURT DIVISION : NO. 21-96-148 VIOLETIE ROBERTS, an Alleged Incapacitated Person PETITION FOR THE APPOINTMENT OF GUARDIANS OF THE ESTATE AND PERSON IN ACCORDANCE WITH 20 PA. CONS. STAT. ~5513 TO THE HONORABLE, THE JUDGES OF THE SAID COURT: The petition of Claudia Davis and Gregg Martin respectfully represent that: 1. Petitioners are Claudia Dayis, an adult indiyidual of 2819 Kingsridge, Quincy Illinois, and Gregg Martin, an adult individual of 8000 Steven's Mill Road, Matthews, North Carolina. Petitioners are the daughter and son of the alleged incapacitated person 2. The alleged incapacitated person is Violet Roberts, born on December 4, 1920. She is 75 years of age and resides in an independentliying cottage at Cumberland Crossings retirement homes, South Middleton Township, Cumberland County, Pennsylvania. Her mailing address is 85 Schimmel Way, Carlisle, Pennsylyania 17013 3. A hearing on the Petition filed by Petitioners was scheduled for June 28, 1996 at 10:00 a.m. in Courtroom No. I, Cumberland County Courthouse, Carlisle, Pennsylvania. At the time set for the hearing, present were Petitioners with their counsel, Robert G. Frey, and Respondent with her counsel, Marcus A. McKnight, III. 4. At the time scheduled for the hearing, Petitioners and Respondent reached an agreement which Agreement was reported to the Court and is as follows: a. The parties agreed to continue this matter to allow further medical eyaluation and treatment by Respondent. b. The Respondent agreed, as soon as is reasonably possible, to haye a Psychiatrist at Holy Spirit Hospital, Camp Hill, Cumberland County, Pennsylyania, exwnine her and make recommendations for her treatment. . c. The Respondent agreed to cooperate with the Psychiatrist and to comply with the recommendations for treatment. d. The Respondent would turn over to her counsel of record her banking accounts and bank statements recciyed. Respondent would haye the use of her checking account for the payment of expenses as required by her. but would not make significant withdrawals from her saving accounts or time deposits. or sell assets without prior notification to Petitioners. e. The Respondent agreed that all infonnation concerning her medical and psychiatric treatment and any records from any facility where she resides would be proYided to Petitioners so that they may monitor her condition. f. The Petitioners agreed to continue the scheduled hearing in order to afford Respondent an opportunity to take the actions set forth aboye g. The Petitioners and Respondent reduced this Stipulation to writing which has been incorporated into an Order of Court, a copy of which is aU ached hereto and incorporated herein by reference as Exhibit "A". 6. Respondent has been examined by a Psychiatrist pursuant to the Stipulation and the Psychiatrist has made recommendations for the treatment and handling of financial affairs of the Respondent. 7. Petitioners desire to have limited guardians of the person and estate appointed to take responsibility for carrying out the recommendations of the Psychiatrist. 8. As set forth in the original Petition filed. the proposed guardians of the person are your Petitioners and the proposed guardian of the estate is Financial Trust Services Company (fonnerly Farmers Trust Company). 9. The proposed guardians of the person and estate have no interest adverse to the alleged incapacitated person. 10. No other guardian has been appointed for the person of the alleged incapacitated person and no other court has evcr assumed jurisdiction in any proceeding to detennine the capacity of the alleged incapacitated person, i .i ~ In Re: : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY. PENNSYLVANIA VIOLETIE ROBERTS, an Alleged Incapacitated Person . . : ORPHANS COURT DIVISION : 2.1- 9, -I'll' : NO.-96- ~, .,~ ORDER OF COURT I,trlf- ~_j~~r AND NOW, this ('-(, 'I day of__ 1996. on consideration of the Stipulation presented by counsel for the Petitioners and Respondent. it is ordered and decreed as follows: a. Consideration of the Petition of Claudia Dayis and Gregg Martin is continued to allow further medical eyaluation and treatment of Violette Robens. b. Violette Roberts shall. as soon as reasonably possible. have a psychiatrist at Holly Spirit Hospital. Camp Hill. Cumberland County. Pennsylyania, examine her and make recommendations for her treatment. c. Violette Robens shall cooperate with the psychiatrist and comply with recommendations for treatment made. d. Violette Robens will turn oyer to her counsel of record her banking accounts and bank statements receiyed. Violette Robens shall haye the use of her checking account for the payment of expenses as required by her. but will not make significant withdrawals from her sayings accounts or time deposits, or sell assets without prior notification to the Petitioners. e. Violette Robens agrees that all information concerning her medical and psychiatric treatment and any records from any facility where she resides will be proYided to Petitioner so that they may monitor her condition. BY,,,, COU!!J~ /1jC[l-! t . Harold E. Sheely, P.]. . .. , In Re: : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS COURT DIVISION : No. 21.96.148 VIOLETIE ROBERTS, an Alleged Incapacilated Person SETTLEMENT STIPULATION THE UNDERSIGNED, being the allomeys of record for all of the parties to the aboye captioned action, do hereby enter into a Selllement Stipulation, as follows: I. Petitioners arc Claudia Davis of 2819 Kingsridge, Quincy, Illinois, and Gregg Martin, 8000 Steyen's Mill Road, Mallhews, NC 28105, the daughter and son of Violelle Roberts, the alleged incapacitated person. Both arc adult indiyiduals. 2. Respondent is Violelle Roberts who resides in an independentliYing collage at Cumberland Crossings retirement homes, South Middleton Township, Cumberland County, Pennsylyania. Hermniling address is 85 Schimmel Way, Carlisle, Pennsylvania 17013. 3. A hearing on the Petition filed by Petitioners was scheduled for June 28, 1996 at 10:00 a.m. in Courtroom No. I, Cumberland County Courthouse, Carlisle, Pennsylyania. At the time set for the hearing, present were Petitioners with their counsel, Robert G. Frey, and Respondent with her counsel, Marcus A. McKnight, III. 4. At the time scheduled for the hearing, Petitioners and Respondent reached an agreement which Agreement was reported to the Court and is as follows: a. The parties agree to continue this mailer to allow further medical eyaluation and treatment by Respondent. b. The Respondent agrees, as soon as is reasonably possible, to haye a Psychiatrist at Holy Spirit Hospital, Camp Hill, Cumberland County, Pennsylyania, examine her and make recommendations for her treatment. c. The Respondent agrees to cooperate with the Psychiatrist and to comply with the recommendations for treatment. d. The Respondent will turn oyer to her counsel of record her banking accounts and bank statements receiyed. Respondent shall haye the use of her checking . . '. ,~ In Re: : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS COURT DIVISION : NO. 21-96-148 VIOLElTE ROBERTS, an Alleged Incapacitated Person PRELIMINARY DECREE AND NOW, this q;if day of /11ttlJl~ upon consideration of the annexed petition, it is hereby ORDERED and DECREED that a citation is awarded directly to Violette Roberts, to be served upon her counsel of record, Marcus A. McKnight. III, Esquire to show cause why she should not be adjudged a partially incapacitaled person and a partial guardian of her person and estate appoinled; the hearing therein to be held in Court Room No. I. Cumberland County Courthouse, I Courthouse Square, Carlisle, Cumberland County, Pennsylyania, on December 9, 1996 at 9:00 o'clock A.M. At least twenty days' notice of the hearing shall be giyen to Violette Roberts, the alleged incapacitated person, by service upon her counsel of record, Marcus A. McKnight, III, Esquire of the citation, a copy of the petition and written notice in conformity with 20 Pa. Cons. Stat. ~ 5511 and by service of notice upon the Directorof the Cumberland Crossings Nursing Home. where the alleged incapacitated person resides, personally or by registered mail. Court: (?-. l . IN RE: VIOLETTE ROBERTS an Alleged Incapacitated : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : : ORPHANS' COURT DIVISION : : NO. 21-96-148 PETITION FOR THE APPOINTMENT OF GUARDIANS OF THE ESTATE AND PERSON BEFORE I SHEELY. P.J. ~R OF COURT AND NOW, this _()(~ day of DECEMBER, 1996, after a hearing held on December 9, 1996, Petitioners' request that they be appointed limited guardians of the person of Violette Roberts is REFUSED at this time. However, Respondent is directed to immediately make contact with her psychiatrist Dr. Amita Nayyar, M.D. of Holy Spirit Hospital, to begin treatment. Respondent shall follow the recommendations of Dr. Nayyar, or whoever is in charge of her treatment. If Respondent fails to follow the prescribed treatment, the Court will entertain another petition for appointment of a limited guardian. Petitioners' request that Financial ~rust Corp. be appointed limited guardian of the estate of Violette Roberts is GRANTED with the following conditions: 1) Respondent's Social Security check and pension check shall continue to be automatically deposited into her checking account at Financial Trust; 2) Financial Trust shall write out checks to be signed by Respondent for payment of her monthly bills, and if Respondent is unable to sign her checks, the bank shall do so; 3) Financial Trust shall .. 0 5~ - c;"') o.!12 .., ,'3 . Ql- 0- ~~ ~1018 015 ~ " ;:0;'0 16l !: cC: .'\ '.Il\l ~.:\ ;:: E..- 0 1... \U ~g> '.0 ~ Sa a: a: IN REI VIOLETTE ROBERTS an Alleged Incapacitated : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : I ORPHANS' COURT DIVISION : NO. 21-96-148 PETITION FOR THE APPOINTMENT OF GUARDIANS OF THE ESTATE AND PERSON BEFORE: SHEELY. P.J. OPINION AND ORDER OF COURT A hearing on this petition was initially scheduled for June 28, 1996, at which time the parties reached a Settlement StipUlation that was incorporated into an Order of Court dated August 14, 1996. Respondent has been examined by a psychiatrist, Dr. Amita Nayyar, M.D., in accordance with the stipulation, and now Petitioners have requested the Court to appoint limited guardians of the person and estate. The proposed guardians of the person are Gregg Martin and Claudia Davis, the children of Respondent. The proposed guardian of the estate is Financial Trust Company, where Respondent maintains her checking account. Testifying at a hearing held on December 9, 1996, were Gregg Martin and Claudia Davis, Ba:bara Ann McClure (Director of Residential Client Services at Cumberland Crossings), and Respondent. The Court admitted the following three exhibits: Respondent's medical records released from Carlisle Hospital (Respondent's Exhibit .1)1 a bank statement from Financial Trust Corp. (Respondent's Exhibit .2)1 and a psychiatric evaluation prepared by Amita S. Nayyar, M.D., of Holy Spirit Hospital (Respondent's Exhibit '3). The Court made the following findings of fact. NO. 21-96-148 ORPHANS' COURT DIVISION FINDINGS OF FACTS Respondent is Violette Roberts, a seventy-five year old widow who currently resides alone in a cottage she purchased at Cumberland Crossings a couple of years ago. Respondent was born in Illinois and had two children from a previous marriage, the petitioners in this case, who are ages forty-six and forty-three. She then married her late husband (Husband) sometime when the children were in their mid-teens. Husband's own children were already grown at the time of the marriage, and Petitioners have little if any contact with them. About ten years ago, Respondent and Husband retired to Florida for several years and then returned to Quincy, Illinois, to be near her daughter Claudia because Husband's Parkinson's Disease had worsened. Respondent had periodically experienced problems with her mental health throughout this marriage- as early as the children's years in high school- and Husband sought the care of a psychiatrist for Respondent. When Husband's health deteriorated and he required the care of visiting nurses, Respondent accused them of stealing. Her problems became more pronounced since her Husband's death, and she began to accuse her daughter of trying to steal her money. Respondent ~uffer9 from a severe eye problem termed macular degeneration and is legally blind. When it became necessary for Claudia to write out checks to be signed by Respondent so that she could pay her bills, Respondent accused 2 NO. 21-96-148 ORPHANS' COURT DIVISION Claudia of taking her money. Claudia then directed Respondent's accountant to manage Respondent's account, but Respondent also accused him and the banks of stealing. Eventually, Respondent moved to Pennsylvania to be near her son Gregg, although she still maintained frequent contact with Claudia. I Gregg helped her to find the cottage at Cumberland Crossings, which has assisted and partial assisted living. Respondent paid $134,750 in cash from the sale of her previous home. If she later sells, she will receive a 90% refund. When attempting to manage her bank account, Gregg experienced the same problem as Claudia concerning Respondent's accusations of taking money. Both children were concerned about the paranoia Respondent was exhibiting regarding unfounded accusations of people stealing her money and other itemsl she accused her neighbors, employees of Cumberland Crossings as well as her own attorney. Her records from Carlisle Hospital indicate that she was referred for involuntary commitment because of paranoid delusions. (See Respondent's Exhibit '1). Dr. Nayyar's evaluation of September 3, 1996, diagnosed her as having Dementia with paranoid delusions. (See Respondent's Exhibit '3). In her report, Dr. Nayyar recommended a low dose of Haldol to ease the paranoid symptoms (id.) and later prescribed the medication, but Respondent has not cooperated in this respect, although she did I Gregg lived in Pennsylvania for about ten years but has recently been transferred to North Carolina. 3 NO. 21-96-148 ORPHANS' COURT DIVISION fill the prescription. Regarding Respondent's ability to maintain an independent living situation, Dr. Nayyar felt that she was able to live independently but should have someone to help with groceries and spend some time with her. (Id.). Currently, Respondent has not requested any of the available services at Cumberland Crossings. Barbara McClure, the director, has indicated that Respondent is able to take care of her daily needs. Petitioners agree, except they insist Respondent can not be trusted with keeping her appointments with Dr. Nayyar and taking medicine in conjunction with her mental health. The Court also notes that at some point, Respondent sent money to an aid who previously assisted Husband in Quincy, Illinois, in order to help her move back to Quincy. The money was returned. Petitioners also expressed concern that last year at around Thanksgiving, Respondent left Cumberland Crossings without following procedures in place to ensure the safety and well-being of the residents. Turning to her financial situation, Respondent has two sources of income, her Social Security check in the amount of $1,120.00, and her Husband's pension check of $568.001 both checks are automatically deposited into her account at Financial Trust. She presently has an arrangement with the bank that allows her to bring her monthly bills to the bank, and then a bank employee writes out the check for her signature. Financial 4 NO. 21-96-148 ORPHANS' COURT DIVISION Trust has indicated that it will not continue to operate under this arrangement without a court order to this effect. Respondent's only other asset is a certificate of Deposit from Harris Bank in Carlisle which she testified as worth $79,000. She does not receive the interest but instead, directs that it be added. Finally, with regard to Respondent's testimony, the Court notes that Respondent appeared confused at times and contradicted her own testimony on some occasions. Respondent denied allegations that she told Claudia her attorney was having an affair with her step-sister and other such accusations. She did state several times that people were trying to take her money. She was coherent, though, and able to communicate well. Respondent insisted that she is able to care for her own needs, and that she would follow up with psychiatric help to make her children happy. She now appears content with her living arrangements at Cumberland Crossings, but would consider living near Gregg if after spending time there, she decides she likes the area. Respondent further indicated that she is satisfied to have Financial Trust manage payment of her bills. She stated that in any event, Cumberland Crossings will provide assistance to her if necessary. 5 NO. 21-96-148 ORPHANS' COURT DIVISION DISCUSSION Petitioners request the Court to appoint them as limited guardians of their mother, Violette Roberts, believing that they should share responsibility for Respondent's mental health. Gregg maintains that once Respondent is receiving the proper treatment for her paranoia, he would like her to relocate near him. Petitioners have not given the Court an explanation as to how a limited guardianship will assure that Respondent receive treatment when both Petitioners live out of state, except that Claudia suggested that an involuntary commitment may be necessary. Petitioners further request that Financial Trust be appointed limited guardian of the estate. First, the Court will consider S 5511 of the Decedents, Estates and Fiduciaries Code, providing as follows: (a) Rssidsnt.- The Court, upon petition and hearing and upon the presentation of clear and convincing evidence, may find a person domiciled in the Commonwealth to be incapacitated and appoint a guardian or guardians of his person or estate. 20 Pa. C.S.A. S 5505(a). Determination of incapacity is governed by S 5512.1(a), which specifies that the court take into consideration the factors listed below: (1) The nature of any condition or disability which impairs the individual's capacity to make and communicate decisions. (2) The extent of the individual's capacity to make and communicate decisions. (3) The need for guardianship services, if any, in 6 .~""., ~__ __...u___A ..- NO. 21-96-148 ORPHANS' COURT DIVISION light of such factors as the availability of family, friends and other supports to assist the individual in making decisions and in light of the existence, if any, of advance directives such as durable power of attorney or trusts. (4) The type of guardian, limited or plenary, of the person or estate needed based on the nature of any condition or disability and the capacity to make and communicate decisions. (5) The duration of the guardianship. (6) The court shall prefer limited guardianship. With respect to the issue of a limited guardianship, the relevant provision of the Code reads as follows: . . . (b) Limited guardian of the person.- Upon a finding that the person is partially incapacitated and in need of guardianship services, the court shall enter an order appointing a limited guardian of the person with powers consistent with the court's findings of limitati~ns, which may include: . . . (3) Assuring that the incapacitated person receives such . . . medical and psychological services . . . as well as assisting the incapacitated person in the development of maximum reliance and independence. Id., S 5512.1(b). The Code sets forth the following with regard to appointment of a limited guardian of the estate: (d) Limited guardian of the estate.- Upon a finding that the person is partially incapacitated and in need of guardianship services, the court shall enter an order appointing a limited guardian of the estate with powers consistent with the court's finding of limitations, which shall specify the portion of assets or income over which the guardian of the estate is assigned powers and duties. Id. S 5512.1(d). This Court has some concerns about Respondent's mental 7 "._.""",-.,---~..,,,--._.- NO. 21-96-148 ORPHANS' COURT DIVISION health. However, we do not find by clear and convincing evidence that the factors for incapacity have been met to adjudicate Respondent incapacitated with respect to guardian of her person. Respondent's ability to make and communicate decisions has not been impaired to the extent that she requires appointment of a limited guardian of the person at this time. In addition, Cumberland Crossings provides an adequate support system and has available additional services. Furthermore, Petitioners keep in frequent contact with their mother. It is clear, though, that Respondent should receive treatment for her paranoia. The Court believes that Respondent should be given another opportunity to follow. the recommendations of Dr. Nayyar and will direct her to do so in our order below. Petitioners also request that Financial Trust be appointed limited guardian of the estate of Violette Roberts. We are in agreement. Respondent is unable to see, first of all, to write her checks for bills. Additionally, her paranoia symptoms lead her to believe that others are trying to take her money. At any given moment she will make unfounded accusations that someone is attempting to steal her money, even the bank she dealt with in Illinois. Should Respondent suddenly decide that Financial Trust is also out to get her money, she will not be able to conduct her financial transactions. Moreover, Financial Trust will not continue writing out checks without court approval, and Respondent did indicate that she is satisfied with that \ ~.. 8 , . J -... , t NO. 21-96-148 ORPHANS' COURT DIVISION arrangement. As our order below will reflect, Financial Trust will also disburse funds to Respondent for reasonable purposes. The holder of Respondent's Certificate of Deposit, Harris savings Bank of Carlisle, will be directed to turn over and deliver the C.D. to Financial Trust for the benefit of Respondent. ORDER OF COURT AND NOW, this /8-t:!, day of DECEMBER, 1996, after a hearing held on December 9, 1996, Petitioners' request that they be appointed limited guardians of the person of Violette Roberts is REFUSED at this time. However, Respondent is directed to immediately make contact with her psychiatrist Dr. Amita Nayyar, M.D. of Holy Spirit Hospital, to begin treatment. Respondent shall follow the recommendations of Dr. Nayyar, or whoever is in charge of her 'treatment. If Respondent fails to follow the prescribed treatment, the Court will entertain another petition for appointment of a limited guardian. Petitioners' request that Financial Trust Corp. be appointed limited guardian of the estate of Violette Roberts is GRANTED with the following conditions: 1) Respondent's Social Security check and pension check shall continue to be automatically deposited into her checking account at Financial Trustl 2) Financial Trust shall write out checks to be signed by Respondent for payment of her monthly bills, and if Respondent is unable to sign her checks, the bank shall do SOl 3) Financial Trust shall distribute cash to Respondent from her checking account for 9 .. ,. c IN REI VIOLETTE ROBERTS an Alleged Incapacitated : IN THE COURT OF COMMON PLEAS OF I CUMBERLAND COUNTY, PENNSYLVANIA : : ORPHANS' COURT DIVISION I : NO. 21-96-148 PBTITION FOR THB APPOINTMENT OF GUARDIANS OF THB ESTATB AND PBRSON BEFORE I SHBELY. P.J. O~R OF COURT I yt/ day of DECEMBER, , ' AND NOW, this 1996, after a hearing held on December 9, 1996, Petitioners' request that they be appointed limited guardians of the person of Violette Roberts 1s REFUSED at this time. However, Respondent is directed to immediately make contact with her psychiatrist Dr. Amita Nayyar, M.D. of Holy Spirit Hospital, to begin treatment. Respondent shall follow the recommendations of Dr. Nayyar, or whoever is in charge of her treatment. If Respondent fails to follow the prescribed treatment, the Court will entertain another petition for appointment of a limited guardian. Petitioners' request that Financial Trust Corp. be appointed limited guardian of the estate of Violette Roberts is GRANTED with the following conditions: 1) Respondent's Social Security check and pension check shall continue to be automatically deposited into her checking account at Financial Trust; 2) Financial Trust shall write out checks to be signed by Respondent for payment of her monthly bills, and if Respondent is unable to sign her checks, the bank shall do so; 3) Financial Trust shall ~ " IN REs VIOLETTE ROBERTS an Alleged Incapacitated : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : : ORPHANS' COURT DIVISION : NO. 21-96-148 PETITION FOR THE APPOINTMENT OF GUARDIANS or THE ESTATE AND PERSON BEFORE: SHEELY. P.J. OPINION AND ORDER OF COURT A hearing on this petition was initially scheduled for June 28, 1996, at which time the parties reached a Settlement Stipulation that was incorporated into an Order of Court dated August 14, 1996. Respondent has been examined by a psychiatrist, Dr. Amita Nayyar, H.D., in accordance with the stipulation, and now Petitioners have requested the Court to appoint limited guardians of the person and estate. The proposed guardians of the person are Gregg Hartin and Claudia Davis, the children of Respondent. The proposed guardian of the estate is Financial Trust Company, where Respondent maintains her checking account. Testifying at a hearing held on December 9, 1996, were Gregg Hartin and Claudia Davis, Barbara Ann HcClure (Director of Residential Client Services at Cumberland Crossings), and Respondent. The Court admitted the following three exhibits: Respondent's medical records released from Carlisle Hospital (Respondent's Exhibit '1); a bank statement from Financial Trust Corp. (Respondent's Exhibit '2); and a psychiatric evaluation prepared by Amita S. Nayyar, H.D., of Holy Spirit Hospital (Respondent's Exhibit '3). The Court made the following findings of fact. ..... _.-._..;.._..__...~.,.......,..;.-,..:"..,. ~ . , . ...< " NO. 21-96-148 ORPHANS' COURT DIVISION FINDINGS OF FACTS Respondent is Violette Roberts, a seventy-five year old widow who currently resides alone in a cottage she purchased at Cumberland Crossings a couple of yeare ago. Respondent was born in Illinois and had two children from a previous marriage, the petitioners in this case, who are ages forty-eix and forty-three. Sho then married her late husband (Husband) sometime when the children were in their mid-teens. Husband's own children were already grown at the time of the marriage, and Petitioners have little if any contact with them. About ten years ago, Respondent and Husband retired to Florida for several years and then returned to Quincy, Illinois, to be near her daughter Claudia because Husband's Parkinson's Disease had worsened. Respondent had periodically experienced problems with her mental health throughout this marriage- as ~arly as the children's years in high school- and Husband sought the care of a psychiatrist for Respondent. When Husband's health deteriorated and he required the care of visiting nurses, Respondent accused them of stealing. Her problems became more pronounced since her Husband's death, and she began to accuse her daughter of trying to steal her money. Respondent suffers from a severe eye problem termed macular degeneration and is legally blind. When it became necessary for Claudia to write out checks to be signed by Respondent so that she could pay her bills, Respondent accused 2 NO. 21-96-148 ORPHANS' COURT DIVISION Claudia of taking her money. Claudia then directed Respondent's accountant to manage Respondent's account, but Respondent also accused him and the banks of stealing. Eventually, Respondent moved to Pennsylvania to be near her son Gregg, although she still maintained frequent contact with Claudia. 1 Gregg helped her to find the cottage at Cumberland Crossings, which has assisted and partial assisted living. Respondent paid $134,750 in cash from the sale of her previous home. If she later sells, she will receive a 90% refund. When attempting to manage her bank account, Gregg experienced the same problem as Claudia concerning Respondent's accusations of taking money. Both children were concerned about the paranoia Respondent was exhibiting regarding unfounded accusations of people stealing her money and other items~ she accused her neighbors, employees of Cumberland crossings as well as her own attorney. Her records from Carlisle Hospital indicate that she was referred for involuntary commitment because of paranoid delusions. (See Respondent's Exhibit '1). Dr. Nayyar's evaluation of September 3, 1996, diagnosed her as having Dementia with paranoid delusions. (See Respondent's Exhibit '3). In her report, Dr. Nayyar recommended a low dose of Haldol to ease the paranoid symptoms (id.) and later prescribed the medication, but Respondent has not cooperated in this respect, although she did 1 Gregg lived in Pennsylvania for about ten years but has recently been transferred to North Carolina. 3 ~ NO. 21-96-148 ORPHANS' COURT DIVISION fill the prescription. Regarding Respondent's ability to maintain an independent living situation, Dr. Nayyar felt that she was able to live independently but should have someone to help with groceries and spend some time with her. (Id.). Currently, Respondent has not requested any of the available services at Cumberland Crossings. Barbara McClure, the director, has indicated that Respondent is able to take care of her daily needs. Petitioners agree, except they insist Respondent can not be trusted with keeping her appointments with Dr. Nayyar and taking medicine in conjunction with her mental health. The Court also notes that at some point, Respondent sent money to an aid who previously assisted Husband in Quincy, Illinois, in order to help her move back to Quincy. The money was returned. Petitioners also expressed concern that last year at around Thanksgiving, Respondent left Cumberland Crossings without following procedures in place to ensure the safety and well-being of the residents. Turning to her financial situation, Respondent has two sources of income, her Social Security check in the amount of $1,120.00, and her Husband's pension check of $568.001 both checks are automatically deposited into her account at Financial Trust. She presently has an arrangement with the bank that allows her to bring her monthly bills to the bank, and then a bank employee writes out the check for her signature. Financial 4 i,r ---\"'.L .--:.o}'. -~ " NO. 21-96-148 ORPHANS' COURT DIVISION Trust has indicated that it will not continue to operate under this arrangement without a court order to this effect. Respondent's only other asset is a certificate of Deposit from Harris Bank in Carlisle which she testified as worth $79,000. She does not receive the interest but instead, directs that it be added. Finally, with regard to Respondent's testimony, the Court notes that Respondent appeared confused at times and contradicted her own testimony on some occasions. Respondent denied allegations that she told Claudia her attorney was having an affair with her step-sister and other such accusations. She did state several times that people were trying to take her money. She was coherent, though, and able to communicate well. Respondent insisted that she is able to care for her own needs, and that she would follow up with psychiatric help to make her children happy. She now appears content with her living arrangements at Cumberland Crossings, but would consider living near Gragg if after spending time there, she decides she likes the area. Respondent further indicated that she is satisfied to have Financial Trust manage payment of her bills. She stated that in any event, Cumberland Crossings will provide assistance to her if necessary. 5 _.. ~......:-_.....,.._.......,~ ",;;..._,~ '0" .' ....!' , " NO. 21-96-148 ORPHANS' COURT DIVISION DISCUSSION Petitioners request the Court to appoint them as limited guardians of their mother, Violette Roberts, believing that they should share responsibility for Respondent's mental health. Gregg maintains that once Respondent is receiving the proper treatment for her paranoia, he would like her to relocate near him. Petitioners have not given the Court an explanation as to how a limited guardianship will assure that Respondent receive treatment when both Petitioners live out of state, except that Claudia suggested that an involuntary commitment may be necessary. Petitioners further request that Financial Trust be appointed limited guardian of the estate. First, the Court will consider S 5511 of the Decedents, Estates and Fiduciaries Code, providing as follows: (a) Resident.- The Court, upon petition and hearing and upon the presentation of clear and convincing evidence, may find a person domiciled in the Commonwealth to be incapacitated and appoint a guardian or guardians of his person or estate. 20 Pa. C.S.A. S 5505(a). Determination of incapacity is governed by S 5512.1(a), which specifies that the court take into consideration the factors listed below: (1) The nature of any condition or disability which impairs the individual's capacity to make and communicate decisions. (2) The extent of the individual's capacity to make and communicate decisions. (3) The need for guardianship services, if any, in 6 .' .~. NO. 21-96-148 ORPHANS' COURT DIVISION light of such factors as the availability of family, friends and other supports to assist the individual in making decisions and in light of the existence, if any, of advance directives such as durable power of attorney or trusts. (4) The type of guardian, limited or plenary, of the person or estate needed based on the nature of any condition or disability and the capacity to make and communicate decisions. (5) The duration of the guardianship. (6) The court shall prefer limited guardianship. With respect to the issue of a limited guardianship, the relevant provision of the Code reads as follows: . . . (b) Limited guardian of the person.- Upon a finding that the person is partially incapacitated and in need of guardianship services, the court shall enter an order appointing a limited guardian of the person with powers consistent with the court's findings of limitations, which may include: . . . (3) Assuring that the incapacitated person receives such . . . medical and psychological services . . . as well as assisting the incapacitated person in the development of maximum reliance and independence. Id., S 5512.1(b). The Code sets forth the following with regard to appointment of a limited guardian of the estate: (d) Limited guardian of the estate.- Upon a finding that the person is partially incapacitated and in need of guardianship services, the court shall enter an order appointing a limited guardian of the estate with powers consistent with the court's finding of limitations, which shall specify the portion of assets or income over which the guardian of the estate is assigned powers and duties. Id. S5512.1(d). This Court has some concerns about Respondent's mental 7 ~ ".. NO. 21-96-148 ORPHANS' COURT DIVISION health. However, we do not find by clear and convincing evidence that the factors for incapacity have been met to adjudicate Respondent incapacitated with respect to guardian of her person. Respondent's ability to make and communicate decisions has not been impaired to the extent that she requires appointment of a limited guardian of the person at this time. In addition, Cumberland Crossings provides an adequate support system and has available additional services. Furthermore, Petitioners keep in frequent contact with their mother. It is clear, though, that Respondent should receive treatment for her paranoia. The Court believes that Respondent should be given another opportunity to follow the recommendations of Dr. Nayyar and will direct her to do so in our order below. Petitioners also request that Financial Trust be appointed limited guardian of the estate of Violette Roberts. We are in agreement. Respondent is unable to see, first of all, to write her checks for bills. Additionally, her paranoia symptoms lead her to believe that others are trying to take her money. At any given moment she will make unfounded accusations that someone is attempting to steal her money, even the bank she dealt with in Illinois. Should Respondent suddenly decide that Financial Trust is also out to get her money, she will not be able to conduct her financial transactions. Moreover, Financial Trust will not continue writing out checks without court approval, and Respondent did indicate that she is satisfied with that 8 NO. 21-96-148 ORPHANS' COURT DIVISION arrangement. As our order below will reflect, Financial Trust will also disburse funds to Respondent for reasonable purposes. The holder of Respondent's Certificate of Deposit, Harris Savings Bank of Carlisle, will be directed to turn over and deliver the C.D. to Financial Trust for the benefit of Respondent. AND NOW, this ORDER OF COURT /8~ day of DECEMBER, 1996, after a hearing held on December 9, 1996, Petitioners' request that they be appointed limited guardians of the person of Violette Roberts is REFUSED at this time. However, Respondent is directed to immediately make contact with her psychiatrist Dr. Amita Nayyar, M.D. of Holy Spirit Hospital, to begin treatment. Respondent shall follow the recommendations of Dr. Nayyar, or whoever is in charge of her treatment. If Respondent fails to follow the prescribed treatment, the Court will entertain another petition for appointment of a limited guardian. Petitioners' request that Financial Trust Corp. be appointed limited guardian of the estate of Violette Roberts is GRANTED with the following conditions: 1) Respondent's Social Security check and pension check shall continue to be automatically deposited into her checking account at Financial Trust; 2) Financial Trust shall write out checks to be signed by Respondent for payment of her monthly bills, and if Respondent is unable to sign her checks, the bank shall do so; 3) Financial Trust shall distribute cash to Respondent from her checking account for 9 '.., '. BRUCE KELLY, M.A. I'sYOlOLOCIST SOO6 \.!mEJ. sl1lEtt MfClWllCSlUOC,l'!NNm.vANIA 17055 (717)T.lO-0733 Psycholoalcal Eyaluatlon Name: Roberts. Violette (Gerry) Date 01 Birth: 12104/19 Date 01 EYaluallon: 4/10,4/17, 1996 Age: 76 years. 4 months R..eon for R.ferrll Mrs, Roberts was relerred by her attorney, Marcus McKnight, at the agreement 01 the parties Involved, Her daughter, Claudia Davis, and son, Gregg Martin have pelltloned lor the appointment 01 a guardian of her estate, Based on reports 01 paranoid delusions, they leel that she lacks the capacity to make responsible decisions concerning her person or estate. Mrs. Roberts wishes to maintain her own guardianship and leels that she Is capable, A psychological eYaluallon has been requested to provide Inlormatlon regarding her leyal ollunclloning to aid the court In this determlnallon, The pet~loners also assert that Mrs, Roberts Is unable to care lor herseil adequately and should now be removed Irom her Independent living COllage to the nursing lacllity on the seme grounds. yet that nurSing home will not adm~ her without the consent 01 a legally appointed guardian, History Prior records Indicated the lollowlng: Mrs. Roberts was born and raised In Nebraska. and reports that she and her younger brother were cared for by her maternal grandparents as It was the Depression and her parents moYed away to find jobs, She claims that her grandmother beat her Incessanlly, She neyer again saw her lather but moved back With her mother at age 12 though It was an .Indlfferent. relationship, She quit school around the 101h grade to IInd employment and soon married, Her husband was In the Navy and they moYed around, They had two children. the current pemloners. who now lIye In Illinois and North Carolina. Mrs, Roberts was later married again, for 27 years, and this husband died 3 years ago, They had no children together though he had adopted children Irom a previous marriage, She claims to haye had an excellent relallonshlp with this last husband though her daughter reports that Mrs. Roberts was cruel and hostile toward him In his final years when he was afflicted with Parkinson's Disease, The daughter, Claudia Davis, aged 43, reported the 101l0wlng Inlormatlon: Ms. Davis reports, by her father's account, that her mother had seen a psychiatrist lor at least the last 30 years and been prescribed medlcallons for "nerves. depression.. and had been addicted to Valium (though Mrs, Roberts denies any psychiatric history), However, she neyer continued with anyone psychiatrist as she tended to blame them, as well as others. lor her problems, Her mother had a yolallle personality, prone to suspicion and outbursts of anger. and consumed too much alcohol, usually nightly (Despite this memory, Mrs, Roberts claims that she and her husband would typically have a nlghlly drink before bed to help them sleep but that this was never exposed to the children), Her mother worked exhaustlyely as a factory supervisor to support the lamlly when single. Elghteen years ago, Mrs, Roberts 1 I. . refused to talk to her daughter for several years for unknown reasons. When her last husband died, Mrs. Roberts accused Ms. Davis' husband of wanting to kill her. but then later was pleasant as If nothing had transpired, Similar oscillation between angry accusation and friendly Interaction has been reported in other relationships and situations. Ms, Davis finds that she has not been able to have a normal relationship with her mother due to the unpredictable suspicious accusations and associated anger. The accusations haye become excessive In the last 1 0 years. She claims that live years ago. her mother was threatening to kill people, Mrs. Roberts accused her son of stealing her money. and also alleged the same of her bank 4 years ago In illinois, She also said that neighbors there were stealing her possessions. and then put extra locks on her bedroom door. not even giving a key to her husband. Ms. Davis last saw her mother one year ago when accused of stealing her bank statements. At that time. she took her shopping and found that she stocked up on alcohol because she said she needed wine at night to help her sleep, She had also been taking oyer-the-counter sleep aids, A physician refused her request for sleep medication to which Mrs. Roberts reacted angrily by discounting his competency and refusing to return, Ms. DaYls reported that her mother has always been quite heallhy, Howeyer, she expressed concern that Mrs. Roberts may not be taking In proper nutrition due to poor food choices. After her husband died 3 years ago. Mrs, Roberts moved from Quincy, illinois to an Independent living collage on the grounds of the Cumberland Crossings Nursing Home in Carlisle, PA near the residence of her son, Mr, Martin, Yet. he was soon transferred by his trucking company to North Carolina, One year ago. Mrs. Roberts accused her neighbor of stealing her possessions, as well as her mall to get her pension checks. and called the police, She reported seeing him wearing her late husband's Wedding ring. She had her locks changed but claimed that this neighbor had a new key made. She was then involuntarily committed to the psychiatric unit of Carlisle Hospital. At her admission. it was reported that she had been refusing to take her eye drops that were prescribed due to recent cataract surgery though she claimed that she had been taking them on her own. She had been refusing to have the Visiting Nurse come to her home, During her hospital stay. she remained pleasant, cooperative. and Involyed. and complied with therapies but refused all psychotropic medication, Her paranoid delusions did not abate, The examining pSYChiatrist felt that her Mini-Mental StalUs Exam scores Indicated mild dementia. particularty in the areas of attention and calculallon but that her mental status was relatlyely clear for the most part, She was diagnosed with Paranoid Disorder, as well as Senile Dementia of the Alzhelmer's Type. mild. As she did not present as a danger to herself or others. she was released after 5 days though It was fell she needed further psychiatric treatment which she refused, In January. 1996. she violated the Cumberland Crossings policy by leaYing her cottage and traveling to Chicago without notifying stafl, She retumed about 1 week later, She claimed that her late husband's daughter had picked her up at her cottage and taken her to Chicago for a Ylslt. and then put her on the plane when It was lime to retum. The nursing home stafl and her children were concerned not only by her sudden absence but by how she got from the Harrisburg airport to home, especially as she Initially claimed that the airport manager personally gaye her a ride, At this eyaluatlon, she reported that an airport manager merely got a taxi for her after she arrived, though claimed earlier In the evaluation that a ride had been prearranged, Teets Administered Weschler Adult Intelligence Scale - Revised (WAIS-R. Verbal scale only); Neuropsychological Screening Battery; Mini-Mental State Exam; Weschler Memory Scale; NCCEA Sentence Memory; FAS Word Fluency; Personality Schema Inventory; Rotter Incomplete Sentences Blank; Duke Depression Scale; clinical interview, 2 . , .' " Observstlons snd Test Results Mrs, Roberts presented as a thin. Caucasian woman appearing her chronological age. She was very suspicious during the initial phone contact and hung up to immediately call her allorney to express agitation and to cancel the appointment she had just made with this examiner. Howeyer. she became more comfortable after later meeting the examiner to sign release forms and to discuss the testing ahead of time. She was generally pleasant during subsequent eyaluatlon appointments at her home. However. she often became suddenly angry for having to undergo eyaluatlon and answer difficult questions. sometimes asking questions that reflected her suspiciousness and at other times angrily blaming her attorney or her children, Yet. these moments quickly abated. especially when glyen encouragement. Anytime cars entered the driveway outside her cottage, she cautiously peered outside and surmised what might be happening, Speech was clear and relevant. No hallucinations were noted or reported. Delusions were noted as she asserted that her neighbor used to steallrom her and had taken all her possessions from her shed. leaving It presently bare. She was oriented to person. place. and purpose 01 exam, A slight hand tremor was noted, She put lorth a good eHort on test Items. often anxiously persisting" she did not know the answer until reassured and oriented to the next lIem, She was open to dlscusslon 01 personal material. She appeared happy to show the examiner around her cottage and to allow Inspecllon 01 her cupboardS and bank accounts. Intellectual assessment using the WAIS.R could not provide a Full Scale 1.0. as her vision Impairment disallowed administration of the Performance 1.0.. a scale that measures spatial and nonyerbal Intelligence, However, the other scale that comprises the Full Scale 1.0.. the Verbal 1.0.. could be administered as it only requires yerbal responses to oral questions. Her Verbal 1,0. was 95 which falls In the Ayerage range of Intellectuallunctlonlng (compared to the highest age norm group of 70-74), All subtests that comprise the Verball,a,lell between scaled scores 016 and 10 (ayerage: 8-12). evidencing no significant strengths or weaknesses, The lower scores fell on measures 01 general fund 01 information as well as mental arithmetic which requires concentration and mental control. The higher subtests lellln vocabulary knowledge and short term recall of digits. Given the observed memory problems. It was suspected that this latter subtest did not proylde a yalld representallon of her short term memory capacity, especially as she seemed to be more adept at echoing what she heard rather than suHiciently retaining to manipulate the Inlormatlon, Thus. further memory and neuropsychological testing was performed. Memory and neuropsychological testing revealed a pattern suggesllve 01 the early stage 01 dementia 01 the Alzhelmer's type due to problems In memory, orientation. and executive lunctlons, The Weschler Memory Scales yielded a Memory auotlent of between 74-84 (design recall was omitted due to Ylslon) which Is much below her Verbal 1.0, 0195. Indicating memory deficiency, Short term memory was poor as she was able to recall little to none 01 each short passage read to her, Her ability to retrieve memories when presented with multiple choice options was yariable but usually poor, Memory problems were also noted by her Inability to learn new material: for example. she was unable to learn a list 01 paired words despite three presentations, Short term memory appeared poorer than long term as Initially occurs in dementia However. this discrepancy was diHlcult to assess given that some long term memory problems were noted and because she seemed to confabulate (Invent memories). Thus. she proylded Information about her Iile that gaye the appearance of adequate long term memory though may haye been false due to confabulation. This was especially suspected as she was unable to provide dates of slgnillcantllfe eyents which Is something that cannot be concealed: lor example. she answered many chronology questions wllh .1966", Thus. some problems In recalling previously learned material were noted for personal Information such as dates and prior jobs. as well as lor generallnlormatlon such as the current or past presidents, Orientation problems were noted regarding time as she was unsure as to the year ("95 or 96.). month. and date though she was oriented to place and person, Her executlye functioning (which Inyolyes abstract thinking. planning. Initiation. sequencing. and monitoring of complex behaYlor) Is better than her memory, but problems were stili noted as through her Inability to add serlal3's or subtract serial 7's. explain proyerbs. or sufficiently generate categorical words (animals. words that start with "a.. etc.) 3 . upon demand, Yet. executive functioning Is adequate such that it does not appear to interfere with her ability to provide for hersell such as through cleaning. hygiene, or food preparation. Mrs, Roberts' performance was also rated according to the Global Deterioration Scale. a scale 01 age- associated cognltlye decline and Alzheimer's Disease. This scale classifies 7 stages of cognltlye functioning from normal to severe Alzhelmer's disease. On this, she largely fell at stage 4 for which a diagnosis of mild Alzhelmer's disease Is assigned. Mrs. Robert's current denial of cognitive and emotional Issues Is also characteristic of this stage. Some stage 3 functioning was noted which contains symptoms compatible with Incipient Alzheimer's, Depression Is currently slgnltlcanl. Though she denies feeling depressed, further discussion revealed deep sadness, loneliness. and a continuing sense of loss over her spouse and prior way of life. Other depressive symptoms Include insomnia, chronic fatigue, hopelessness, and feeling that her lIle Is empty and that she Is gelling useless, Mild dementia Is suspected; however, this does not eliminate the smaller possibility that the aboye cognitive Impairments are due to depression rather than to dementia for the following reasons: The elderly are prone to developing .pseudodementla" when depressed In that the depression may manifest as confusion, memory loss, and even disorientation, She does present with a past psychiatric history and some problems with remote memory. characteristics more common in depression than early dementia, The depression could have also become chronic and severe enough such as to cause paranoid delusions, as does occur In the elderly, In addition, normal age-related declines In cognltiye functioning can appear worse If accompanied by significant depression. Her Mini-Mental State Exam score of 20 Is the average score for pseudodementla patients, being more unlikely for dementia (unless. perhaps. in an earfy stage), At such a point In cognltlye Impairment, it can be very difficult to discern between an actual and a false dementia Yet. Mrs, Roberts tends to beller fit the pallern for actual dementia due to other characteristics typical of that disorder such as lack of a clear onset, lack of memory complaints or other woes. denial of depression. good effort on psychological testing. and confabulation, Also, early dementia can exacerbate prior personality problems, and it Is noted that Mrs. Roberts' paranoia has become dramatically worse, Personality assessment Indicated significant paranoid Ideology to the extent of delusions, She continues to assert that her neighbor has been stealing from her, pointing to obviously distorted proof. Interview with her daughter reyealed a history of suspiciousness to suggest a premorbid diagnosis of Paranoid Personality Disorder that has existed most of her life, The diagnosis comes from the category of Personality Disorders which refers to a disturbance In the normally Integrative functions of acting, thinking, and feeling that compose one's personality, and which tend to be a lIle-Iong disturbance, A Paranoid Personality chronically expects, without justification, to be harmed by another, reads demeaning messages Into benign remarks or events, bears grudges. questions loyalty or faithfulness. and Is quick to react with anger to perceived allacks, At this evaluation, she endorsed nearly all of the common cognltlye schemas that Paranoid Personality Disorder persons manifest. The statements she endorsed with "yes" included: I cannot trust other people; other people have hidden motiyes; others will try to use me or manipulate me If I don't watch out; I haye to be on guard at all times; it Isn't safe to confide in other people; people will take adyantage of me If I give them the chance; for the most part, other people are unfriendly; other people will deliberately try to demean me; I will be In serious trouble If I let other people think they can get away with mistreating me; if other people find out things about me, they will use them against me; people often say one thing and mean something else; and. a person whom I am close to Is disloyal. Paranoid Personality Disorders typically do not manifest blatant delusions as does Mrs. Roberts. The exception Is a subtype of this disorder known as "decompensated paranoid. personality as these Individuals are prone to psychotic (delusions and/or hallucinations) episodes when experiencing intense 4 '. stress, Ills possible that the passing 01 her husband provided that stressor as II was then tnat her daughter recalls what appears to be the Ilrst slgnillcant delusion 01 Mrs. Roberts accusing her son.in-Iaw 01 wanting to kill her. The ongoing loneliness Is a significant stressor, and continuing depression Is sometimes sulllclentto produce delusions, But the most apparent explanation Is that these are the persecutory delusions that sometime occur In early dementia. especially ilthere was similarly disturbed prior personality lunctloning; In other words, the apparent dementia has exacerbated Mrs, Roberts' prior paranoid personality lunctlonlng, Combining all these lactors. It Is not difficult to understand the development 01 her delusional thinking, Indlylduals with Paranoid Personality Disorder tend to generally lunctlon higher or to be more psychologically sophisticated than other Personality Disorders. This means that they are beller able to selectively Inhlbllthelr behaYlors or IIT\Pulses lor temporary periods when needed. This Is likely what Is occurring now as her daughter and nursing home sta" report that since the hospllallzatlon, and especially since the court petition. she seems to have exchanged the Inappropriate behaylors lor a more pro social appearance, Mrs, Roberts also evidences some qualllles 01 an obsesslye-compulslve personality style, and endorsed many 01 those cognitIVe schemas, which Is also belleyed to be another subtype 01 Paranoid Personality Disorder. Such persons are seen to be perfectlonlstlc, oyercontrolled, and wllhdrawn, Though Mrs, Roberts prolesses extreme loneliness, she may tend to ollen wllhdraw, She will occasionallY socialize such as through coming to lunch or a beautician appointment at the nursing home. but these yentures are relatively Infrequent and circumscribed given her need lor company. Her compulslyeness compensetes lor dementia dangers such as lorgelllng to turn 0" the stoye as she compulslyely checks things In her envtronment and makes order, Also, the sta" report that leavtng the stoye on has not been a problem wllh her as with other private residents. Finally, her diet was Investigated by revtewlng her cupboards. This reyealed products that can be easily used given her vtslon, leaturing canned goodS and loods that require lew steps to prepare. This actually Increases the salety 01 her kllchen usa as there Is less to remember and to cuI. There was a yarlety 01 all lood groups to Indicate adequate nutrition. There were also lew "junk" lIems, In lummlry, eyaluatlon suggests that Mrs, Roberts Is experiencing the eariy stage 01 dementia, though there Is the smaller possibility that thesa cognltlye Impairments are Instead the resull 01 a longstanding depression, The dementia and depression has exacerbated the symptoms 01 a prior paranoid Personality Disorder to the point 01 creating persecutory delusions. II could be said that she Is evtdenclng the classic example 01 dementia wllh paranoia which Is presented by the domineering. emotionally cold. and suspicious woman who, In old age and a selling 01 Increasing memory Impairment, hides what to her are yaluable' objects, cannot find them again. and then deyelops delusions 01 thell. pllanostlc ImerMalo"- 108M-IV} Dementia 01 the Alzheimer's Type. with delusions (290,12) Depresslye Disorder NOS (311) paranoid Personality Disorder (301,O) 5 RecommendeUonB 1. At present. Mrs. Roberts Is capable of running her affairs of daily liYing including hygiene and diet. Thus. It Is recommended that she be left in her priyate residence for now, Persons ranking 3 to 4 on the Global Deterioration Scale can maintain independent lIying; this especially applies to Mrs. Roberts giyen her Average Intellectual capaCil)', Also. her paranoid ideation does not appear to presently pose a threat to others or to her ability to function. There Is the question 01 Inevitable deterioration if Alzhelmer's disease is present; however. many individuals have been found to maintain this mild cognitive Impairment where independent functioning Is possible for at least several years, and continuing to haye an aide Into her home will provide further support as well as monitoring for dangers and medical compliance. Lastly. there is the diagnostic uncertainty at this leyel of Impairment, meaning that whereas mild Alzheimer's disease appears likely, there Is the smaller possibility that the symptoms could be due to another condition such as depression. Thus, she could remain In her current Independent living situation; however, glyen these possibilities, it Is recommended that she be reevaluated In one year. Successive eyaluatlons that can build upon a previous base of Information of functioning Is the best way to diagnose a progressiye dementia and to monitor the course of its Impairment. especially in relation to ability to handle affairs 01 dally living. A continuing decrease In mental status, memory, and Intellectual scores could Indicate a need for Change in care and guardianship matters, 2. Regarding financial matters, this eyaluation Indicated compelling reasons for both transferring financial guardianship elsewhere as well as leaving it with Mrs, Roberts. Reasons for tranSferring It include her potential to be taken advantage of giyen her loneliness, desire to move though need for help In this. and potentially (not displayed at this evaluation) Impaired judgment capacity associated with dementia, especially as she may not suspect another while busily blaming her children for wanting to steal her money. In addition, It Is at stage 4 of the Global Deterioration Scale that persons lose the capacity to manage the complexities of financial management. Reasons for leaving Mrs, Roberts to her own financial guardianship include the fact that. whereas she Is at stage 4. her financial matters are neither complex nor does she handle them herself now anyway. She maintains a simple checking account yet has been having her bank regularly write her checks for all bills and for her own cash withdrawals. These withdrawals also Indicate a reasonable use of her funds as review of recent months' records Indicate she utilizes a maximum of $100 weekly, When requested to produce her documents. she had them neatly organiZed along with bills that were ready to be brought on her next banking trip, She reports that she has her bank maintain her checkbook due to her vision; this also helps bypass difficulties managing funds that might potentially arise due to cognitiye Impairments. It Is suggested that she be permitted to maintain financial guardianship as this evaluation did not provide sulflclent evidence of a present and active Incapacitation in using her funds or in evaluating and communicating Information In these matters, This Is provided that compensation for her yisualimpalrment continue to be made by her bank writing out her checks and ledger, This capacity would again be assessed with the future reeyaluatlon mentioned under recommendation #1, However. if she continues to take any trips without providing notification, then the potential for overreaching Increases, and financial guardianship should be transferred at that point. If It Is decided that financial guardianship will be transferred, then Is it recommended that it be assigned to a financial Institution rather than to priyate Indlvldual(s). This will avoid the conflict that would ensue should she make paranoid accusations toward the person that had been appointed. 6 f , . , - ., \. ~ I I. Carlisle U~!:It r::J ifJ')pnU& CONSENT TO HOSPITAL ~MISSION AND MEDICAL TREATMENT ~\, ffi~~'t~c\ ~ Time. \ (AN)_____(PMI---- Name of Attending Physicisn (s). ~ Admiaaion. ,!,.W 1. I, (or acting on behalf of) Q \ \ . ~. 01 Authorl"'" R.~\lU" ~\~~. \. O\Q)h " sufferlng from a conditlon requiring hospital care, hereby N..... or FlU.... consent to rendering of such care, which may include routine diagnostic procedurea and auch medical treatment as the nsmed attending phYBician(a) or other of the hospital'e medical ataff consider to be necessary. Dste of 2. I understand that the practice of medicine and eurgery ia not an axact aciance and that diagnosis and treatment may involve rieks of injury, or even death. I acknowledge that no guarantees have been made to me as to the result of examination or treatment during thia hospitalizatlon. 3. I underetand that' (AI It ie customary, abeent emergency or extraordinary circumstancea, that no eubetantial proceduree are performed upon a patient unleaa and until he or she has had an opportunity to discuss thsm with ths phyaician or other health professional to the patient's satisfaction, (B) Each patient has the rlght to consent, or to refuse consent, to any proposed procedure or therapeutic course I and (C) No patient wlll be involved in any research or experimental procsdure without his or her full knowledge and consent. 4. I understand that many of the physicians on the staff of this hospital, including the attending physician(s) named above, are not employees or agents of the hospital but, rather, are independent contractors who have bsen granted the privilege of using ita facilities for the care and treatment of their patients. Further, I realize that among thOBS who attend patients at thie hospital are medical, nursing, and other health care peraonnsl in training who, un lees requested otherwise, may be present during patient care as a part of their education. still or motion pictures and closed circuit television monitoring of patient care also may be used for educational purposes or for documentation of the clinical course unless a patient expressly requests otherwise. 5. I release CARLISLE HOSPITAL from all responsibility for all articlee which I am retaining' or will have with me during my stay at the hospital. 1 understand this includes clothing, bridgework, false teeth, eyeglasses, jewelry, money, radio, razor or any other item kept in my possession. I understand 1 may deposit valuables in a safe provided by the hospital, only if this is done wlll the hospital assume any responsibllity for the safekeeping. 6. 1 hereby acknowledge ,~hAt 1 have receivpd written ::(j);;J;di2(;;;;;;' M:; . I information on the topics of {\"'I\.~~) ah\~"'- (SIGNATURE or. P~T,l. ENT) '{SIGJQ.TURE or WITNESS) . I q', '.1 (If patient is'unabJb'tq conse~l"br is n minor, complete the following.l patlent Iii! a ~inorl --'-" IYf'~f~ 0(. ,ge 1 lis unAble to consent because l' I '\ j' . ,..I' .rr . , "I . . I, I ' . . . r l: (SIONATURE or LEOAL GUARDIAN OR CLOSEST AVAILABLE RELATIVE) (SIGNATURE OF WITNESS) liD 0315 (10/91) PATIENT'S NAME: INSURANCE CO.: 00 0 , @/Carlisle Hospital O~)~\~\\J')' t.\~~\\,_\\\. ~o <.'he' c \:\' ~\\;_\.~\\ \,.'.w:.\. o " . , . Statement to Permit the Release of Medical Infonnation and Payment of Medicare and/or Other Health Insurance Benerits and/or Phvslcian, I authorize Carlisle Hospital as the holder of medical information pertaining to me to release the necessary and appropriate medical information to the riscal intermediary of the Social Security Administration and/or to my primary or supplemental health insurance company or it's designated review agency for payment for seryices rendered, I authorize the Carlisle Hospital's and/or the physician's billing agent to submit a claim to Medicare or other health insurance on my behalf, or to request, 011 a one time only basis. from the Social Security Administration. such inrormation necc~sary to complete the claim submission process, I am the individual to whom the information/record pertains, or am authorized to consent. on behalf of the individual. to the release of the information/record. I understand that any false statement or representation knowingly and willfully made or caused to be made for use in determining rights to Medicare benerits or payments may be punishable by a rine of not more than 510.000.00 or one year in prison. or both. I request that payment of authorized benefits be made on my behalf. I assign the payment of inpatient or outpatient hospital benerils to Carlisle Hospital for those seryices provided by Carlisle Hospital and/or I assign the benerit payable for phy- sician services to the physician. I certify that the information given by me in applying for payment of seryices under. '- Tit~/" ofAh}ff.;.ial ~~tYf:t rlror any/all othcr health insurance is correct ^ ~ 0/ &{j.0dL(U j.\~.cl~ Patient's Signa lure SSN Dale r JICU[ Responslble Party If Pallent Unable to Sign ilIP2SJd JT82rf2 l~I~[~I' HOeeO r un In8llr<<IlPa~gn't :tIVlBlJ''l'r [' !. t _ (ItdlflOCll\1llfLOnmatJer~tf M II'ftjont r\V'lmlnor.) U~l~~ IfDREU12' AlcrEJ!E H' ~.~ .vr; . . ,. .If. ..~ " '. Relationship Dale Dale Raasan Pallent could not, sign. ',\ \\. Witness " While ell/!y - Heallhcare Billing . .: ~ .. . ..,.,., ", ';~..'~'.,." ';'':.-<It'~'i''''. " '.' ~ .;, '-~-_.--..~.....'tT~~,v '." . Canery Copy - Medlcel Record. 1 Anclllery OeparlmenlB AD 1825 (10192)' '<' t' ',..-,:;'~:-' ," ~'. '-'. :,ovo: .~, -~':~.. .~.':..., " '" .~t.... .; ,,;'. ~ '-.~: ~_" ~::~ \: .~~' . . ,~.i: ',,' 1-" ,(' i: ':':'~tl'..,.' '. ... 1.:" '1':';;' .V:;." :.: 'tt""ci.::..:.: t..;;.. .~...1.' >-~. "';;.."'IIr."", " , .... '... ..~., -'. . ~..... .' . , '. .. ci Carlisle Hospital 246 Parker Stroot P,O, Box 310 emUslo. Ponnsylvanla 17013.0310 "eOO,346,4789. (717) 249.1212 AN IMPORTANT MESSAOE rROM MEOICARE (FOR ADMISSIONS TO PPS HOSPITALS) YO\1R RIOHTS WHILE YOU ARE A MEOICARE 1I0SPITAL PATIENT . . You have the right to receive all the hospital care that is necesssry for the proper diagnosis and treatment of your illness or injury. According to Federal law, your diacbarge date .uat b. d.t....in.d aolely by your m.dic.l n..da, not by "Diagno.is Related Groupe (ORG'a) or Medicare payments. . You have the right to be fully informed about decisions affecting your Medicare coverage and paymsnt for your hospital stay and for any post-hospital services. . You have the right to request a review by a Peer Review Organization (PRO) of any written Notice of Noncoverage that you receive from the hospital stating that Medicare will no longer pay for your hospital care. PRO's are groups of doctore who are paid by the Federal government to review medical necessity, appropriateness, and quality of hospital treatment furnished to Medicare patients. The phone number and address of the PRO for your area are: Keystone Peer Review P.O. Box B3l0 HarriSburg, PA 17105-8310 1-800-322-1914 TALK TO YO\1R DOCTOR ABOUT YOUR STAY IN TilE HOSPITAL You and your doctor know more about your condition and your health needs than anyone elee. Decisions about your medical treatment should be made between you and your doctor. If you bave any qusationa about your medical treatment, your ne.d for continu.d boapital care, your diacbarge, or your n.ed for poaBible poat-hoapital car., don't h.aitat. to aak your doctor. The hospital's patient representative or social worker will also help you with your questions and concerns about hospital services. Ir YOU THINK YOU ARE BEINO ASKED TO LEAVE THE HOSPITAL TOO SOON have have PRO. . Ask a hospital representative for a written notice of explanation immediately, if you not already received one. This notice is called a "Notice of Noncovsrage". You must this Notice of Noncoverage if you wish to exercise your right to request a review by the . The Notice of Noncoverage will state either that your doctor or the PRO agrees with the hospital's decision that Medicare will no longer pay for your hospital care. P. - If the hospital and your doctor agree, the PRO does not review your case before a Notice of Noncoverage is issusd. But the PRO will respond to your request for a review of your Notice of Noncoverage and ssek your opinion. You cannot be made to pay for your hospital care until the PRO makes its deCision, if you request the review by noon of the first work day after you receive the Notice of Noncoverage. . - If the hospital and your doctor disagree, the hospital may request the PRO to review your case. If it does mBke such a request, the hospital is required to send you a notice to that effect. In this situation the PRO must agree with the hospital or the hospital cannot issue a Notice of Noncoverage. You may request that the PRO reconsider your case after you receive a Notice of Noncoverage, but since the PRO hae already reviewed your case once, you may have to pay for at least ono day of hoapital car. before the PRO complstes this reconeideration. AD 0901 (9/93) --....""~4'1~.::,~~ . . . . . Page 2 IF YOU DO NOT REQUEST A REVIEW, TilE II0SPITAL HAY BILL YOU FOR ALL TilE COSTS OF YOUR STAY BEOINNING WITII TilE TIIIRD DAY AFTER YOU RECEIVE TilE NOTICE OF NONCOVERAGE. TilE HOSPITAL HOWEVER. CANNOT CIIARGE YOU FOR CARE UIIl.ESS IT PROVIOES YOU WlTlI A NOTICE OF NONCOVERAGE. HOW TO REQUEST A REVIEW OF' TilE NOTICE OF NONCOVERAOE . If the notice of Noncoveragc states that your phy.ician agree. with the hODpital dec iolon. - You must make your requeDt for review to the PRO by noon of the fir.t work day after you receive the 1I0tice of 1I0ncoverage by contacting the PRO by phone or in writing. - The PRO must ask for your viewD about your case before making ite decieion. The PRO will inform you by phone and in writing of its decision on the review. - If the PRO agreeD with the Notice of Noncoverage, you may be billed for all costD of your stay beginning at noon of the day after you receive the PRO's dec1oion. - ThUD, you will not be responsible for the cost of hospital care before you receive the PRO's decision. . If the Notice of 1I0ncoverage states that the PRO agree. with the hospital's deciolon. - You should make your requeDt for reconsideration to the PRO immediately upon receipt of the Notice of 1I0ncoverage by contacting the PRO by phone or in writing. - The PRO can take up to three working days from receipt of your request to complete the review. The PRO will inform you in writing of its decieion on the review. - Since the PRO has already reviewed your case once, prior to the issuance of the Notice of Noncoverage, the hospital is permitted to begin billing you for the cost of your etay beginning with the third calendar day after you receive your Notice of Noncoverage even if tbe PRO ha. not completed its review. - Thus, if the PRO continues to agree with the 1I0tice of Noncoverage, you .ay have to pay for at lea.t one day of hoapital care. NOTE. The proceee described above is called "immediate review.. If you mhs the deadllne for this immediate review while you are in the hospital, you may etill requeet a review of Medicare'e decision to no longer pay for your care at any point during your hospital stay of after you have left the hospital. The Notice of Noncoverage will tell you how to request this review. POST-HOSPITAL CARE ) When your doctor determines that you no longer need all the Dpecialized eervicee provided in a hODpital, but you Dtill require medical care, he or ehe may diecharge you to a Dkilled nureing facility or home care. The die~harge planner at the hospital will help arrange for the eerviceD you may need after your diDch1irg~: Medicare and Dupplemental ineurance policies may have 1~~Sd c(E~tir ge f~~~f' ki~~~d n~r ng facility care and home health care. Therefore, you shoul#,P ,,1,.# HW, 'J.<:h'li.6'V~C"lVr~1 r will not be covored and how payment will be made. . Consult wit l'/s'ur dcl /'r, <fib p't"a~ II! '!5q6 planner, patient representative, and your fal)llly in making preparations for care 1\ ter you leave the hospital. Don't huitat.. td, i,.k que.tion.. I . ,n~1111 ROIUTS, f/OLUn II . '.' ACKNOWLEDGMENT OF RECEIPT - Hy lsign{'tf're only ackno~!lQtlb.,.~ t,c'8\ff'NlltLt'V''f.1essagll fr.om Carllsle Hospital on } II ...,..:)_ and does 'l'tt/llem annf, fUr[~lil to request, a review or make me liable for any payment~ NUrREDI ROCCO L 'NO . I 0J",ofi1!;.tff, !.,i\ ~~~;;'1q 1185~5 ""...~,~;'d Signature of beneficiary or person Date of reCD pt ~. acting on behBlf of beneficiary ..:&l'yM . ~ ' \ . t', .'-....~......,.- . ... ci Carlisle Hospital 246 Parkor Slroot P,O, Box 310 Carlisln, Pnnnsylvanla 17013,0310 1,800,346,4789' (717) 249.1212 AN IMPORTANT MESSAGE FROM MEOICARE (FOR ADMISSIONS TO PPS HOSPITALS) YOI1R RIGHTS WHILE YOU ARE A MEDICARE 1I0SPITAL PATIENT . . You have the right to receive all the hoapital care that is necessary for the proper diBgnosis and trsatment of your illneas or injury. According to Federal law, your di.charge date au.t be datermined .01ely by your medical needa, not by "Diagnoais Related Groupa (DRG'a) or Msdicare paymanta. . You have the right to be fully informed about decisions affecting your Medicare coverage and paymsnt for your hospital stay and for any poat-hoapital services. . You have the right to request a review by a Peer Review organization (PRO) of any written Notice of Noncoverage that you receive from the hospital stating that Medicare will no longer pay for your hospital care. PRO's are groups of doctors who are paid by the Federal government to review medical necessity, appropriateness, and quality of hospital treatment furnished to Medicare patients. The phone number and address of the PRO for your area arel Keystone Peer Review P.O. Hox 8310 Harrisburg, PA 17105-8310 1-800-322-1914 TALK TO YOI1R DOCTOR ABOUT YOUR STAY IN TilE HOSPITAL You and your doctor know more about your condition and your health needs than anyone else. Decisions about your medical treatment should be made between you and your doctor. If you have any queationa about your medical-treatment, your need for continued hoapital care, your diacharge, or your need for poasible post-hospital care, don't hesitate to alk your doctor. The hospital'a patient representative or aocial worker will alao help you with your questions and concerns about hospital services. IF YOU THINIt YOU ARE BEINO ASKED TO LEAVE THE HOSPITAL TOO SOON . Ask a hoapital representative for a written notice of explanation immediately, if you have not already received one. This notice ia called a "Notice of Noncoverage". You must have this Notice of Noncoverage if you wiah to exercise your right to request a review by the PRO. . The Notice of Noncoverage will state either that your doctor or the PRO agrees with the hospital's decision that Medicare will no longer pay for your hoapital care. - If the hospital and your doctor agree, the PRO does not review your case before a Notice of Noncoverage is isoued. But the PRO will reopond to your requeot for a review of your Notice of Noncoverage and oeek your opinion. You cannot be made to pay for your hospital care until the PRO makeo ito decioion, if you request the review by noon of the firot work day after you receive the Notice of Noncoverage. - If the hospital and your doctor disagree, the hospital may request the PRO to review your caae. If it doeo make ouch a request, the hoopital is required to send you a notice to that effect. In this oituation the PRO must agree with the hospital or the hospital cannot iosue a Notice of Noncoverage. You may request that the PRO reconsider your caee after you receive a Notice of Noncoverage, but since the PRO has already reviewed your case once, you may have to pay for at least one day of hOBpita1 care before the PRO completes thie reconeideration. . AD 0901 (9/93) '. . , Palle 2 IF YOU 00 NOT REQUEST II REVIEW, TilE 1I0SPITIIL MlIY BILL YOU FOR IILL TilE COSTS OF YOUR STIIY BEOINNING WITII THE TIIIRD OilY liFTER YOU RECEIVE TilE NOTICE OF II0NCOVERIIGE. TilE HOSPITIIL HOWEVER, CIINNOT CIIIIRGE YOU FOR CIIRE U11l,ESS IT PROVIDES YOU WITII II NOTICE OF NONCOVERIIGE. BOW TO REQUEST II REVIEW OF TilE NOTICE OF NONCOVERIIOE . II the notic~ oC Noncovernqe otnteo that your phy.ician agrees with the hospital decision. - You must make your requeot Cor review to the PRO by noon of the first work dsy after you receive the Notice oC tloncoverage by contacting the PRO by phone or in writing. - The PRO muet ask Cor your views about your case before making its dscision. The PRO will inform you by phone and in writing of ito decision on the review. - If the PRO agrees with the Notice of Noncoverage, you may be billed for all coste of your etay beginning at noon of the day after you receive the PRO'e decision. - Thus, you will not be responsible for the coot of hospital care before you receivs the PRO's decision. . If the Notice of tloncoverage states that the PRO agrees with the hospital's decision. - You ohould make your requeot for reconsideration to the PRO immediately upon receipt of the Notice of Noncoverage by contacting the PRO by phone or in writing. - The PRO can take up to three working days from receipt of your requeot to complete the review. The PRO will inCorm you in writing of its decision on the review. - Since the PRO hao already reviewed your case once, prior to the issuance of the Notice of Noncoverage, the hospital 10 permitted to begin billing you for the cost of your stay beginning with the third calendar day aCter you receive your Notice of Noncoverage even if the PRO has not completed its review. - Thus, if the PRO continues to agree with the Notice of Noncoverage, you Olay have to pay for at least one day oC hospital care. NOTE. The process described above is called "immediate review.. If you miss the deadline for this immediate review while you are in the hospital, you may still request a review of Medicare's decision to no longer pay for your care at any point during your hospital stay of after you have leCt th~ hospital. The Notice of Noncoverage will tell you how to request this review. POST-1I0SPITIIL CIIRE When your doctor determines that you no longer need all the specialized services provided in a hospital, but you still require medical care, he or she may discharge you to a skilled nursing facility or home care. The discharge planner at the hospital will help arrange for the services you may need aCter your discharge. Medicare and supplemental insurance policies may have limited coverage for skilled nursing facility care and home health care. Therefore, you should find out which services will or will ~ot be covered and how payment will be made. . Consult with your doctor, hoopital discharge planner, patient representative, and your fllmily in making preparations for care aCter you lea.ve the hoopital. Don't helitate to., ~sk question.. I f II~ PI' 'oauTS. ytalUn ., RECEIPT - Hy j' iq't'\~re on I y aCknowretll1'lt 'hfv 'IScl$ilt>l:""1 lthlil1"'essage from on ::! 1-\0' and does npt;/~Bll,v,,~ a(!~ IR!I ,urig;.ls to request a liable Cor any pnyment,- IUllrH(~1 ROCCO L '''0 1- q/ ~-tJT: ~ <<II .# I 8t1bS21Q 1185'15 ~ 'xCP.IJ 16i{'k(~ ~ \\-~[DICU[ Signature of beneficiary or peroon Date oC receipt acting on behalf of beneCiciary IICKNOWLEDGMENT OF Carlisle 1I0spital review or make me .:.~ ,~ ;'.' .' I I , . ROBERTS, VIOLETTE M, MR #718545 512W ..- DATE DISCHARGED: 05/09/1995 DISCHARGE DIAGNOSIS: ., .,t1,Cl Axis I - Paranoid disorder J' . 0 (] Senile dementia of the Alzheimer's type - mild J'l Axis II . No diagnoses 'D Macular degeneration !J v '). ~ Axis III. Alds IV - Patient with frequent moves and change In living situation Axis V - Global assessment of functioning scale at time of admission - 40 Global assessment of functioning scale at time of discharge - 60 IDENTIFYING INFORMATION: this Is the first Inpatient psychiatric admission for this 75 year old white widowed woman from Carlisle, Pennsylvania where she lives at Cumberland Crossings Nursing Home In the residential section, She has no prior psychiatric history, She has a high school education and has worked In the past primarily as a homemaker, She was referred for admission on a 302 Involuntary commitment from the Emergency Room because of paranoid delusions. CHIEF COMPLAINT: The police came and got me and I don't know why, HISTORY OF PRESENT ILLNESS: Mrs, Roberts was doing relatively well until two years ago when her third husband passed away, She claims that she has been quite lonely and Isolated since then, She moved to Cumberland County Nursing Home to be closer to her son who lives In Boiling Springs, Since being there she claims that her next door neighbor an elderly male has been stealing her arti- cles. She claims that she used to be best friends with this man's wife and since the wife passed away, the husband has become "a thief'. She claims that he steals her pension checks out of her mailbox and cashes them, He takes boxes out of her garage and puts them In his own, He goes Into her home and steals articles Including cash out of her house. She claims that he has keys to her home, The staff at Cumberland Crossings changed the locks on the patlent's home but she claims that he made new keys for her home, She claims that he has never tried to harm her, She claims that there are no other thieves besides the man next door, She claims that she has seen him wearing her hus- band's wedding ring, The patient denies any previous psychiatric history. There was a report by Crisis Intervention that she has a previous history but would not discuss II. this has not been verified yet with her family. The patient has no major medical Illnesses except macular degeneration, Her only medication are eye drops due to recent cataract surgery, There are reports that she was refusing to take the drops. She claims that she was taking them on her own. She was refusing to haye the Visiting Nurse come to her home, . ! !''- 1,"1 l r :l' t . . ". .: ~;~~~". f " I r 4 I 1', "0 ~"I X ~ l L . A Y I.' I~, 4 I II ~ H li ~ l E. P A t' ~ v f r. i I. H"' C ':'~ L IIC: -. c. ,~ l. II 8 Slf 5 Page 1 of 4 ORIGINAL ... ." ."'1 CARLISLE HOSPITAL' " .' DISCHARGE SUMMARY , . ROBERTS, VIOLETTE M, 512W MR #716545 .- The pallent denies any history of substance use. PAST HISTORY: The pallent was born and raised In Nebraska. She claims that she and her younger brother were given to the maternal grandparents to be raised as It was the Depression and the parents moved away to find jobs. She did not see her mother again until the age of 12, She has never seen her father since, She claims that her grandmother used to beat her Incessanlly, The police would be called to take the pallent away but she would reluse to go she wanted to stay with her brother. At the age of 12 she went to Iiye with the mother, She claims that It an "Indifferent" type of relallonshlp and that she was too old to "play the daughter role". The brother died of cancer following Wo~d War II. The pallent's stepfather also died shortly thereafter, She has many other half.slblings from dad's other re.lationshlps but she does not know them. There Is no other family history of emolional disorders or alcoholism, The pallent has a tenth grade educalion, She claimed that she quit to find employment. She was married shortly thereafter, He owned a restaurant and night club, They had no ch\ldren together, Her second husband was In the Navy. They moved around quite frequenlly, They have a son and daughter together, The daughter lives In Illinois and the pallent Is estranged from her, She claims that the daughter Is jealous of the relallonshlp between the palient and the pallenl's son, The pallent's son lives In Bolling Springs, Pennsylvania and works for a trucking company, She claims that he Is the "big boss", She Is In yery close relallonshlp with him and her grandson, She was married the third time for 27 years and he died tow years ago, He was In the 'IV business, She claims that they had an excellent relalionshlp, He had adopted children from a previoUS marriage, They had no children together, The palient's past medical history is significant for macular degeneralion, Surgical history is significant for bilateral cataract surgery, cholecystectomy, and an appendectomy, She Is ALLERGIC TO PENI- CILLIN, She currenlly take some type of eye drop. She is a Gravida 2, Para 2. REVIEW OF SYSTEMS: Was noncontributory except for blurred vision, The pallent's height and weight are 57 7 inches and 62,25 kg respectiyely, Her blood pressure is 120/60 and her pulse 64 and regular. She is afebrile. Respiralions are 16 and unlabored. SKIN: HEAD: EYES: Warm and dry without lesions, Normocephallc, Normal hair distribution. PupilS equal, round, and reactiye to light and accommodation, Extraocular move- ments Intact. Without arteriolar narrowing, AV nicking. hemorrhages. or exudates, There Is conjunctival erythema on the left eye, Clear without lesions, Uvula midline. Supple, Full range of mollon without JVD, thyromegaly. or lymphadenopathy, Clear to auscultallon and percussion. Regular rate and rhythm without murmurs or gallops. Solt. Flat. Normoaclive bowel sounds. y.Jit~oul organQm~ly" l!.'~sSj!~,.q,r It~llfl~r' K . ness. r '. ! . d /,', · ~ :' ~ 1 M M [L .' A Y 1'/"4/11 [AHISLE, Pi ~1~1'1 :1, ncc~ L Yo: . ~C21 llPS~S OROPHARYNX: NECK: LUNGS: HEART: ABDOMEN: HI: I"HI . Page 2 of 4 ORIGINAL CARLISLE HOSPITAL DISCHARGE SUMMARY . . ROBERTS, VIOLETIE M. 512W MR #718545 ...- EXTREMITIES: Full range of motion without cyanosis, clubbing. or edema. BREASTS, GENITALlA.AND RECTAL EXAMS. Deferred, NEUROLOGICAL: Cranial Nerves - Intact. Motor Exam - No atrophy. fasciculations. or tremors. Sensory Exam - Intact. Cerebellar - Good finger-to-nose and heel-to-shin. Romberg - Negative. Renexes - +214 and symmetrical throughout. Babinski - Negative. MENTAL STATUS EXAM: At the time of the evaluation. Mrs, Roberts was neatly. casually dressed, well groomed, and appeared her stated age, She was pleasant and cooperative and offered Informa- tion freely and spontaneously. Her speech was nuent, coherent, and goal directed, She was oriented times three, Her affect was blunted and her mood anxious, She was angry about being in the hospital and she felt that she did not belong there. She reported the persistent belief that her next door neigh- bor was steeling her articles Including money and her husband's wedding ring. She had no other delusions or paranoid Ideation, She denied auditory or visual hallucinations, She denied that Inser- tion, thought broadcasting and thought withdrawal. There were no unusual tics, tremors or mannerisms. She denies Obsessions, compulsions and phobias, Her recent and remote memories were Intact. Her mini-mental status exam score was 24 out of 30 with errors only In calculations and orientation, Her judgment was Impaired as demonstrated by her fixed delusion, Her was good, good, HOSPITAL COURSE: Mrs, Roberts was admitted and treated with Inpatient psychotherapy, milieu therapy, activity therapy, occupational therapy, and group therapy, She refused pharmacotherapy. She responded slowly to this multidimensional treatment regimen and observation period, Her para- noid delusions did not abate over the course of her hospital slay. She continued to belieye that the neighbor was a problem in her home. She refused all type of psychotropic medications. She was quite cooperative, pleasant, and involved on the Inpatient unit. She interacted very, well with patient and staff, She demonstrated and voiced no suicidal or homicidal Ideation. plan, or Intent. Her mini- mental status exam scores did Indicate some mild dementia, primarily in the area of attention and calculation but for the most part. the patient's mental status was relatiyely clear, Information collected from the family over the course of the hospital stay Indicated that the patient has seen psychiatrists In the past but does not follow up with recommendations, She had been addicted to Valium In the past which was a prescribed medication, She had also been on some other type of pSYChotropic medication which helped alleviate the patient's mood, The daughter states that the pa- tient has always been angry. hostile. and difficult to get along with, She has been quite oyerly emo- tional. The patient had a difficult marriage despite the patient stating that it was a good marriage, The patient has always been recommended for psychiatric care but constantly refuses. this was her only psychiatric admission. ,. I J. .. l-~"'~. ~':.lrTTE H. : . I r .: : . '. .', S " I H H [L .. A Y 1:1"':/11 CIRLI SLE, PI t')~r:.[_:. L?~CCC L~:' .. -, ~ ~ 2 l'\ II 8 S Lt 5 ~t:i ~IR[ Page 3 of 4 ORIGINAL CARLISLE HOSPITAL DISCHARGE SUMMARY ,-,~~_.o..--....-_~_'_"_'--_'~'~ - '<.. ,""co.\ . "'-'. -,,,,~,,,,,':'\.'_'r"c'!i-~~~~ , . ROBERTS, VIOLETTE M. MR #718545 512W The patient was strongly encouraged to remain in a hospital setting, She refused this opndFJ, however. She very much wanted to retum to Cumberland Crossings to take care of her living, arrangements so that she could move with her son to South Carolina,' It was discussed with the patient's children that Bhe definitely needs psychiatric care but that she Is refusing It. As she presents no clear and present danger to herself or others. there Is no way to commit the patient against her will, It was recommend- ed to the son that he pursue guardianship, DISCHARGE PLANS: 1. The patient will return to Cumberland Crossings, She Is in the process of moving to South Ceroll. na with her son. 2. It was recommended to the patient's son that he pursue guardianship. .. 3. The patient Is refusing psychotropic medications. RLMlbjw 0: 05/0811995 - 11 :07 am T: 05/10/1995 cc Dr. Manfredi Cumberland Crossings . l. Manfredi, M.D. .. r:-,:, ,'o:q~. vl~L(TTE H I r J I <<I 1', ., ~ H I H" E L ~ & T · 1~/~4/Iq CIRLISLE PI ~H'Of:l. ~~ccr L'H:: .-~C21, 1185~5 "1:lrlRC Page 4 of 4 ORIGINAL CARLISLE HOSPITAL DISCHARGE SUMMARY . . . ROBERTS, VIOLETTE M, 512W MR #718545 .- IDENTIFYING INFORMATION: this is the first inpatient psychiatric admission for Ihis 75 year old white widowed woman from Carlisle. Pennsylvania where she lives at Cumberland Crossings Nursing Home in the residential section. She has no prior psychiatric history. She has a high school education and has worked in the past primarily as a homemaker. She was referred for admission on a 302 involuntary commitment from the Emergency Room because of paranoid delusions. CHIEF COMPLAINT: The police came and got me and I don't know why. HISTORY OF PRESENT ILLNESS: Mrs, Roberts was doing relatively well until two years ag(; wnen her third husband passed away, She claims that she has been quite lonely and isolated since then, Slle moved to Cumberland County Nursing Home to be closer to her son who lives In BOllir,g Springs, Since being there she claims that her next door neighbor an elderly male has been stealing her arti- cles, She claims that she used to be best friends with this man's wife and since the wife passed away, the husband has become "a thier', She claims that he steals her pension checks oul of her mailbox and cashes them, He takes boxes out of her garage and puts them In his own, He goes Into her home and steals articles including cash out of her house, She claims that he has keys to her home, The staff at Cumberland Crossings changed the locks on the patient's home but she claims that he made new keys for her home. She claims that he has never tried to harm her, She claims that there are no other thieves besides the man next door, She claims that she has seen him wearing her hus- band's wedding rlng, The patient denies any preYious psychiatric history, There was a report by Crisis Intervention thai she has a previous history but would not discuss It. This has not been verified yet with her family, The patient has no major medical illnesses except macular degeneration, Her only medication are eye drops due to recent cataract surgery, There are reports that she was refusing to take the drops. She claims that she was taking them on her own, She was refusing to have the Visiting Nurse come to her home, The patient denies any history of substance use, PAST HISTORY: The patient was born and raised in Nebraska. She claims that she and her younger brother were glyen to the maternal grandparents to be raised as It was the Depression and the parents moved away to find jobs, She did not see her mother again until the age of 12, She has neyer seen her father since, She claims that her grandmother used to beat her incessantly, The police would be called to take the patient away but she would refuse 10 go she wanted to stay with her brother. Atthe age of 12 she went to lIye with the mother, She claims that it an "indifferent" type of rel"tionshlp and that she was too old to "play the daughter role", The brother died of cancer following World War II. The patient's stepfather also died shortly thereafter, She has many other half-siblings from dad's other relationships but she does not know them. There is no other family history of emotional disorders or alcoholism, The patient has a tenth grade education. She claimed that she quit to find employment. She was married shortly thereafter, He owned a restaurant and night club. They had no children together, Page 1 ORIGINAL r'l: r'/', or ':"!'. '/.'LlTlE H. l l ~.. If, .. l f. t' I II( Ii {l lit. Y / 1,4/1" ~h:/:ll, PA ~Hr.r I 0.... .. ... L /I'" . '':'lC21. . llPSliS · [ : 1 . AP I CARLISLE HOSPITAL HISTORY , . ROBERTS, VIOLETTE M. 512W MR #718545 ,- Her second husband was In the Navy. They moved around quite frequently. They have a son and daughter together. The daughter lives In Illinois and the patient Is estranged from her. She claims that the daughter Is jealous of the relationship between the patient and the patient's son. The patient's son lives In Boiling Springs, Pennsylvania end works for a trucking company. She claims that he Is the "big boss". She Is In very close relationship with him and her grandson. She was married the third time for 27 years and he died tow years ago. He was In the TV business. She claims that they had an excellent relationship. He had adopted children from a previous marriage. They had no child ran together. The patient's past medical history Is significant for macular degeneration. Surgical history Is significant for bilateral cataract surgery, cholecystectomy, and an appendectomy. She Is ALLERGIC TO PENI. CILLlN. She currently take some type of eye drop. She Is a Gravida 2, Para 2. REVIEW OF SYSTEMS: Was noncontributory except for blurred vision. RlMlbr 0: 05/05/1995 . 09:17 am T: 05/05/1995 ROCCO L. Manfredi, M.D. I f rtJ '''iP'' o'qP~. ~I:LETTE K. .,: r~/C4/1~ ~~ 5"1"~EL .AY 11/~4!11 eARLI~l[, PA ~HF~E:I. ROeCe l M~ ~~bS21~ 118S~5 H13I C IRE Page 2 ORIGINAL CARLISLE HOSPITAL !'IISTORY ,; '. 1 (. j t'.l . ' '.' I I '1 ' "J l' C" . ' I. t .' SOCl~ woal PSYCBIA~RIC PSYCKO~oc1~.A8~,~8M!NT ~. ~. I\I\IJ(-;;orlHI'I.' \/ ( .. '- '. 12 ''15;'" I :: ~l [r ~ \ J. Name I .li " . r-ge t :., l,l t\ar i:~_li lSJ.tA.t'V"l Ethnic Backgroun I ---- ------ . ~..ra.' ::;:] '. ~I . --- j/ L~ ~ '-:];;> ~..::; /, --r z.::- ,J2VO ~i i!P-) @I~~ SOCI~ WORI SERVICE . PSYCHIATRIC PSYCHOSOCIAL ASSESSMBNT ,0512"'. ROIEIlTI. ,'OLUTE ' '1 05/04/~5 85 SKIKKIL waT ! 12/04/1~ caRLISLE. pa "l"fAEOI. ROCCO L MO . S'\bS21Q . 1185'\5 . MEDICaRE SS*20 (5/94) or. . (717)249-1106 ROBERTS. VIOLETTE M. 75Y F W W 85SH1Io\M~L'WAY'" 12/04/19 CliMB CROSSINGS 327-\6-2BB2 ' I::~- ROBER1S. VIOL~TTE M. B~, SIIH\MEL W/\Y ClIMU CROSSINGS C/\RLISLE r/\ 1701 ~, NiJnt.58 I MiONE I fltlA11(lM' SOC.SEC.NO ~lEll) C/\RE 32716288211. VIOLETTE M. CONFUSS~D UPSET MV BRIEF VISIT 26700 CLMlS 1 VISIT 26710 CLMlS \I VISIT 26720 CLMlS 11\ VISIT 26730 CLMlS N VISIT 26740 CLASS V VISIT 26750 CONVENIENT CARE I 27020 CONVENIENT CARE \I 27025 MINOR SUTURE EOSOI MEOIUM SUTURE EOS 02 MIIJOR SUTURE EOS03 INTUBATION EOS 04 N SET UP EDS OS CAR()\fIC MONITOR EDS II PELVIC EXAM EDS 14 NIlRO SET.UP EOS 16 CMlT, seOT01 SHORT ARM 26031 CMlT, SCOT01 LONG ARM 26032 CAST. seOTCI1 SHORT LEG 26033 CMlT, SCOTCH LONG LEG 26034 . . . NUT EMPLOYEU nIlN,,^NUIU!\ t.Mtnlll 111 /) .:,19-IIUb 327-16-28ll2 \0 HMI20IB'\ ~\/\RTl N. GREGG 1717125B-6904 04 II.FTRA HEALTH FUND 340079010 70 IBOOCAPrlNG ROBERTS VIOLETTE M. 1rotE0CJ.l ~SijiV.HCE 01 JOHNSON G MD ALL AODmONAL CHARGES 26037 r - - - - - - -, r - - - I I' 79064 I " I I' ' 26060 I... _ _ _ _ _ _ _ _.I I... _ _ - - - - - _.I 26048 r - - - - - - - -, r - - - - - - - -, I II I 79670 I I I 1 sooe' I I I ' 1..._-------.11...--------.1 26074 r _ - - - - - - -, r - - - - - - - -, ESTAT I I I I I 11 1 POXEO I " ' 1..._-------.11...------ _.I 26760 r--------,r------ -, 26770 I ' I ' I 11 I I 'I ' 1..._-------.11...--------.1 r _---- ___---'r--------'r------- , I \I I I ' , ,," ' , ,," ' ,-------------,,--------"--------' r_------------'r--------'r--------' , ,," ' , ,," ' , ' , . " ' ,-------------,,--------"----- --, ER.o5OB (REV, 7/94\ CAST ROLL, PLMlTER BIP MONITOR 26075 PACER PAOS GMlTR0/11EMO SLIDE KIDDE TOURNIOUET QCL PER FOOT F5B.S. TUBE GAUZE PER FOOT EO STAT pULSE oX EXTENOED CHARGE I EXTENDED CHARGE \I , . , /" . .' j(OBERTS, VIOLETTE M. CHIEF COMPLAINT: Confused and upset. HISTORY OF PRESENT ILLNESS: This 75.year-old lemale was brought under some coercion by State Police end Cumberiand Crossings officials, She has hed several months 01 Increasing paranoid delusions and was now thought to be a polentlal hazard to her own health. Basically she has been living Independently In a collage at Cumberland Crossings and has had delusions that her neighbors ere stealing from her, breaking Into her house, erasing the phone numbers on her telephone, and stealing her money end clothing, She has brought these complaints to nursing officials, administrators, State Police and lewyers In Ihe past month, Additionally, the visiting nurse has been coming to the house on a regular basis and has found her to not be complying with eye drops prescribed for her recent cataract surgery. The left eye has become Increasingly red and the patient has missed several doctor's appointments, The doctor did examine her once and ordered the medication Increased but the patient hes been noncompliant. In this fashion she Is placing her vision at risk. She has not made any direct threats of harm but Is angry at the neighbor and has stated that she will "get him", In her previous residence In the Midwest she once owned a gun but the family has taken this from her. She does heve e history of past psychlalric disturbances but has not been on any chronic medications nor under ongoing psychotherapy. She does not abuse drugs or alcohol. She has no family physician locally. MR '71"" ~ S\~ 05/04/1995 REVIEW OF SYSTEMS: Negative for fever, cough or other recent health problems by the patient's own admission. PAST MEDICAL HISTORY: Negative for slroke, coronary disease, diabetes or other serious medical problems. PHYSICAL EXAM reveals a mildly anxious, thin white female who has a slight tremor at rest. The heart shows occasional premature ventricular contractions and a grade 2/6 systolic ejection murmur Is best heard at the apex radiating toward the aorta and Is suggestive of aortic sclerosis. The lungs are clear bilaterally, The abdomen Is soft and non tender. The liver and spleen are not palpable, The neurologic exam Is without focal finding, Mental Status: The patient Is dressed appropriately. She Is somewhat anxious and very guarded and speaks hesitantly about eny personellssues, She denies delusions or hallucinations. Her speech Is fluent. Her Insight Is poor and her judgment Is poor as described above, LABORATORY AND X-RAY: A CBC was normal. An electrocardiogram showed borderilne left axis deviation with no evidence of acute Ischemia nor ectopic activity. There was no significant change from the prior tracing of 12/94 In the Emergency Deparimentlnterpretatlon. The urinalysis was normal. The chemistry profile had no significant abnormalities. The thyroid studies have just been ordered and are pending. A chest x-ray Is sllll pending at this time, TREATMENT: The patient was given e lunch tray end she was not willing to sign voluntarily for Inpa- tient eveluatlon. I felt she was et risk for herrn to herself end possibly to the one neighbor and there- fore I signed the 302 Involuntary commitment papers. I spoke with Dr, Manfredi at 1420 and he agreed to be the admitting physician etthls hospital. Page 1 of 2 ORIGINAL CARLISLE HOSPITAL EMERGENCY ROOM RECORD , 05/04/1995 , . MR #718545 , ROBERTS, VIOLETTE M. FINAL DIAGNOSES: 1. Paranoia, 2. probeble dementia, 3, Rule out hyperthyroidism. JGC/vfn 0: 05/04/1995 - 03:22 pm T: 05/07/1995 oyle, M,D, ....PATlENT ADMITTED.... Page 2 of 2 ORIGINAL CARLISLE HOSPITAL EMERGENCY ROOM RECORD NURSING DOCUMENTATION - EMERGENCY / CONVENIENT DEPARTMENT CARE CENTER D8Ie:~blQ:1 Arrlvod W'lh: o Pollco 0 Frlond o Poronl [] Fomlly [] Soil 0 Other .J k Carlisle I-h;pitaI CY Copyrlghl1992 NAME _ViS,) \ '\ LR&Q"n:.\~ ROOM. AGE 2\;> Wr. VITAL SIGNS; TIME ~T -?~r- P _Lo-.!:.\ ud l} Q Bp \ J,0__ ALLERGIES; -D , CURRENT MEDICATIONS; ~ TRIAGE NOTE: Trlnge Slnlus: [) Prlorlly I o Prlorlly II [) Prlorily III LI Fnsl Trnck Chiel Complnlnl: S-2..t t~-w::7 ER 2010 (4194) Mode 01 Arrival; o ALS 0 BLS [] Ambulalory [] Whaelchair (J Cnrrlod TETANUS STATUS: ~lIhln 5 Vears m:lO Years o More Ihnn 10 VeRls o Never Onset 01 Symploms; NursIng Action/Commonts: Childhood Immunlznllons: 0 UTD Trontment Prior 10 Arrival: = GENERAL APPEARANCE PULSE: .",.,. Regular [) Full ~EJ.P: ~..ormal o Audible Wheeze o Rotractions .!fOLOR: )C.l,Good o Pale ...e..KIN; UJ...Warm o Dry TRIAGE NURSE SIGNATURE ~ o Nevor o o Dusky o Cyanollc o Nallbods o Clrcumorol o Locerallon o Edoma o Other [] Flushod o Jaundiced o Cool 0 Ecchymosis, o Clammy 0 Rash, o Irregular o Wenk o Shallow o Doep o Loborod [] Rapid o Slow o Stridor = TREATMENT IN PROGRESS ON ARRIVAL: o CPR Down Time o Airway - 0 Orol. 0 Nasal [] Airway. Endolrocho zo o Alrwoy, N oal - Slzo o I olullon Silo [] Monllor - Rhylhm o O.ygen - 0 Mask. [] NC o Splnallmmoblllzollon, o Mast, Slzo 0 Pressuro Crossing 0 Other Menial Alltumen': Affect: Appropriate a uoted/Flal o Oorenslvo o Apprehensive o nestlossfCombalive 'n. LU~ Soundl: Righi: a Aales o Wheele o arm.1 o Rhonchi o Absent ~NIA lort: o Rales o WheelO o Rhonchi o Absent Pupil" I- . 4. . Righi- SilO Reaction _ 2. . ,. . lort - Size ~'A Reaellon _ 3- . e. . Though!: l\i:-Cloar /Sponlaneous aVaguelOlsconneclad o DisorIented a Slow to Answer VI lUll AClIvlly: 00_ OS o With Glassos o Withoul Glassos ~ N/A = INITIAL NURSING INTERVIEW: REASON FOR VISIT; 0 TRAUMA ~MEDICAL PAST MEDICAL HISTORV; TIME; o PSVCHOSOCIAUEMOTIONAL SUBJ~nVE: C,uso o~. Istory o~:o.senllllnk IW~:hO palienllells you):'Si_ - !L0 \1\)"1\ \ "'-'U,-\A~lb """' C\OJ.fr\r~': OBJEC~ I~formalion (Whal you are able 10 see). ~'\rv-- .. '"k PATIENT PROBLEM: Nursing Diagnosis _ Noncompliance ~Setl Car. Deflcil Comlor1. Alterallons In: _ ommunlcalion Impaired _ Coping, Inellective _ Ftuld Volume. Altorations In: _ Gas Elldltlngo. Impaired Tissue Perfusion. Aft. In: _ Sill" Integrity Impairment _ Thought ProcelSe,. Alt. In: _ Hyper1hermla (Feverl _ InroctIO". Potenlial _ Intury, PolenUal _ Knowtodgo DefICit _ Mobilify Impaired O!her _ Airway Clearance. Inelfecllve _ AMldely _ Brealhlng Pallernl. Inolfncllve _ Cardiac Outpul, Decreased Other OUTCOME/GOAL; E.poclod by Discharge; r~I~~~ "'- 1\Lvv0 NURse's SIGNATURe RUGS: .-- ------- .. Speech: ""'bl Normal/Cloar U'silonl a Tnlkallv8 a Rnpelillve o Mumbling *mory: nlact mpalred o Aocenl a OlstantIPasl WI F lMP: ... o o Maintain Pallont Alrwoy Manlier Cardiovascular Slalus o IV 0 BP Monllor o EKG 0 Cordloc Monllor o Saloly Moasuros o Rostralnls 0 Sulcldo Proceutlons o Seizure PrecauUons o Side Ralls Up Comlor1 Measures o Pain Conlrol [] Posilion lor Comfort r Preparo lor Exam ) Explain Procoduros I J Emolional Support [ Palenl T oachlng [ D'schargo Inslruclion: [ Olher ( Olhor Olher o Olhor i"n" .. I~ FLUID: --, .. MEDICATIONS Typo/Ami. su. C11lh. SII' TIme Slgnltur. Mod. Dol' Rout. 11me Slgn'ture . j ; .. TREATMENTIPROCEDURES: o RESP. THERAPY TREATMENT o TIMF TIME o OXYGEN o INTUBATION. SIZE o ABO'S TIME TIME o PULSE OX TIME o AIRWAY. TYPE o NASOGASTRIC TUBE. SIZF o GASTRIC LAVAGE .. INTAKE: IV Typo AmI. .. OUTPUT: . PO Typo AmI. Urine Ernel'a Other o FOLEY CATHETER. SIZE AMT.OUT COLOR .. VITAL SIGNS. 0 ON Bp MONITOR Time BP P R NOTES: TIME .. NOTIFICATION OF: D Hospital SocIal Worker o FBrnily o PollcB o Crisis InlervenUon o Nursing Home o Femllv QocIOf' o Coroner o Consullanl o Olher o Olher o MANUAL /WI / j", j _,,, /' /l L1 , "flj Jnh/-' J--Y~ d./f),(JJ //1 /. li~~ X-A/l'. J- . ~/ .. -X ~ /: "'" 7_../ A u _ f(l/ . A Ju F 1x:1J- ~~ hA A'" \< ~ y_..I /> _ JI r=-:- 'W-l- ~ . T. . d ~ .\uyn 'L.fC.1': ~J.- ~ O\? I.; (,' 0. "_I IJ ' A .. L1 II .....-L.//~, ~ L1,/ )l- /.'" /~.... " / ' , - -~1. V;- ,,-~ I~ It/;. 7{fl I.CIY f.~7h I~'-ID &It<.ll.... .. EVALUATION AND DISCHARGE NOTES: 1J-\~ o PATIENT I FAMilY VERBALIZED UNDERSTANDING OF DISCHARGE INSTRUCTIONS. DISPOSITION: DISCHARGE: 0 WRITTEN INSTRUCTIONS GIVEN ~mlned 10: 0 Ambul'tory 0 Self 0 Chell 0 UTI --5.\'2..",") 0 Ambol.,Of)' C AIII"Bnce 0 FBrnily 0 Crulch.. 0 KId.BY Slone D For Observallon 0 Wheelchair 0 Friend a Abd. Problem 0 Pelvic Inl. 10: 0 Ambulance 0 Police 0 Wound Care 0 SpralnIBrulle o Yran'lerred to: Other 0 Valuables 0 Clear llq\rld 0 Aslhma o Fever 0 OCUCasl o URI 0 HBId I\:Ju'r\ y)~~ ,~ o Oeneral o OIlier -tJ f\ o Other r- a Morguo PAllENfS NAME _\111 \ 1\ \e. ~w--' NURSE'S SIGNA lURE .~...",."~_._.~ '--'~.. ".-.-..., ",.".",;:...,,', '" "~~-:...-;..,,.....,,. . . :. I, - -, " . t.~.. I!-.!...." J. "",,,',''\;, r..fL"l.,....J.,.~....t..~~~j.~..~.~~.~~ll t...l.~lj'.":J!;~C."...j'i" '". ",,:,','. ,,," . ".;;..",." ;:j;I,""":;..I. ,,:': >":: ":"::'1'('1,h:,\'""'''''fi'~:<)<;:''''''i''''f'''\'';;~t;' .,iI!.., '. ""j't~"d ~" I' "", '. (. ,I. '.,',.. ,t t" '~"" ..!', 1~ \,00:- .,ut'.- C..~ "'.;l\o'\: '~~.):., T:, :9',~\', 1..,:". \-' : ,'\', .,!.....,tilo t . _I. \"'" ,,- t"'" ..J.t...:....! .,'.,...... 'r..'-.~\...l ,. ,I'. ,~t..~' "'" '\:' i .,',. t~f, }:t\~f..',:/.,\-'...;:\. " 'i~~ ..." (\ )"" '" ' . ,.,.,,,".,.,',.. .,..,..','"..'....1">"..'.,...., ,r - .,"~' .... .'" ...!.....,'.'.,"~..\.~il~:.!..~',.<;.<r1J... .., . ',' "" r f~l,ll".' '1..1,',:,'...I'.tJ.it'.C.4.......,r:.rk:.f...:..1...p.,~,\H., ''1<. .; I ,., .....,. .,'.' I~ ,_,..;' ... I' ~ ..... ~.' ,,,,,,,"""'tf1,,:~1.'" ~'~ ;:,~~I",,~:,t4e..:::81.,~,PAltola.()316h .... ;' , ''':..Cllnlcal Laboratory.~eJ)ort ' " ';":'~,r.~:,~, ROBnTS, VIOLKTTIl H. ADDIlNDIlH LABORATORY IlIlPORT PRINTED 10HAY95 ' ooB:12/04/1919 AGE 75 YRS F TIME 2206 (000)718545 5C 0512-W ADMITTED 04HAY95 DISCHARGED 09MAY95 DR MANFREDI. ROCCO L. PAGE 1 ~r:ry-; .' -~ . ~, f.'" 'U';;',;-;;.:;;; }5Jl'i:~;':' . . " (".' -, ~ : .,1 ," I "',' ';,. . i' ;J' ~..;:: ~ " .. ~I, :'- .:-'~',~~ ;:-:~'~';3;~:;'~~;~-,'::' ,':. DAY OF STAY SAT 003 :',:cOLLi hATI!l 06HAY95 & TIME 1745 PROCBDURE : . DROOS or ABOSIl IlVALOATION-OIlINIl---------QOALITATIVIl ANALYSIS . , ORucH/CREB iI Nl!GA'rIVB . .... I' . 0Il00S or ABOSIl CONl'IIIHATION-OIlINIl RtHARKSI g' n RAHf . 06MAY95 1745 .................................................................... 'THESUeHITTED URINE SPECIMEN WAS TESTED AT THELISTEDCUTOFFSI...~::;.:<,... !,";"". . . ',"~.r '~;"'~ ,----. ~. , . . -\" - ... . . ..':',: IU~FEIlENCBUNITS '.'" .,.. " ~,.--; ...., - ..~; ';. . " I: I. INITIAL TEST LEVEL (NG/MLI P' "<""... '.. CONFIRHATOR'l '.... ~.,:.~l;.:r:.,:~ ":""i',. METHOD ,"","', ,~,~.~',~. 'J:-<,.: :~i:'~:.:;~!t/'~"...) >..;;G'1f{~~)" DRUG CIJ\SS ., I 300-1000 300, ,. 300-3000 ., 300 " 20 300 300 300-3000 75 300 500 0,01 G/DL GC GC '.~ ~":,',:,' HPTLC . :; ;~. HPTLd<n,~_ jr.'~..-i"'l::-;:.;~::~,:;:\i~~;'. ".;, AMPHETAMINES BARBITURATES ..' ; I' BENZODIAZEPINE METABOLITES COCAINB METABOLiTBS I \;:' MARIJUANA METABOLITES . METHADONE .... "'.,:' METHAQUALONE OPIATES " PHENCYCLIDINE PROPoxYPHENE . i TRICYCLIC ANTIDEPRESSANTS ALCOHOL, ETHYL ' !' . HPTLC ,;. . ", ;:~;_'o~:;:.~<,:::;~l;ij~:: :Y'~~:'~,-~',j" GC OC/HP'l'LC ',;-.;' ......, , GC 'GC' '.,'. GC GC . .~.~ :J':~'~;.,,:~'r:{-~' THIS TEST IS FOR MEDICAL PURPOSES ONLY AND IS NOT TO BE USED IN A...', ,. FORENSIC CONTEXT. ...,.....,...........,.,..,...,...""..".......,.....,...,',..,..~. SPECIMEN WAS RECEIVED WITHOUT CHAIN OF CUSTODY AND HAY NOT HAVE BEEN HANDLED AS A LEGAL SPECIMEN. RESULTS SIlOULD BE .USEO.,.. FOR MEDICAL PURPOSES ONLY AND NOT FOR ANY LEGAL OR EMPLOYMENT EVALUATIVE PURPOSBS I . , , . f.:-.... ...'~..- .' ... .1 1'\ :.~ ~:~/ '" . ,~i!~L' 't" ,..'!.-,' '. ,,'., i ':"';', ; V;: { .!. :'; :~, :, " 'I. . ~. ',' "1; ;' '" .~_. :.' " ',-, .,.--'-tF".t;.....'.~r-: ;-. ~"'''!il;~~ ~ . ~;.,~;; ';''-'1 ~::' ....,.;.:.. ",,-f ,:,"",\+I.i41";'Y' \~a,""'; :..l........:.,:n Footnotes and Symbols f -FOOTNOTE, n -NeW on Chart ~ = DRUG SCREEN. REMARKS: REFERENCE LAB. .SMITH-KLINE LABORATORIES .. ;. .:'~ 7:,' ,; -: . ROBIlRTS, VIOLllTTIl M. 5C 0512-W PAGE 1 r.1-I~U/C:TRV t:nrl ,,( t:Je""rf ~'H;~~~it~':i~:~l: -1':~_:iJ" "", . :;:{' Y~~~;'" /' ''\,; ~ -:f:\~ fCJi,. /' .-{:; " ,~,,"'.:~)\".~,.,.'.';.':':,:.'.j:-.'~ '1i~tNrj.,.~~~~~~\,e~i~.:rJj'(::l~'x:~.~~~~.{iWfr.\ij~~}i$~ :l%~~hl:'" '~.\'i..'t-.,~,~,..~ P \'rf,IW~/;I,.., ~~,,'\'{'-' '1',,~~,,:,,\ !". ,. ., .. .h:.:N1"ffl.'~~'J.~'\'...~""'~.!.\ . ~,.Sif!':/...51. """\1i';'Y~'... 'i'" J',."" , ., ..j~' ' .." '. " ,.." ':., " ...;<,.' .".'.' \..,.!.".!!, ,~.u"",,,~\,~,,,,..,,".. tj~~';:;;;~"i.::;~;~.~W' '~ilnl~lla~orat~f,~~~~!)\'~j;~\~a~~j ROBOTS, VIOLETTE K. FINAL LAJlOIlATORV J\J:PORT PRINTIW 09KAV95 '" 008:12/04/1919 AGE 75 YRS F TIME 2153 (000)718545 5C 0512-W ADMITTED 04HAY95 DISCHARGED 09HAY95 DR MANFREDI, ROCCO L. PAGE 3 -.;. F-1N""~'(')".'~~ \ \" .~r .'!" ",'; .,I,c.'" ,.': , .,..... " ""-" 'F;~' ",";.' ; :.~'~~;_;~~.:~ :::~:;y; '.;. \)~r' '/, !_~'?:.',',: B 135 s 90 8'20 e 23 II 4/i' ";',. ,'< ,-., "1 -, ., ., " l .. " I 1 I . ,. J, ~.-. . ::;':!;f <.:..,.", :.\7 ''-t''~ '>1' ;l'~ ': . ,"'.",'-r..;;"- ." ,c,"". DAY OF STAY ': . coLI:. i DATil ' Eo TIME ,1":;~": I'RlldiouJtB' ." ., BNZYKB8 'Lb"' . ALK P,!OS. SOOT SGPT ."oor';' . THYROID EVALUATION . ;. ll'irlROltiNB "'c' , 8 9 10 T3 UPTAKE s 35.3 "":F'r:t"'i'''' l.cI "'a 9ir,' TSH s 2,71 ',;"'l,."i' .'....,"! " EMR 04MAY95 1400 ....'.'. '-'-""" 'REFERBNCgi"UNITS , ."" :Y[iOO-19lil'U/L 150-136) WL ., li5"3'1) < u/L '}'l~:~~l":.~~~"; -,...... I';" . ..~ ',' -, . '.' .~", -:'" " \" ',-'- .. '., ;., 14.5-1:a.Olug/dl' . . ,.,l29..9.-~5,0].'..> '..'''' , ',q .. . .:1,....15 j 6;.121 01 ,.",~..T.:'';::r'lil \ : "or .lo.3~~.?:.~~I'!rU/mL;-.. '1 I,l,', 1,'>,.'> n\';~~ rt.i,.....'\,bt-J.....'!:f..t:..I:, .. '.\ ",",1".; .:~,'I;.~~i-.~:; "". . -......,., ','. .,,' "":1 I~ _.... . ,.,- . -.....--..- -::1'-- ~-'''--' -,.- '~l \':Pl.;" .-...," A..~ "'[l"1~ ~ .1.l',J;'} ~_. -tit").. ,...".....:r.t' ~ r::".; 'i~. or'J. "",<."P, '~.:;uJ ."''\'''~f~!''..t'....~:...~_.-1".~t .... . '., :'1 ,-..,-" '( . . \- -'. .,.;. .~7r , ,.,...-.'7""'--' DAY OF STAY ....,. ceLL ,.' bATE . Eo TIME PROcBDURE olDlZ1lAL SOoLOGY RPR 8 NON REAC EMR 04MA'i95 1400 .'.'" ~ ,-',,' REFERENCE UNITS [NON REAC ':",,':"1';', ~ .."i.':""" ',.-' ":" ..;~ "., "~';' ':'};'~'._~,7'" ':. > ., \~ . ~ : ,~ ; \\'5" '.\ ,,'-, ;'I'-."l-,. ). \ I' ." ~ .' .; '.. :.i,~.t,'!~ \,:'4""\"l''- , . . _ . .. i.-~ ". ":': '~('.;,',,'~.;'-\,V~ ,~,~;...;~'_r '''';:V'''l _' ~_,. --\H;'. '. ',-.<.l< 4. :,~~:;,1-.L~tt}~~ l:~'t<!.1 ;$,.:11,. \.....: b.ff;...l , Footnotes and symbols . ., "STAT . :'.1 ~ l' ". ",:\.,.., " . " '.~ ......, . :. . ',< ':~,;. ,:-,:\';~; -;~';\','~i:~~-:r,;',:':'_-j~',..~:.t~JV;\\'~ '". .~ " .\~. .I\OIlJ:1\T8/ VIOLlT'd ... CHEMISTRY SEROLOGY 5C 0512-W '." End of Repor! ~. ;'_ :..~t',..',~~\ ~AaB : :::~:3;';',:;; :'.'-0-'::,,';\' ~ . 't' h',. .' I '.' ~.#.~,.,wtI'j' :f"'t~; ~!C-., '. '," 'Ill' '!'~'~ ~..' ~ . ,.:, 01..\.', :"'\I~"'l:I';'. ,f,......;~ ...-t!J!;'.'::.!I~.'J ',,'0.1 ..{'''',....,' . Ii', .' ..'f,'.....;tuf ' ...... 1(' ," .1'.,.. ~'T.~,.l." ..\'-4,\ J -''',C.,.,....j'.....''''l:;:.{\i. 1',,10 "'I" ,j'.- .,." .,.. ,." ,'.'" "\ "" i'.... ,.. .-. '. " "1" I"".""" n, <'.f.:"', ,'..((,-: '/"'1""1 I:': t~'f.,t,i.-..,'t tlil""I~" '(n.'~ '~';. ,', .~I-.\:),lrr.::.'1. :l,~rL 1\,.!f.t~,t:1'~.;,.~.....'l,,\".:IV'.: ~.. 'I , ' ,.... '\ ," '. ,'."" !. ".... ,,"",1,',. . ',,:;,C,:-"':':";h'," I ,.:~. ~. '"I.... ..,~.'I'.,. ;. ,.~_:''''....:'~.".!';..fl...(lill.-'l'1.".,j...:t,,\ f l\. t." \", (.. I' .. -' -t'.' ':'.: ~.~ ". :'.'~ .:.....J..t:...:.;:,~.,:.'; ~, .,: ':'!'DoIJI. '. ~"'::';:"".."";il ~"\,, .... "'".1 "'." -; .,1.,..,., ...,..,."../t,... .... ...},: '~i.."'.;",:;>.;t.e 1lIP1~~ tfilt4 to.::.' ...:" Clinical Laborator Report' '. .:",:;::.=..~u.o.:- ROBIll\TS, VIOLllTT& H. FINAL LABORATORY RBPOIIT PRINTIW 09HAY9S ooB:12/04/1919 AGE 75 YRS F TIME 2153 (000)718545 5C 0512-W ADMITTED 04HAY95 DISCIIARGED 09HAY95 DR MANFREDI. ROCCO L, PAGE 2 "'bAY' of 8TI,1/ . COLL. DATE to T!!IB' PROCEDURE MAl:Il118CbllXd; . SP,GRAVITY s 1.015 . IitcIl6ilcop%c!~ (Reforene6 va1u.. baud 6n 12ml eanhHugad volume. I VOL.TESTED s 12 ML WIlc . .: '. ~. II 0-2' RBC s 0 BACTERIA s oce.' CABT/BJilF . kYLNB/LPF DAY .OF STAY COLL, DATE & TIME PltOCEDl1ltE CHEM CONSTITU&NTS . " . FASTiNG s UNKNOWN BUN s 13 NA s l~BL K s 4,0 'CL .',,' II i03L C02 s 24.5 llLUcOSER 103 . I GLUCOSE Reference range comment: NON-Fastingl No krtown reference range. s ,8 s 9,7' s 3,7 s S.l11 s ,5 s -;,1 s 3,9 II 297 Reference Range: Footnotes and Symbols . L .~. H -HlllH. · -ALPHA ABNORMAL. s J8TAT :. 1l0I&ll'l'S, VIO~H. UA/CLlN MICRO CHEMISTRY CREA cALCIUM PIIOSPHORUS URIC ACID BILl T ToTAt. PRoT ALBUMIN CItOLESTERO CIIOLESTEROL Tlt!llLYCBRI . TRIGLYCERIDE f-=:;t:~.'i.;Jll}'l=VTT:V'ii>1ITl'J':T':T:'{.;:mEr'.'lI\""\~ , :~i..~'t."r-;:.r'...j.I'/~;:f~.... ,'/. " r; BM1l 04HAY9.5 . 135S " .. ".'1" - ", ..,-..., "., -..-} . ....~ - ..'" ,",' :',,'..," ... " i' " .,...., ::~t', I. : \ : REFERENCE UNITS -:~-~~ ..:,'.: ~'-(t~';~j~: :.j:~~::: <, ,'.-": " :, ,..--\ ~ . . '. ~ . ,. ..'.. ,..,' 1<4: !c',',' 1 <2.1. ," ....', ...~ 1 ;.'~.! '":"" -;". i~!~" e nnf" . ,..t' . ,- '~:,~f'~:' .. ~~... ~ , .' r., EMR 04HAY9S 1400 I" I I -. ,... .'-'''' . REFERENCB. UNIT8" ;> '! . ,'- ~. ...,.......::,..: ... ,,' -:,' .;' . ..-t-,'" , ". ,.. ,e .~ [7-181 mg/dl [140~lS2f MIl0L/L ;.;~' '." [3~6-5,t).}IMOL(L_.". 1104-1hl MIlO!./!. .IC, [21.0-32.0IHHOL/L '" 170-11(1) mO/dl ";, , ,,",\ . ,'. " [.6-1. 0) mg/dl 18.8-iCU]mg/dl 12.5-4,91 mg/dl 12,6-6.01 nlg/dl [.0-1.01 mg/dl .,. " 16.4~8.:iI' gm/dl 13.4-5,0) gm/dl ,.. '. . <lIlliidl i <200 mg/dl 200-239 mg/dl >240 mg/dl s 211H ! ., non fasting tt'iglycerides: no non fasting ranges . .' ! desirable cholesterol borderline high cholesterol high cholesterol '[30-2001 'mg/dl currently available~, .; ". ,r '1'. ,I ". ': ,.., ., '..,,.e.: :,~j 'rl.' :~,':E;~i::f ;'~"'J:~::> SC 0512-W Continued,.. . '.. "" . .':-.T:-:- :PAOB ""2' . ". \", " ;t,...", ....,."......:.... . FINAL LABORATORY REPORT . I . . . " -;~ ~ (.'~.'.f,'~....:.., ~"H~;:,"::-.t .;,.tr..:,h' .';'-i:"":'~J~ ,,',,'{; i':,";'-: . ..' ,.r" ,,::,;:.:'(:t::~.:r.~,\y~?,':\{8~:~~'P{~(:i\ ." r ,I ..-: ..~:.. t ';Il,t~ ""~1~~r;.; ~,~,~)!_~""-"-i,~".'J"~ Ollnlcal Laboratory, Re . ort.j'.,;~;--? '<ti., ~_~!\ 0911AY95 2153 04HAY95 09HAY95 1 PRINTED TIME ADMITTED DISCIIARGED PAGE """~' :. _1.1 "';"''Y,~'#'t.' rt'; ,\,,.'. ,; -,i'",''-' ..-....;..'. 't', ,v.~....t.r~,~::t~:o',~.. \ :i~.."r"":, ".'"'''' '," .,\:"f :':~i;.'~~pitaf'::';}\ .l..';~'i1i~:;l'l e.PorWt8t.,CMIUI,,,",,.i O!s-Oii 0.. :.." :' ROBOTS, VIOLBTTB K. ooB:12/04/1919 AGE 75 YRS F (000)718545 5C 0512-W ..'~i.':'>;: 11;(:,,:,>,; , ':,1 ',./.\: tl".I -. i'I"t./ :;;,;/ !~.} ~1 :';':'i;':'.'-J;; :....',': DR MANFREDI, ROCCO L, I!': '7"W~ .j '. . .;; ,-"-' ! . ',-... ~. '. . '. .~',' .. .,,". : oM! oti STAY 'l!MR COLL, DATE 04HAY95 . "', TIMk' ::'. 1400' ..,. PROCEDURE ltLOob <<!1It.t. cOUtft' " ' . WBC. s 9.9 Rae s 4,47 11GB s 14.1 'Her s 40,S MCV s 90.6 . " Mclt:.s 3Ls;' ",: MCIIC s 34,8 Row . s 12.6 PLT s 288 AbtOItAm DlthJ\BNTIAL . " NEUT , s e4.1H "iNM~~ " '0 10.,i,' .:. MONO' s 4.4 -~EoS Y iI ,2 '. BASO , s .6 NEUT . s 8.32 LYMPH . s 1. 06. MONO' s .44 EOS . s ,02 BAsa . B ,06 ,.1"1 ' : .,: :~;-,; .',:r'j :. ,';;"-t. :.. ,.:.~L~.1ij~-:'.~'l"\~ . ,'i \. ~';," . ~.;' ~ ;y~:;" ..-~. . j~. ~ f,._'-.~.~..:;i: ;"'-,~. : :' :,~;..:.i':~'~l . REFERENCE . UNI~S, , .' " ..', . '-"t".. . I" , " . I " ,-' '", " I" ",' ',"".,. ~,. '-,. .\ ':'- .. ~. . - ., , .. -. . I I' [3.8-11.0IXI0.3 , . ..:,...h.5li:;s~26IXitl"6. '\L'i .., Jll.0~1~,Olg(dL. "., '.132,'1~4SI0It:.', , [80,O-99,OJUW3 "; ~':;'12i,tl~34;0IPO"" '. ,[32,.0-.36.0Ig/dL, .' ,.lll.0-16~OJt<,:' . ""', [~4?,7.,48,o!"''\~~.~''';''''1 .. .... L' ',- <,;.-,".."" I.".. '.~j t. -, ~~J i ."J i I .' .__ .....J48...0.~.80,.OJ'.,... ...' ".. 12tl.Ow45,Olt'. ...11" O,71~. 01\ ,. ,. .' [.0-5.01, t." [.0~2.01 \, [1.30-9,80IltlOA3 . .[1.00-.4.2~IXI0.3 1,00-.601 XIOA3 1.00- ,40J XI0.3 :[,OO-,20J'XIOA3 P'; , . . ..,~ I, ;.' bAY OF STAY COLL. DATE " TIMI!: PROCEDURE MACROSCOPIC COLOR s YELLOW APPEARANcE S SL CLOUD PH s 5,0 . PROTl!:tN S .NEGATIVE GLUCOSE s NEGATIVE kEToNI!: S NEGATIVE . BLOOD s NEGATIVE UROBILINOG S NORHA~ BILIRUBIN s NEGATIVE NITRITE a NEa LEUK ESTER s NEG . EHR 04HAY95 .1355 ,',j, , , " .' ,",' REFERENCE UNITS . . , . I '. . . [TRACE' f' .:::'( , [NEGATIVE I ':'[NEGA'l'IVE'1 [NEGATIVE I t,',. ... . . . ,,:,. I <!,,1BU)c111Ilu/dl: . [NEGATIVE J .... [NEG;I'~:\';"'" ",', :'''Jl ._ [~EG. I '. .. 'i.~'.I~._:,;:/i.,::-~..::'....< I ..., . Footnotes and Symbols L -LOW, H =HIGH, s -sTAT ':..-' .':;'!;...'.,~y:~~(':,~'r-:. I\OBIIJI.'1'S, 'nOLl'1"1'Jl H. HEMATOLOGY UA/CLlN MICRO 5C 0512-W Continued.., " :'i.--:-- PAGB~...,.l':..: _. t", . '. ' ."d"""_ CARLISLE HOSPITAL FILE * DEPARTMENT OF CARDIOLOGY ERG I PATIENT: ROBERTS, VIOLETTE M, DA~E/TIME: 05/04/95 PATIENT II 8965279 ROOM/BED:~\~ DIAGNOSIS I CONFUSSED UPSET ADMIT DATEl 05/04/95 BIRTHDATE: 12-04-19 MRI 718545 PT: 3 PT ADDRESS: 85 SHIMMEL WAY CARLISLE, PA 17013 ADMITTING DR: COYLE, JOHNSON G MD ORDERING DR:COYLE, JOHNSON G MD ATTENDING DR: COYLE, JOHNSON G MD REF/FAM DR: <<<<<<<<<<<<<<<<<<<<<<<<<<<< ERG REQUEST >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> ORDER I 0005 START DATE: 05/04/95 BY: RNLO * TODAY: 01 ELECTROCARDIOGRAM ~ _ '. FREQUENCY: ONCE SPECIAL INST: ~,........ 5&5" 35 13~1 INS: MEDICARE 2500 ELMERTON AVE OP HARRISBURG PA 17177 CERTIF I 327162882A GROUP * HH120184 BRIEF HX & SPEC. INST. aaa..aaamaaa..aa...a...aaaaa_: INTERPRETATION aaaaaa==..===aa=_aaaaaaaaaaaaa_aaa AFTRA HEALTH FUND 261 MADISON AVE NEW YORK, NY 10016 CERTIF * 340079010 GROUP * 1800CAPPING Roberts, Violet Electrocardiogram Tracing AI1" ~ 1, Normal sinus rhythm, rate 60, 2. leftward axis, 3, Nonspecific ST.T wave changes, 4. Compared to previous tracing, no significant change, DGKlbjw D: 05/05/95 . 1112 am T: 05/05/1995 1 ""YDU David G, Kann, M,D, PH ICIAN DATE 'I' :jl: :l~; ;';' ]:;: .!;! l;:l !( -~:'I ':i "":" ! II; ,II I 1:\ ~:L 111l I'... ~"i:";:,;', ":l I ~~, I" I : ; , I . i. ,~'. !: l: I ,:\ :t :.. 'I i:f: "': '~li' ',' , ',,"1... t, "1"" ,., 1..1 '1" ::! j i: j~ HJ I ;: :~ I 'I:: :!:' :: :, ;... .~t' "1'" ,I I". ,.;", t~', ; L.I I ' 1 T I.: .i;, .:~. ... " "I' , " "'". ... . '~lj~:: ;:~. I. ,', : :lL L.. .... :Ii' 1:;: :1::.. 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'." :.;t ':' ".. .::' :':." .... ":.: .... ; . ... . ~ . ' .... ::-. :.;:j.':": ;... ..:: l.' . ;: ~: : . . ... ~:. I ". :.. T iiiiii:~':1:: ~I: ::: : !:~ Q ,., Ii: ;;:'~. li. , "', .;',.. , :; ..1.. ;': ';j< :" "I: ':1' ::;1;! : ..' ::1;' .. ~ .. .. .., .1 ,'I) ",: ... .. l' Ii, '1" ... ':,', ". " ::: iJi: :!:: ;[:: :I!: .. .; ... ".~! n .. '! .' ';" Q :: u. ........ .. .. .a .., U > II .- n ".. ~:. ~ c:r - .. .0 ,: . I .... ... "':"":':::; I:: . ",;;, .11, ~ ::~ I':::!'::::i:j.: "11 ",:' ": :~:; T: II . :::..:.. .... "t: 'on ... 'II 1. u ,; .w :i " , ADMITTING ORDERS. PSYCHIATRY DRS. ERIC K. BONSALL & ROCCO L. MANFREDI ,- -DATE ORDERED ORDERS NOTED BY v Room 51) IJ IJ.. 2, DIAGNOSES: ./ 3, DIET: Re ular ,/ ./ 4, VITAL SIGNS: Per unit routine / V 5, ACTIVllY & OCCUPATIONAL THERAPY: per unit routine ./ va, lEVEL I .I 7 -MEDICATIONS: 1, Tylenol II p,o, q 4 hours PRN pain or 2, Maalox 30 cc p,o, q 4 hours PRN Indigestion V3, Milk 01 Magnesia 30 co X one dose PRN for constipation lasting over 48 hours, may be given lor a period of two days ~- j rtc. /; .,......... r " , \ 9, CIICBT )( rv,Y /l~(Dr, (V\.. ~ ) 10 Read 11, AEl6L~gC[rff CUIDELlNCS /12, O,T. EXERCISE 3XN1K ~s JCj{5 : / M!.> W/L ,.//~ '~':. PA IDENTIFICATION ".J. Carlisle Hospital ~46 PARKER ST,. p, 0, BOX 310 CARLISLE. PA 17e13-o:110 C51lW ROBERTS, "OLEYTE 05/04/Q5 85 SHIKIEL WAT 11/04/1' CARLISLE. PA "'NFREDI. ROCCO L "D 8gbS21Q 1185QS ADMITTING ORDERS "EOlelRE PS 0103 12193 :r."'''' , '.f ':i::-~ .,-.-,. . '~i. . ,J " i I " , ' .. <, 'Y ...,. 05~.-t/ ROBERTS,...-410LETU 1.-,-. f;,: 05/04/'J5 85 Sill ""lL wAY '~. IZl0411~ CARLISLE, PA PROG ESS 0 MANfRfDI. ROCCD L MO ~i'ir,llDINa ~HnICIAN '11 8'lb521tt 11 ~,~ '~ -- 'j -- " '. ~ . ..... - , , " 'ilPII 104195 'OHI9 ROBERTS. 'IOLETTI 8!1 3H IIIIIn WAY CARLISLE. PA DATE ~b 2 q ~ I .. \ ~ . . ' i \ , . . ',I ' . I~, . 'f,051111 ' ROBERTS. f10LET RESS NOTES '. OS/04/~5 8~ 1M 1 RKlL Ill' ATTlENDINlJ PHYBICIAH \' 12/04/1'1 CAIILISL!. Pi . ' . . ~-""i <V ,,::nv DA'E S'lbS2,'l 1185 ~.." -~... ~lll,f~1 Ufl71r. ) 0,1<: J~ .' ," :'vJ::.-rTIII,.IOi d -, ~-' ' ."r~") . ,.~ ~ 7/[.-1 -J-. ), 7j;; /J 7' ~/dCKAJiJ ,,'11'110;- nw .",'" .n "JIlH ~~."" "tJtJ:/I,~I-r./< I -('~ ~J1;, I JI _. . .T -, , r \7 JJ A'" ., C'" ~ ~ - {J...,J-J,.. JJ u.n.:N- AliA. ~ ^"'^-" 1-: "'. . _ II. 1\l.D I-Z I M".,,~....-Jr, , ,T' ~, ' -cr -:(}.. I'jYL~ L"Jal1\' I nl-lO" I. ". -: A7,' "~.. ,",' "7 -}.tJ. ~ Jl?~i.. ., ,,- II J , / A "/\ =:..---- " ,vv /_ 'is Slqs }; <' ;, . L" "V-L. .... (I A . ..:,,,^ ,j) J7'.. _lA' ~..7T'. ";''1 t..{)c::, " '~-.: t'n1,/\ n (j" 1OA11 \/-.fvJrl, ,II: A',. tJ t; ll]" L 1,_" /v.7 '\;:-r. "rl),. V-ln L/~~l,,";;(JR,"A:;u;--..;':f;I1&II,-h ~ "- J j 1'1/1/10,,, . L' I) M.~"~ A ~ 1- /J /1" A /.,., 7- 'IA'{I)'V., IJ ,'" .\J-' N~i.", ,.y 'fIr- ','~ ..~ 1e.,~) -P J'A f,.7IJJ. ~OJt\. (.: -Q u. .\n -t. : I , tJj)/J ~ M\. 'A' , /l -(), A~I !, "/li.Af..lIl,IJA 7. " IAA ..A .:. (1'-lt:- E" ^ AL ,~-71-tlJ. ) d(l.."., 'J, of..l. 7dA (II A'. j 'A ) ~ ~.r): . " ) (>( 'A '""P ~ I /I ():/l i-.1 ~ Wo L1J -fJ,;...J~. :rOl".- il,IOAllll....j ......l14~\$:(l..I,n.!.:.(cA,/l " iIJA-J- II _ .>... 'C'('") ~j- \Jv (j, ~,Il~-'tf-11{) ~I,-J t,;~, ()/J. ~a;/' fA', . :-;;j~ ~ 11 ,-,. /J ,t "- .. I A' _. iiO~ Ik 0 A' ~,.~ ,i' ~ I.. ,jJ-,- ,,,f J, L,l. 1 A " '. H. 'M. ~ -+; .:,- '~P.<"/. _~'-Lt, ~"^\ ~Ot\Il_L':".. f\n,,~1:.t../lA A~' 'TjL'~ \JJu,~ ) ti.GJ J...... -/1 ,(\' In~. "(1 ;~: '-r<~'t-.o '/~':--'ifI-IA ; ,,",..,," iJ.rv ,,() AA -::..,,(.. ~\..I,,! MA 11t\liOlla~ ~) <fin 01'7 ~I- QA~ ....n (j'--' ~ , . ~" '."'.1 I 1 1'1 J / - /-,( /l .1\,. ''''.,!rJ.~rl1''>''~i (1/170.. _ J'trl' .A JJ~;{II.;O A{J",//.IJ." I.' \ ~ l : ~+~): ,111\ J ,~~ I I ~.~ f (1 1/1",0 t1 Ot" ,_ I:JJ I 1 I;;L. n (J;- ~~J..I"d /A"~ r:..,~L~!r\ IA-tLA^ A.......A \J _r U .,"""'" v,......... , -,-,~ ~_ ... . VY 9/8: 7625 1 ; , \ , f. ~-~- Oil l.t.. ~""T.__ ""-"?4mjI~' ..,.~ - : Ilm:m D!"':~'".___...... _ ----_r'...;'".\.'.------ 1~1ILl.:..-~ DOnJDOnJDlIl ~--_~~__~I ',.' I: I' '1 "( D"I' ,I ': 10'1211' I t1,jOB!RTI. YI'OL['TTI It . 0"04/~' 85 SHIII"[L WAY Itl04/1t CARLIILI. ra "ur'[OI 1I0CCO L liD I ' - . t ',; C ' Ill! I 11\11 ,II .t 1 IJ; ., 'rr) I . , 11" I ~~ HJspita1 ~ CUNICAL RECORD ' ,'~': ,I . . , DAn HOSPITAL POST.()PER, OAV S""' A PM, AM WT H' I e .2 I e .2 I e '2 F C '078 t2 '051 .. W a: ,~ '0 ~ ~ '021 " ffi Q. '00' N ~ He " H' :18 15 S& 110 liD .eo liD ,"0 ':lO W .... 120 ~ a: w liD Ul '00 ..J ~ Q. 10 10 10 eo 10 <10 ') I I', , AM PM AM, PM, AM, P,M, A. 12 . e '2 . e 12 . e 12 . e '2 . e 12 . e '2 . e 12 . e 12 WEIGHT ScALE CALORIE COUNT ------ .----- .----- .----- .----- ------ ------ .----- ------ ------ .----- .----- ------ ------ .----- ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ .----- ------ ------ ------ ------ ------ ------ ------ ====== ====== ------ :===== ====== ====== ------ ------ ====== ------ ------ ------ ------ ====== ------ ------ ====== ~==S== ------ ====== ====== ------ ====== ====== ------ ------ ------ ====== ------ ====== ------ ------ ------ ------ ====== ====== ====== ~===-= ====== ====== ------ i.il.f DATI: I l'IloII ,,' ,." ".r .', ,." "., ,,' J.lt "., ,., So" It" ,., ,." II.' ,., ,." tI., ,., ,." ,.., ~O lUll '110 IV .. ~ _TlON ell ..... TOIAl .. .... TOTAL WHOU IlOCO ~ACllID CULl Al'WIN " PlA.au. "'ATun. TIUI 1,1 .." tI., '.1 .." I.., 1-1 So" tI., f.I .." ,.., f.I Soil n.' I" So" "., '.1 Soli ,.., _D . , ~ 'Olly DflAIN. . ~ 0 NO TUlI IWI... . .... TOTAL 14 .... TOTAL , ~ ACTUAL . RINAl OU"UI - .:. .....TOTAl, r I~ k....TOTAl. , I' IT -., . - - .~, ~ " , .,\1","" "- STOOI.I , , . '" . ~ I L II IHlau. , I,' . " , ":Jr I r I " 1;1 All INrAKfAN6'dUl{~Oi- WIL~ BE RECO,RDED iN cC's ONLY All Bl( ") AND BlOG 'RODUCn 'ILL BE REC IDEO IN UN j ONLY NO o32SiU/U7) I-PART From 05/09/95 01 07;01 10 05/10/95 01 07:00 DAY SHIFT EVENING SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 07. 1.1500 1501..2300 2301.0700 PREDNISOLONE n OPllTH SUSP 105-05-95 -'l IIUU. l~UU_ 2000_ 12400_ 0400_ SCH TO LEFT EYE = I roSE OPH Q4HWA 005 INFLAMASE FORTE I DROP IN 'LEFT EYE '----- ~ / ~ ~ / "'-- ""'" X / ~ ~ / // ,/' ~ / ~ ,/ "" // // O~...I !!!Ii!!. Nm ......on lVC.....VWII LAT.lefuntthlgh lO.....~()Cj UQ.....IodI'Q\I.d INITIAlS SIGNA ruRE 1N1T1AlS SIGNA ruRE RVC.rlQhlvtnl RAT'righllll'ldttllgh nO"lQf1lde'Otd Ala' 11Ij1\11oM1 quad I,ll/I) l/i f ,,;, J[..!I!!f ) lOC ' ""dOtl&l Uy.....1a11h91 RLA "IQN "'arm lua.1ett upper qlUlll ROC"~dorI'l RLT.fiItlIla'lh91 lLA .""11,.,,1."" noo. '-1'1 ~ quid /(1 lVl.W'!v....1 rY RVl........., N.NPO R.nefuHd p.OnP... NN . Nlu..alVomlhng I..) " Adm/nlcm Dat,,' 05-0e.95 T.r.It~ CarliSle Hospital Medication Administration Record NOIJ05A (REV'/PIU) Ndmt ROBERTS, VIOLETTE M. n..,,,,, 0512-W ARt: 75 YRS 5..: Female 111,: WI: F,llQIIc/oll, 008965279 I'hyuci..,,' MANFREDI. ROCCO L. PaR~ I: 1 ttt continued ttt /'1, N""'t: ROIlER'tS, VIOLB'I'I'E N. AlinK'" PENICILLIN AND DERIVATIV ,- MR': 718515 ", Carlisle" Hospital Medication Administration Record NO/JOS'!' (REV 9191941 "'fUR;'" PENICILLIN AND DERIVATIV HaM" ROBERTS, VIOLETTE M. R..'m': 0512-W ,!.R': 75 YRS Suo Female III.: 11'1,: F;"".rfall: 00B965279 Ph)'s;r;,..: IlANFREDI, ROCCO L. '- From 05/09/95 at 07:01 to 05/10195 al 07:00 DAY SHIFT EVENING SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0701-1500 1501-2300 2301.0700 ACETAMINOPHEN mHG TABLET 105-04=J5 PRN 650 IlG = 2 EA PO Q4H 001 AS NEEDED FOR PAIN .. ALU-MAG SUSP(HAALOX) JOHL 105-04-95 PRN 30 NL = I EA PO Q4H 002 to SHAKE WELL to AS NEEDED FOR INDIGESTION NILK OF MAGNESIA SUSP JUNL T05~04-95 PRN 30 NL = I EA PO PRN 003 'SHAKE WELL'- X I DOSE PRN CONSTIP LASTING 4BIlRS, MAY GIVE FOR 2 DAYS WRAZEPAMIATIVAN) O,5HG TAB 105-04-95 PRN 0,5 HG = I TAB PO Q4H 004 PRN ANXIETY !!!! WPERAIIIDEUHODIUHj lHG CAP 05~07-95 PRN 2HG=ICAP PO PRN 007 AFTER EACH LOOSE STOOL . HAl{ B PER 1124 HOlIRS - ~ - '. / , , " / '. ". -.-. rZ. ". . // --- ~ ///0 " ------ -- . au.,,' ~ "m _... LVC.""~ LAT...,untrugtl LO.1ith dtllod llQ. "I'lIoMf quad INITIAlS SK'.NA TURE INlTtAlS SIGNA runE RVC..""" RAT. noN end Ih~ RO.'Jgt1l_OId RlO. '~bJm quid lDC .1If'I dorMl UY.lIfIlIlthigh RLA . rlgtlt III arm lUQ. left l4lPI' Quad ROC. ~ datul Rll . rl;N IIllhil1' UA.1ttt 11.1,'.11"" ROO. 'Vol uppet quad LYl. WI VII lit RVL. righl.... lie N.NP_O A.RefuNd p.Onp,.. tW. HallMalVomrtr.g AdmiJlIOfl Dalt: 05.0t.95 T.T'I!"!I P",.,: 2 .to end of report tI' PI, Ham.: ROIlE1lTS, VIOLB'1"l'B N, MR': 7185t5 (:arliSle Hospital Medication Administration Record NOIJ051o (RIiV 9/9/941 M/UK;" PENICILLIN AND DERIVATIV Nam, ROBERTS I VIOLETTE M. Rood 0512-W ,- IoK': 75 YRS s..: Female /II.. II'" fO"a.d,,/ I: 008965279 /,h.",,"". MANFREDI. ROCCO L. From 05/08/95 01 07:01 to 05/09/95 01 07:00 DAY SHIFT EVENING SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0701.1500 I 1501.2300 2301.0700 PREDNISOLONE l' OPHTH SUSP U~'U~'~~ linn t_ r ~ i4UU U4UU. SCH TO LEFT EYE = lOOSE OPH 041ll1A ~ 005 INFLAKASE FORTE I DROP IN,LEFT EYE . RISPERlOONEIRISPERDALllMG TAB 105'07-~5 InROO J-n DfL); SCH 0,5 MIl = .5 TAB PO OAKHS . T"f" 116 006 ....NOTE DOSE.... "'. V . , " ~ ./ / ~ / i'-.. /' "'" <( / ...... / ~ .......... 7 ~ .- ~O : / / ,// / GU.,a' !!!Ii'l. Ann _on rlTlAlS LVC ...th'.m LAT...,..ntlf'l91 LO.1eft dI.od UQ.....~qu.d INITIALS I ~)tIGNATU"[ SIGNATURE RVC'figt'Cvtnt RAT. ngN and Itllgh RO'flgtlldeltOld RLO "~11oMr Quid I Jr-ll ,fFI.tel\dlA .,/~ ,'"' lDC'''''dorn' LlT ...ftIII thigtt J\t.A"IgIl'Ia"fm lua.lthI(lpefQu.d ROC . J911 dortll All . 11I\1ll1l'lhqI UA. "" 11"'1' ImI ROO. r.ghlllPC)er QUId J) ('1 / -; "1fi lVL.lllftv....' .Iv RVL.rlghtv....' N.NPQ n.netuHd p.OnP... NN. NIlIlfaNomll.ng ,7\ ~. ()')- JO#v Adm;uIIJfll>m,: 05.04.95 '.r"11'lO PaRt I: 1 ... continued ... PI. Nllmt: ROBERT&', VI H., Y MRI: 718545 . l;arlisle Hospital Medication Administration Record NO/JOJA (RIiV 9IP194/ AII"~,,, PENICILLIN AND DERIVATIV Ham, ROBERTS, VIOLETTE M. R'H>M', 0512-W '- AN" 75 YRS StI: Female lit. II', ruumd,"': 008965279 "h)'llf",n: IlAHFIlEDI, ROCCO L, From 05/08/95 al 07:01 10 05/09/95 a\ 07:00 DAY SHIFT EVENING SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0701.1500 1501..2300 2301.0700 ACETAMINOPHEN mHG TABLET 05-04095 PRN 650 HG : 2 EA PO 04H 001 AS NEEDED FOR PAIN " ALU-MAG SUSPlHAALOXI 30HL 105-04-95 PRN 30 HL : I EA PO 04H 002 "SHAKE WELL" AS NEEDED FOR INDIGESTION HILK OF MAGNESIA SUSP JUHL Os:ul~5 PRN 30 HL : I EA PO PRN 003 . SHAKE WELL'- X lOOSE PRN CONSTIP LASTING 48HRS, HAY GIVE FOR 2 DAYS ILORAZEPAH(ATIVANI O,5HG TAB 105-04-9, PRN 0,5 HG : 1 TAB PO 04H 004 PRN ANXIETY !! II 11.OPERAHIDElIHODIUHI 2HG CAP ~ PRN 2 HG : I CAP PO PRN 007 AFTER EACH LOOSE STOOL - MAX 8 PER 24 HOURS 0"'...1 ~ "m ~ LVC.....vent LAT',-"anlthql LO.1et! df.Old LlO'''''~OUId INITIALS SIGNA TUnE INITIALS SIGNA lunE Rve..vc ""' RAT. 'igN andth.gh AQ"lQhIcMIOId RLQ . ''It bMt qUId LDC.~doful lUd.ttlllttl-1l nLA"'If'llallrm LUa . r.tt ""* Quid noc.fl!tICdorul RlT'f~lIlthoCfl lLA . 1ef111~.I.rm nue. 1'ifIl LW* quid LVL.Wlvallll RVL..vulll N.NPO n.JWuMd p.OnP." N/Y.NIU...-vllfMlf'IQ Admin;,," lJalr: 05-0t-95 "'"Ing PIIRtl: 2 ... end of report'" p" /lam,: ROBERT8, VIOLETTE H, MR': 718545 Carlisle Hospital Medication Administration Record NOIJOSII (REV'I9IP4) AII"N'" PENICILLIN AND DERIVATIV N....t: ROBERTS, VIOLETTE M. H..'ml 0512-W '- IIRt: 75 YRS Sn' Female 11/,; 11'/ Fi/UJ.e/all; 008965279 I'hyde/.m ~.AIlFREDI. ROCCO L, From 05/07195 al 07:01 10 05/08/95 al 07:00 DAY SHIFT EVENING SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0701-1500 r 1501..2300 , 2;l~1-0700 PREDNISOUlNE n OPHTH SUSP 0;..05-9; , IbUO~ '~nn } 0400. SCH TO LEf'r EYE = 1 roSE OPH Q41lWA T . 717 'diip 005 INFLAHASE FORTE I DROP IN .LErr EYE ~CI"",Jr.U 0.) ~ pu (;7 awW f- .J.dOO -'if ~ ttm II ~ ~ ~ !.'l'lI!!. .... ~ lVC.lItlnnl LAT.lrtttanlthlgh lO.letIde.CMd lLO.lefllowerqu.d INITiAlS SIGNA TunE INITIAlS SIGNATURE RYe . 'igH nnt RAT"li1'Iandlhll1l no. f'l1ll dellOld nlO'f'ltlC~Q",'d (JP r 1__ Ie. #.1- lOC. W1 doIlIl LLT.!tftlalthigh RlA"9"lat.tm LUa -lett upptf qv.d ROC 0 rI(flI dorll' AU . rV1illl ~ UA."" "WI.llnn RUQ. I.gN ~ quid ):.-J rf'.. lVl.lItlv....l ..-1\ '"1'-..1...... RVI..rl(tltv'.1II N.NP.O n.RtfllMd p.OnP... NN. N'UMalVomlln; tV 1/ "j' Admiu;rJn Dati: 05-0&-95 T. TtIlI'lO PaR' I; 1 t.t continued tt. 1'/, Nam.; ROBERTS, VIOLBT'1'B H, MH I, 7185&5 Carlisle Hospital Medication Administration Record HO/JOJI. (REV PI9/94) AlltlN"" PENICILLIN AND DERIVATIV Ham" ROBERTS, VIOLETTE M. R,.,... OS12-W '- ANt: 75 YRS StJ; Female /I,; 11',; FiM",;a", 008965279 I'h)',;,;",,; MANFREDI. ROCCO L. From 05/01/95 al 07:01 10 05/0B/95 al 07:00 DAY SHIFT EVENING SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0701-1500 1501.2300 2301..0700 ACETAMINOPHEN l25HG TABLET 05-04-95 PRN 650 HG : 2 EA PO 04H 001 AS NEEDED FOR PAIN .. ALU-HAG SUSPlHAALOXJ JuHL 05-04-95 PRN 30 HL = I EA PO 04H 002 "SHAKE WELL" AS NEEDED FOR INDIGESTION HILK OF HAGNESIA SUSP 30HL 05-04-95 PRN 30 HL = I EA PO PRN 003 . SHAKE WELL'- X I DOSE PRN CONSTIP LASTING 4BIIRS, HAY GIVE FOR 2 DAYS WRAZEPAMIATIVANj u. ~HG TAB 05-04-95 PRN 0.5 HG = 1 TAB PO 04H 004 PRN ANXIETY !!!! ~(J '-:r,-,".:d 0 v. ,"," ...;- -\-.\..1.. 'f.., ) 1100 SLU ~ r I. m~v.)o..'\l'r \:Co"n" ILo('~ I ~ QI ) S^ ..k:tb (1'lOj.,. Pi !!!!!!!!. !!5!!.. = ~ INITIAlS SIGNA TUnE INITIAlS SIGNATURE LYC.llttwM LAT.llttanllhtgh lO.~deROld UQ .Ittllower quid RVC'flghI\'Int RAT.tlQhtll'ldth~ nO.righldetlOld Ala"l!;fIl~lq\l'd C;;' " c, u).!J.dn ) l;e LOC. "" donIl lLT. Iefl: III thigh RLA"lQtlltlllrm Lua.IItt~IQ\I.d ROC . tl(t4 dotUl RlT"i!1I4"l~ LLA ..." Iallllllrm ROO. IIQhl uPJ* quid lYl. WI VII lit RVl'~v..1It N.NPO R.ReluMd p.OnP." NIV . NIUMaNom1l1f'9 AdmllSifln Datt: 05.04.95 T.T"ling : I " , , PaKt I: 2 ... IIld of report'" p" Hamt: ROBERTS, VIOLETTE N. AIR#. 718545 Carlisle Hospital Medication Administration Record NOIJOSII (REV P1P1P4) AllaN"" PfJIICILLIN AND DERIVATIV Namt: ROBERTS, VIOLETTE M. N...m' 0512-W ,- ANt: 75 YRS Su' female III: 11',: fiMnrlu": 008965279 I'h)'f"wn: MANfREDI. ROCCO L. From 05/06/95 at 07:01 10 05/07/95 at 07:00 DAY SHIFT EVENING SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0701.1500 1501.2300 "- 2301.0700 PREDNISOLONE I' OPlITH SUSP 105-05-95 ~ 7000,./ 7000.....", 7400 , U4UU_ SCH TO LErr EYE = lOOSE OPH QIII\lA ()'I-"-' 7fT . if 7U 005 INfLAMASE FORTE 5v 1 DROP IN'LErr EYE ~'l.JI ?'5",mg ,po ,'Ji~ ~ filii ~ ~ fJ.S :;;/;ff,..,-/t) ,.9~ """., !!!:i!!. "m -... lVC.IIIft..". LAT ...fUnllh9h LO.lettdt.~ LtO.1eft IOMf quad INlllAlS SIGNA TunE IMTlAlS SIGNATURE RVC.r~venlI RAT .rqM and Itugh RO.rlQhldelOod ALO. r"i1't IOMr Quad (~ < (.' flI ..4J,PIlV we. WI dot.., llT.ltftltlthlQh RLA"'\1IIl&llrm lua.left~qu'd RDC'~ldof..1 RLT'f9'llal~ lLA.1ef'I lI'-'a'arm ROO. rlQl'll "PI* quad RD K! (\., I LYL.lIf1wIILll l~ RVl.nght'....' N.NPQ A.RefuNd P.OnP.1I N/IJ.Nau,alJ'v'Otrul.ng ~ ~~. ='U;fJ Admission Dalt: OS.OC-9S T.te"r'IQ PaRt I: 1 ... continued ... IJ/.Hamt: ROBER'ff, VI~ H. U MR': 118m . ,.... . i Carlisle Hospitat Medication Administration Record NO/JOM (REV 9/P/94) AllnN'" PENICILLIN AND DERIVATIV Namt: ROBERTS, VIOLETTE M. R...d 0512-W '- Agt: 75 YRS St>: Female )11.: 11'/,: Find"eM'" 008965279 Ph)'Jlci<l", MANFREDI. ROCCO L, From 05/06/95 01 07:01 10 05/07/95 01 07:00 DAY SHIFT EVENING SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0701-1500 1501.2300 2301.0700 ACETAMINOPHEN J25HG TABLET 05-U4-~5 PRN 650 HG = 2 EA PO 04H 001 AS NEEDED FOR PAIN .. ALU-HAG SUSP lHAALOXI 30HL I u~-u4-95 PRN 30 HL = I EA PO 04H 002 "SHAKE WELL" AS NEEDED FOR INDIGESTION HILK OF HAGNESIA SUSP JUHL 105-04-95 PRN 30 HL = I EA PO PRN 003 'SHAKE WELL'- X I DOSE PRN CONSTIP LASTING 48HRS. HAY GIVE FOR 2 DAYS LORAZEPAMIATIVAN/ u,5HG TAB I u~-u4-95 J 31 V ;\911, PRN 0,5 HG = I TAB PO 04H 004 PRN ANXIETY !!!! GIut"lr !!!!ill. Amo _on L\.C.letSvtnl LAT............. lO.!ef1dtltOid llO'IIfl~quld INSJlALS SIGNA ruRE INITIAlS SIGNATURE Ave. ~ venl RAT. f9lt and thigh no. rlQhl dtltod RlO. r9'lloMr quad r<'O Q tJuA<;c-hLPW lDC. WI dorSlI LLT. teft III thigh RLA.tlghllll.rm LUO.IIf'l\qltfquld RDC.~dotu.l ALT...,...'..... llA. Itft 1t1"111"" ROO. rlQht upptf Qufld \<hn ,~\\"Yllcv'4\ I~H.; LVL. WIn. III RVL.~Ya.1al N.NP.O R. fWUMd P.OnPa.. WI. NauMlI'v'omlbng - iJ A.dnrlssioIlOatt: 05-0c-95 T.Tlllng PaR~ I: 2 ,.. end of report'" PI, N<lmt: ROBERTS, VIOLE'I'TE H. AIR'.. 718545 . Carlisle Hospital Medication Administration Record NOIJO,IIo IHf:I' '191911 No"". Viola f).lilJ.Lr/1 II",,". ",I:" fUlIII/.,../' \.. 1/, II, -- ' Atlt'It",! 15/).. 'v '- "/"'''1111I D/.:. 'In (tf] h, ,u From 05J;sis;'~~ou DOSE ROUTE ~- \-JnUa11~~: g1U- -- - - ' 0/;/- - '0 ; '10 v>V OW ~'fL lis . _g-/iA.Jt.J!.~ia'dk_ ____ loM"%,9S01 0100 FREQUENCY START .--,..,-- ._,__.. .__1-..___ ---.--- -,-..-.---- ~ lYC......"ff" AVC"~".-nl lDC'~lctolUI noc rtllflldotUI A"""tl"'"/J",,- 1"'':'" ~ IAl ~Uf'4I"'\1' 'IAI ''9'"''''''''''Itw1' III 1f'fl1l11"9' RLI'I9'C1.a1tt"O' IVt If"",""'l !lVI 'f/"U\1.I1 'om lO.'-ho.lOol;J nO'IIQhtct.I()Ol) filA 19"'llll"I"' IIA '''''''''.''1.'''' ~ llO.""~'QY'\] 1110 19'1t~q",,~ IUO IltfI~Qol"1 flUQ ,qt\l~1f""'q",.,, '4 ""0 ro On f'~" r h\l~ n UM"".., "."" '.,..'.........'''r....'., ", \',,,,,, -. DAY SHIFT EVENING SHIFT NIGHT SHIFT NO STOP 0701..1500 1501.2300 "I 2301-0700 -.-- /{,OtJ i.A./ q;/J(~r ~O~ ;1000 V- 7 , ,"O,"A,S S1GNAlunt" l~lTI"'LS SiGNATURE : lId,' i ", 'e.. .,{~ ft.u...d..rm (;)- ~.~1i~~~.t~,," ~ [t?" , , . , . , L MHI' Carlisle Hospital Medication Administration Record NOIJOM (REV 9/9/94) AU"",,, PEllIClLLIll AND DERIVATIV ~ NnMt ROBERTS I VIOLETTE M. /I..,,". 0512-W '- ARt: 75 YRS S,,: Female II/.' 67.0 IN II', 62.2 KG f,"n",in"; 00B965279 l'/')',,,'i,,", MANFREDI, ROCCO L. From 05/05/95 at 07:01 to 05/06/95 at 07:00 DAY SHIFT EVENING SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0701..1500 1501.2300 2301.0700 ACETAMINOPHEN J25HG TABLET IOH4-95 PRN 650 HG = 2 EA PO 04H 001 AS NEEDED FOR PAIN .. ALU-HAG SUS[lfHAAUlXI JOHL I 05-UH~ PRN 30 HL = 1 EA PO 04H 002 .. SHAKE WELL" AS NEEDED FOR INDIGESTION HILK OF HAGNESIA SUSP JOHL 0l-TI4- 9 5 PRN 30 HL = I EA PO PRN 003 . SHAKE WELL'- X 1 DOSE PRN CONSTIP LASTING 4BHRS, HAY GIVE FOR 2 DAYS UlRAZEPAM(ATIVAN) U,~HG TAB 05-UH~ ;21 'i~ PRN 0.5 HG = I TAB PO 04H y..- 004 PRN ANXIETY !!!! , , ! I I I ~ ~ "m ~ lVC.Iefl~ LAT,""anlttugh lo."ndeIO<l llQ. IIfttow.l Quid INitiAlS ~- INITIAlS SIGNA. TURE RVC.'9tven1 RAT "9'1 and th91 no. IIQhC delOoCl nLO' 'f/ll lower Quid {JhJ , ,~ lDC.ltf1dofwl LLT.leftllllh9h nLA'flQhl Ial I'm lUO.Iefl~IQUIH~ RDC.~dol'ul RLl. '1IOtlt III th9l LLA . left "~f.t 11m ROO. ''!tl1~' Quid TT lVL.ltf1v....1 RVl. ngN va. "' N.NP.O R.n.!uMd p.Qnpa.. N/V.NIUMAlV0'Tl4ong V AdmllJi(Jft Dart,' 05-01-95 T.T.'11nQ -- - PaRt #: 1 ... end of report'" Pi N"'.t: ROBERTS, VIOLE'l'l'E H. AfRO 7185.5 Carlisle Hospital Medication Administration Record ND/JDSiI IRIiV'19194/ N/J1fIt: 1// ~lLL fCl Wr f!. H_': S 1;)- tv Mltrg/II: '- iI,t: YRS Su: Female II,: \I',,: "'Mllt/al'; Phy,lcI...: DQ '-}1/llnfr ut " From 01/24/95 at 07:01 10 al 07:00 . DAY SHIFT EVENING SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0701.1500 1501.2300 2301.0700 ACETNllllOPHEN 325HG TABLET PRN 650 HG : 2 EA PO QfH 001 AS HEEDED FOR PAIN ,. ALU-NAG SUSP(l4AllilX/ JOHL PRN 30 HL : 1 EA PO QfH 002 "SHAKE liELL" AS NEEDED FOR INDIGESTION MILK OP NAGNESIA SUSP JOHL PRN 30 HL : 1 EA PO PRN 003 . SHAKE WELL'- X 1 roSE PRN CONSTIP LASTING f8HRS. HAY GIVE FOR 2 DAYS 1/ II ,){It''l {1,!fto m 3' I' 0 frl/hr.. fJKtY (X~ lI.ll-lUtl7f- I , . . , . Ou.." ~ "'.. -- lVC.W1V<<\1 LA T 0111, ani fI9\ lO.""deIOid Lto...,.1oMt quid INITIAlS SlGNAT\JRe IHmALS IlKIHAl\JflE RVC.,lI1'C'IenI RAT. '1QI'lI1/'ld'" no""""dllOId AlO. ltgi'll bww quid Mr t;) !fur;, LOC......cIcltMI UT........... RtA.rigN-.c.rm lua."""PPt'~ ROC '. doful RlT'flQl'll"l~ UA. WlIlIef.1 ann RUQ"911 upper quid lYl. "" ,,""I ~4>1 Ij!.J/Ldi (/J, .-;- RVL'~w'I'" N.NPO. R. fWu* p.OnP... Wi. N............omltIQ !J AdmJu/fJfl Ddlt: T. 'eSMg Pagt I: 2 ... end of report'" PI, Namt: MR': I I I I I I . See Progreaa Hot.ea ,I Select. appropriat.e code a and place 'i in Uae alot. for ahUt. with your I PSYCHIATRIC DOCUHENTATIO~'bHEET 'l : ' ADL FLOW SHEET ! " I SHIFT [" l ':; J I J 1 ~\ (: d 2 , .. I 'I .. I' I' J e c c r ~ u ~\I1 rlarl1rr' bY DATE DATE - ATE r ,DATB SAlK 5/40&'5~' 115N! ,~ .A ~iA It , I) ra. (...h .... DATB i. ACTIVITIES or DAILY LIVING lIat.hino a. Bat.hee independent.ly b. Bat.hes wit.h reminder c. Needs assist.ance with preparation d. Needs verbal direct.ion during bath e. Is bathed bv ot.hers 7-3 3-11 11-7 . 3-11 11-7 7-3 3-11 11-7 , , 7-3 ,f.' fJW t',.L- ~ {A LO I I), /~ I?'/~ -p'.t-~ ~(_1'7J -P,lr16 Grooaino/Hvoiene f. Dresses independent.ly g. .;.eda verbal reminder h. Ia dressed by ot.hers i. Combs hair/ehavee/make-up j. Heeds assist.ance with grooming k. Does own laund~y ToUeUno 1. Continent. m. Incontinent of urine/feces n. 2 hour training schedule o. Aseist o. Indeoendent Aooetite/reedino/Ambulat.ino q. Assiet with preparing food r. Hseds Assistance to select e. reed t. Feeds self u. Eat.e < 25\ v. Eats < 50\ w. Eats 100\ x. Walke with assistance y. Uses cane/walker &. Wheelchair 7.3 1-1' DIU,p...,O .~,-iJ '/;?L\ Ip.L<- .l2/f- 1J -f,f~""d .-t,f....,71 3-11 -tv P Ir,W>"7o -t V t, .J# - c.( (.,.. /'y IV Jr t lCl.td ~l)I-..J ij {.ll,-o 11-7 II. SLEEP PATTERN a. Sleepe 6-8 hours/night b. Falle aeleep readily c. Ueee relaxation tape d. Has difficulty falling asleep e. Awakens frequently f. Awake most. of the night g. Medicated for sleeplessness 3-11 11-7 q &... ~.t. lL~(,.. PATIENT IDEHTIrlc ~TIOIf 'if ~/ 4, . Q./ ' a, .9L Init. Signature Init Signature , f 51lW ,ROBERTI, 'JOLETTe I. S/0./95 8S SHINNEL WAT 2/04/1~ CARLISLE, PA lHfR[Ol.,ROCCO L MO 89bSa 9 ' 118SQS ',\ "[OICARE ~ PS 1630 (10/93) , "- ,. . I ~ ~ '~ r · S.. progre.. Not.. Slllet Ippropriate cod.. and i ti 1 t f bift itb PSYCHIATRIC DOCUMENTATION SHEET J j : ' l~ .! c:' ADL FLOW SHEET :. 7l..J', 'c e r' " ',' , \, I . I t\ f ~, I ~ '". I . place I : 1 \ I J Cf Hf I zr (' ,./ I U'I' n .. . 0 or . w your sk: . ',1 \ r\,' ~ ( 'fl ,,~: I I DA~B I r initial I in low.r rioht hand cornaro S I~" DATE, r DATB DATB DATB I. ACTIVITIES OF DAILY LIVING S/1 J/AJ 5/11 ~ 5A3 lI.thino 7-3 q .;<. a. Bathe. independently , ''1 ""'- b. Bathea with reminder 3-11 "\. c. Needa aesietance with preparation d. Needa verbal direction durlng bath 11-7 '\ / a. I. bathed bv othere 1\ Oroo.ino/Hvoiene 7-3 E-11~ , \ / f. Dreeee. independently g. Need. verbal reminder , \: h. Ia dre.aed by others 3-11 J i. Comba hair/ehaves/make-up j. Needa aesistance with grooming \ / k. Does own laundry 11-7 ToUeUno 7-3 I,f~ \ / 1. Continent \/ m. Incontinent of urine/feces 3-11 n. 2 hour training schedule 1\ o. AuiBt D. Independent 11-7 APoetite/Feedino/Ambulstino 6-,~ / \ q. Aeeiet with preparing food 7-3 r. Needa Aeeiatance to select a. Feed / \ t. Feeds self u. Eats < 25\ 3-11 v. Eats < 50\ w. Eats 100\ 7 \ , x. Walka with assistance Uses cane/walker . , y, 11-7 ) , z. Wheelchair \ " 7 \ : U. SLI!:EP PATTERN a. Sleeps 6-8 houre/night / \ b. Falls aeleep readily 3-11 c. Uses relaxation tape 'I \ d. Has difficulty falling aBleep e. Awakena frequently 11-7 kl/1. f.; , f. Awake most of the night I , g. Medicated for eleepleeenese Signature~ ,0/ PATIENT IDENTIFIC rIaN Init Signaturs Init ...., ~J t;. U)J TJ ~I\ , /.J,r (./ .., , :11 , , . " 'of o5izII ," ROBUTI. "DUn!' I. , ,of, I'''' " 05/04/~' U SK I ""n lilY . 'l"'~l 12/04/1' CARLISLI. Pi '1 \,. . "';'v' IUNrR[OI. ROCCO L MD "".\i ......i.. . ..\-;:,1 . PS 1630 110/93) ~Carlisle li)spital Sllb521Q 1185'15 ; ,"';;:~ ~',1:J/'~~~~"":'1 .J . ~ _, ' . ~ . I N(OICARE , -----..,.-. .-'. ~~ lbipital "!::!) CARUSlE, PA 17013.()310 NURSING ASSESSMENT FORM l;;~~, WIMlll/llwrmtlll (Dew'" reacllon) IJ ,~ ,"I" "lilt". "outt':"""~' P.../M~/" - !~ ."..,,, " ",..n ItU ' ~':".; .,It.,,' ell"'.'. fa ' " " "'V~~'f~""tcct L-rt8511S":'~?"" " ..I.C.I. \,'" \ , I' ! jI , PfoQE I II_tJt~~~, ~;~ru<n~ ~~~~1 \ i , DAn: 1lME 7 '11 (jfilt.RI " ". lASl 1. IJ ( DOSf :, iJuQ)- wuu.di 4, ~ ~jUJ :J 5 ,\ '.j *~,M); ,\:4 :: l"'.J{~"';J V, t/Yh' ~ l.AS1 !lOst l.AS1 !lOst l.AS1 !lOst IlIlCATllIIIOI tal_ 8. 9, 10, mUllUI WI: 'l\:s 0110 ~~ 0 Senllo Phannacy o Home 0 Bedside - mil 1111l1W1IIIlAID: o A normalwlce o Aloud voice o ()ojyloudoolses o DoeS noI heal HearinO .Id broul~lIlo hcJslliIal ,.1101 1111l1lAS1I1 o Sees _Inl o Sees obslacles o Can lei ~I trom darll o DoeS noI see G1a.... 1x""",,1 10 hospital ~I1JlIXIfHlIllllllIII ~A normal voice oAloudwlce o ()ojyloudoolses o 00eS noI heal oVes 0110 I111tOOT IlASllt o Sees newsprlnl ~obslaCles o Can tellltll lrom dar1l 'I.l 0 00eS noI see o Ves,PloIlo .i!".... V .':8M In,...... 0 S1deraRs "I I fl ~ limo ;ijDrlSitino ~1Ions PlIIDlIl. amWlClIT UII1ttOl ~'^'" IJOOl11OCI 0 _1111 dls!IMIed our/1y\lOnlc oOoeSnoI.ppIy Conmlnls: ~CaI~1 o Bed conlrols /oJ I fl ~Smoklno regu!allons LEGAL CHARGES YESO NO~ :z ~ GIla ra Gmlda LMP l'edIablclan Inlanl FoedI"'l 111m -== o E.,SmoI<er,03lll SllJIlIled o Smokas.- elQarell.. per day ~ I I) . r . I Para EOC 8Iood Type ~o UIlClltI!!JDS balty ,2l'ir91sh 0 01"" I.a~ o Non,ytfbalty, Etplaln o DoeS nol cOl1llTlll1icaI. Pnmary Unouage: IltITll nuVl II" OrtoatMl- }1[Yes 0110 " no. tl'<<k lIeP; , of dlsofientallon: o nme. Oay/Oal. o P\ae. .locailon/Add'ess o _. FamilY/MO/lbse 1I"a11117 bil"~ 0 110 "no. check ~ IeYet of CQI1SCiou5IIesS; R"lJOl"!s 10: o VlSUal/Aud~"y stimu\Js o Tactll./Para stimu\Js o COO\atos. N.tDIIOlIl1UI,tol.Dh o jlone I ''"7'1' "^V ~5lonal ^mooot .a. J 't h 'I O ' Dally A""""I , 11JUT DlUU ~.1Io DYes, Type{.) .!!J'" .u.tol .....,.tatel )!!J.Ves 0110 " no,lndical. bebavlDl .d;bited: o Aoilaled . Hyper_, AnlM o ()ISfI.\lIIve . ()Islllbs o\hel' by ytIIinolshoutino o Depressed. bpr.....l'qleIes5nessf help1esSl1llSS oOthef " disll<lenled, lJIespoostve .. behavlDlInaJllllllll'IaI. al admls!lon. wet' lhose problems evtcIenl bel... "'is ~...ssl 0 'l\:s 0110 PUT IllllCAl II1TOIIT . - J. . ~avIouS S1JOOIY & type of .....thesl.a: ~ tJ t.J. IL..I..UI il J I "'ItA .u.a ~~~; '.4i~~~ " I' PtavlouS medical & psythIall~ condillons 1') \.../."">\ D J , 1n1","",,1 ill /l.l "'- I). -rn cV.ll.J fj,;'(, 5- 'f.q ~ I ~ 00 ~SIg1atll'ZT tl Da\e/Tlml Rec.nllwlthln 30 doyo) ..poaure 10 Inlectlous dls....? 0 Ve. ~No Speclly FOOM NO, 0110 (1/93) a...MAj ~'I'KA-" Rcllglon/cullural beliels and their slQniflCance . l. Exlslence of Advonce Dlract1v8 D Yes nib'",' " ~M..L.c.- - Ju..L.,J u",-'t 2, Requesl furlher Inlormallon or desires 10 formulale Advence Dlrecllve DYes D No tJj.;t ~ M'C..I-~ " PAl1mrr":J:.~~I~:::MI!HT AND D:~~n~~~~..~L~,N. ,P,~v.~~~~~ ,~~&AL FI~~I~~,S. ,~~ ,~~~.I~~~~.~........., D Hcg 'VMPTOM' OnKRVml D Paln/Tendeme.. ~/MosI Te<1tI Net.roIogIcaI ,...,.,......................... ~Hcg D \\Jnjllno D Few/Hcg D Headachs D Nausea D t.\Jcous Membranss D Pareslhesla D llIanllea D Den"... D OIlrlness D Consllpalloo In Hospilal D SeW.. D DIffICUlty In Swanowlno DGallProblems DChanoslnl'klght D AI1mllons D Tany SlooIs In Sensation D -no D Othel D Other GenIt""lnary.",,"""",.,',.,.,.,.,.....~ D Paln/BtmnoIRchino D Frequency DI'oiyfIa D Nocturia DOIigurla D_no DDrlbblino D IlIschargs DOthel Oltler ..............................,......, D None D T1m1lus D Sensllivity 10 l~1 ~VIsIon DllIpIopIa D Hoarseness D Other ~. '. r.~ 051211 ROBERTS. 'IOLETTE K. , 05/04/95 85 IH I "IlEL III T 12/04/19 CARLISLE. PA MI"rREOI. ROCCO L liD ~. SQbS21Q 1185.5 1'1 I:! IIf.DI CARE o c ~Carlise~ ~ CARUSLE, PA 17013-0310 NURSING ASSESSMENT FORM IOClAL p,t,OE3 ..';~ ..'~~ .. Marital stalus Reeenlloss Of lifestyle change? " ~on /\t11JJ(.J.l.J) If Occupallon . cu.J..t... ...:, How do you normally deal wilh problems? '\....!) "'/\....l/\K.A ~ ,\..(."J. 'Fo ~ld tUnu.- <h..nl c.t -v.r' q J. H' ~ D\'os DNo JoInIMoIlon................................~ Wiltlln NonnaI Llmils 0 \'os 0 No II No, Describe Umiled MotIon. Pain, Conllsctures. Inslabl1ity .. Othel Problems Respiratory ..................... ....... ....):iNane D Pain D~ D Shor1 of Brealh DOthel Cardlovascular"..",.,..,"""""",..,"~ D thestPaln D Palpltsllons DCyanosls DEd<ma D Jbnbnoss DOthel S..uaIReprOllJctIoo ........................ DNone D Breast ClIanges " ~:I::trual~~ y~.aJ D Ingur1Ialhemla Skin Cor<lilions (brlel descr1ptloo I . .. . .. .. .. .. Jl(!Ione 1. Abrasions 2, Pressurs Ulcer ], BruIses 4, lacerallons 5, Rash 6, Scars 7. Ulcers 8, Other IlrtlIIl IIOSmAl. IlATIOI UIISTAIICl KU lOT ;; 111111_ III n0111l1l1111 iiI<I>I*>o Meal PI!ll lIIrdry "oust 0eam:I 000 0 _Oy Ilna ""'1' 1rI11ftII WT ..-m (UIt U) .. nl UI\ ,.( If PhysIclan{s) ,/fU) f."/"u,-~ JA, o ()(. ..:J~ - .-u..!.v.>..-' fJK 0 Ea' o " Home Care ~ o ~ Oltler conrnuni1y,based services I u;t a/l)\.UL<.,(~l\) JJ..rn\ III1P nmlllllllllllllllllll_ II Ikt ""'I )( Sleep! tlYour/IltIo nigll 0 Fa" ssleep "adi~ 0 Awakens II!<luenl~ o 1lI11Icutty gslllno 10 sleep 0 Awakens ear~ o Awake mosl of niglt 0 Sleep slds INDICATE AIT IOD' IUIINeS If IIIN CnOlnON NU.'EN .. CI.,..VU .2<10. O/lV I ~ Conrnenls' JU.a4 "'-' Q -ntL 'UJ) lWlse'S Slgnolure<1 ru" c.. j. <f. if!; o o c ~ Carlise lb;pital ~ CARUSLE, PA 17013-()310 NURSING ASSESSMENT FORM ~ i:, WllU .. " .., " '~ - - .... - r.' 051211 _ HeIo ..... l.. ~./ 'X ROBERTS. VIOLETTE H. Med1arical__ OS/04/QS 85 SHI""EL WAY tUnan _ fWu IZ/04/IQ ClRLISLE. PA FUIICTlDIIIIIB _ and tUnan_ IIAHFREOI. ROCCO L "D " SQb5219 1185'\5 STATUS Does Not _ [ '~. IIIFDRMATlDII Desalbe; I '~IIEDICARE ..'~ ' 'M: ;'~ Help , gw,~.' t Existence 01 Advance Dlrec11Yd DYe. mils .. II .., II . , 2. Request further InfDmlllllon or desire. 10 formulale - - .... - Advence Dlrec11ve o Ve. DNa -- IAlIU .. II .., II IftU IVICTlGI .. II .. II Med1arical HolD _ - - .... - - - .... - tUnan Helo _ -- . 'u 1../ IX Conti"",1 ~ L- "';- ,~ Med1arical and tUnan HoIn Mec:Nrical Inalnllnonl Is Wheeled BY 01hefs tUnan ~ less Than Once/Wlek Does NoI WlloeI.WaIles " '//' X Mec:Nrical and Ilman IWn More Than OnceJ\\\lek Oescttle: II , Is Bathed ~ 01hefs OsIMN.seIf Cart Help DosaIle: I Not Sell Cart Adaplalloo ~ Sl>eclfy T)110 Ostomy () Othel ROiFnon: I CUD ITAIU .. II .., II - - .... - IIUIU .. II .., II .., II - - .... - IWIIlI IIICTllII .. II WIlhoutHoln - - .... - _ HeIo ~ '..... r./ r)(. Conlinonl ',- 1";.... rK --- ... Mec:Nrical Inalnlinonl !\man """ fWu !\man ..... fWu less Than Once/Wlek Med1arical and !\man HolD Mec:Nrical and tUnan -.w;;- More Than Once/Wlek Does Not Cl cnb Stan v L 'L ')c Is ll'essed ~ Others ~ Oescttle; I I Is Not ll'essed lJavandNiMI He/p DosaIle: I OsIMN,SeIl Cart Help WGIlUTY Uftl .. II .., " Not Sell Care - - .... - .. II .., II ExllleYlce.SeIl Care Goes nrtsIde Wllhout HoIn \.. 1."1 "J. Uml/~ - - .... - Not Sell Cart Goes nrtsIde WIth HoIo , -..... l- '\.; ',..... ''/.. Call1eler,SeIl Car. ConrlllOd 10 Home Mec:Nrical ~ Not S3If rMl Conllnod 10 Bed and Chaw tUnan --.w; fWu Sl>eclfy T)110 Ostomy, Conllnod 10 BedITIII1S Soil _ and tUnan HolD ExlernallleYlce.CaIl1eI'r. Conllnod ID Bed/InYnollita ~r.d ~ Trllr/ng Sche<Ue HoIp /11/ TiAls DIll. r.d TlAIllftII .. " .., " Desalllr. IIII - - .... - He/p Without IWn "NDlMaI Flrw:fInot Irlcftat. . nHd lot fur1Mf .....1fMftt: 8pedf'f 01", Mdt Pwton/o.pt.... AHMd.nd IIgned Appetlt. - OWl MJRSE (OUC f.HTEnosmEn HOOI'lCe lIT: tUnan 11010 lWoI _ and tUnan HoIn ,tOME ttEALnt 8PEECIt CHAP, TIIU1I .. II .., II Is T.w'errod e- Others - - .... - -..... " l- 't :..)(. Is Not TrIllS''''''' " ~ rV v.. i~~? 51~ / Cl.NCAI. Desalbe: IIII 5 L/ ....ClAUST -~ Ilman~ He/p CARClAC .cue. PT I DEWl't I OTIIER M>lSE Mec:Nrical and !\man HoI" Does Not Use ToIIot Roam ~ III II: lbnlClhu R"y cJ 5- t/.qs lit DesaI>a: IIII M>lotC~f;~~::;a;;T~, J9;~- He/p ., <. t.U c- t; 'T oSl/ IIICWIlIUlIm In _I ..J) cin. ' t ...... '" DAltT k/YLMI!' ,- If. t '_t ~, AI.A"x'/, '^" e r....t, " IWlE4 I i I I i OD 111/.1 :r. I ) J' l~ .' . 0 ,:.;' II :' :: C ( II r 0 H , ; 'H ~ .... f. . !;(, .... l.:l , "nil C Hr I ~ l.:l ~ ~ .... :z: ,e., .... ~ lo. 1Il .... . , 1\ I,"' (1" :' III ' ~( H' U. 1Il U 0 ~ ~~ ~ I' v PI Y 1 r . ,~ 91) ~ " ~ ~ 1Il H I I " 1-<' I, 5 ~ 1Il :w III :J< 1Il ~~ ~ 1Il ~ W ~~ 0 W ~~ ~lo. '" Z ~lo. ~ '" :z: ~ 101 ~ lIltl ~~ < W ~ !ol lIltl ~~ '. "l~ I>< ~ l3~ '" ~ WlIl .... ~ ::llll .... <", S~ H l.:l'" 1Il ~~ 1Il III e:~ ~g g~ III !ol e:~ l.:l ~ '" 1Ill/) '" 1Il1ll HH ~ re ~~ i~ ~~ li! !olO i~ Eli! ~ ~ uo W ~~ u ::)te ~~ ~ '" H ~ ~ e~ 0 GROUPS Q 1Ill>< H.... >.... GROUPS Q !i:", > ColIrllUni ~/ fite?!nq-!E. IA -'-' Body Hi~ J S( J ?.s- I'A v <--- CommUnity Heeting ~ LeiBure Skills . pa community Heeting ~ Values community Heeting ~ Recreation community Heeting ~ Relaxation CommUntiy Heeting ~ Group Assessment pa ColIrllUnity Heeting ~ Current Events Depression Group 1 Nutrition 2 Process Group Social skills Anger control 1 2 Rscreation Self Esteem 1 Goal setting 2 Stress Hanage/ Group TheraQY 1 Relax 1 , 2 ., 2 3 Grief/Loss/Attitude 4 conflict Resolution Assertiveness 1 Hen/women Issues 2 List others spiritual Issues Vespere PATIENT IDENTIFICATION 'Please Sse Progress Notes Init Signature Init Signature c..h PS 1603 110/93) @/~~ f:.a ~"li . ',1"~ ROBERTS. 'IOLETTE R.~~ 85 SHI""El WIT ~ '10 . I2I04/l~ ClRlISlE. PI"UJ>,!n "AN'HOI. IIOCCO L "D 5 5 r.', S'lbS21'\ 118 Lt :;."j GROUP DOCUHEllTATlON/PATlElIT TEACHING FORH '~p;::;r . "EDICUE _~ ' r :' I , I I~ I :,-, '. , I :.-: JI , 0 J ..1 0 I ~ ( I r;' .... ,~ ., , (0 I ' 'lH '.... ' ~ ~ .... '... .... u ~ " I J t r ~, '~f . u I\- 3 .... :<: .... Z .... I<. III .... : \ oJ J , ,,:Jj,; ~r III .... U 0 >< ~~ III ~;j >< il ~ .... ~ 0( ... I ., jll .;<:. III A (( ~IL ... III :. .., , ~ III ...=> !il ~ III W ~I<. 0 Ill"; W 0 ~... I\- l/: ~I<. ~... e: z ~... ~ W !;l W :l! ~ !;l W ~ ,.J ~7. W lilt! ~Z ~ VI III VlW .0 I\- ~ l3~ l>o w.... WVI ::>... .... Will .... ~~ ... ... VI <w ~~ ... III ~ ,.. b~ u:s 8~ ~ b~ u ~ I\- III III ...... ~i:! I\- VI III ...... i::l 0 "'0 ffij ~~ 0 "'0 ~~ ~~ ~ '" ~ S~ uo ~~ W 0: S~ U ~ '" "'!:; ....1<. ~ '" e~ ... ~ S~ oz ~ f; GROUPS '" Ill'" ....... >... GROUPS '" VI'" Community H~7~~ tPlt,;}.. .,/ Body Hind ~.'" ~w./;! v Leisure skills ./ community_~e!.tin I~ Values ~ COmmunit~ ~;ef,f~ ~ ~5"' Recreation community Heeting ~ v Relaxation Communtiy Heeting ~ Group Assessment Community Heeting ~ Current Events Depression Group 1 Nutrition 2 Process Group e.-r IL b..." ,/, Social Skills 5/:; .Q) 1- Anger Control 1 2 Recreation Self Esteem 1 Goal Setting 2 Stress Hanage,~/~l ~ ./ Group TheullY 1 Relax 1 2 . 2 3 Grief/Loss/Attitude 4 Conflict Resolution Assertiveness 1 Hen/Women Issues 2 List Others spiritual Iesues Vespers Notes PATIENT IDENTIFICATION PS 1603 (10/93) ~. @/CarliSe lb;pital r~ ,~ 05ltW ROBERTS. ,~~;t: '.}~,~' , ~ O!l/04/~5 85 IH I un lilt, '.;: ,. I2I0411~ CARLISLE. Pi ""(;~1 i .:' "'s"~b[S2'1~OCCO L,"f8S'\5, ,;:::'~ ,I , i'i:-",,,,,ir,/, GROUP DOCUHE~T^TlON/Pt\TlENT Tj:ACI~IlO 1~1ll[ (... ! I :1 .. ',-" DIAGNOSIS I AXIS II 6-/f(>(q r ~ AXIS II: ))~~ AXIS III: s:.~ t-I-..( f 6iV!1f' ADMISSION DATEt AXIS IV: fJ~ G IJ1t $V AXIS V: DATEt Social Worker: Nursing Staff: .1.Ij),;(J-"J>y)~IC- occupati~~ ! Therapy: 'I ~9~,.;ft...- t others: ! , Physician: Social Worker: Activity Therapist: ~u , r};~ r'ri /HA~ ( ASSESSKENT OF STRENGTHSt CRITERIA FOR DISCHARGE I ,,.;) . 1 ANTICIPATED DISCHARGE DATE: C4 ~ AFTERCARE PLANt ~v3 h~.J~ JJ.'-- )~ Date EATKENT TEAM BEEN FULLY PATIENT CO @/CaI1i93~ INITIAL TREATMENT PLAN AND REVIEWS PSYCHIATRIC UNIT .~ :::~~'1. I"'"" "IL ilL!. .. . '. :,::\ IIUFR[DI. ROCCO L liD ' ~~;,?~ S'lb521Q 1185'+5 ,'. ":; I"....I'!\" ,,.. :-\' I IIEOICIRE ;~,~'~ ~ PS 0915 (5/94) B.SOCIAL WORK SERVICES PROBLEH LIST 1. SUIcIdal IdeatIon 2. Depr.ulon ~ Peychoeie 4. Hanla 5. Del1r1um FemUy luu.. Temper Cont.rol Dhpoe1t.1on PIannlnl/ ~::J~ ~""b,.)J+ WEEK 2 Date 3 Date 4 Date 5 Date ODJECTIVES HETHODS IndIvIdual paychotherapy Group therapy J. COl/nltlv. therapy 4. FemUy/couplea therapy 5. IInl/er prot.ocol 6. Selt-eat..em protocol 7. Convnunlt.y resources Inveatil/ated B. Otherl Develop Ine1l/ht. Involva famUy. Develop aupport ayatam, Salf-aateem. Develop coplnl/ etratel/lea f. Improve temper control. 1/. IIddreaa laauea of conflIct.. h OutpatIent plan eatabllahed. L Other. REVIEW B. INIT, PROBLEM # PROGRESS GOALS INTERVENTIONS TIHI rRI\HE ~ ole DATE PATIENT IDENTIFICATI~ '( 0511W ROIEIITS. Y10UTtI.~' " " 05/04'" 1I5 IN I un III' ,~'-i 11/04/1' URLIlLE. '1 ,.X;:.... "lNfR[OI. ~OCCO L liD , t:!,.;,:J SQbS219 1185'15 '. .':.,..., . . I,l,.~~t ' " E 0 I C lR E ::!i?'~ " ,f l \ @/~ lb;pital INITIAL TREATKENT PLAN AND REVIEWS PSYCHIATRIC UNIT PS 0915 (5/94) A. PSYCHIATRY PROBLEM LIST 1. Suicidal Ideation 2. Depresaion 3, Paychos lB 4. Mania 5) Dellrium 6. Family Issueo 7. Temper control B. Disposition Planning 9. Other: WEEK 2 Date 3 Date 4 Date 5 Date INIT. OBJECTIVES a. No suicidal ideation' for at Leaat 72 houra. b, Voico feolLngs to ataff. c. NormaL Mood - Sloep more than 6 hrs - Eat 3 meals a day - Beck inventory less than 17 ~) No hallucinations or delusions for 72 hours. No major mood fluctuations for 72 hours. Reversible causes found and treated, 4:1 Family relationships/issues ~ clarified and stabilized. @ Coping strategies developed. i. Comprehensive outpatient plan. j. other: REVIEW A. PROBLEM # GOALS PROGRESS I:g( Carlisle I-b;pital INITIAL TREATMENT PLAN AND REVIEWS PSYCHIATRIC UNIT PS 0915 (5/94) '- METHODS ~ Physical exam Individual therapy & Supervision of ~. team TIME FRAME 2. Ll{0 4~ Medic~tio~ (&~1' ~ 5. Other: INTERVENTIONS DIC DATE . ,(i. PATIENT IDENTIFICATION:" -:r}~ . \~. ". 0~1~1I "OSHU. 'IOLETTI I. ,., . 05/04/95 85 SHIRREL WiT ' 11/04/19 CARLISLE. PA ~ANrREOI. ROCCO L "0':: 8'lbS21'l 1185'\5. ,'; ,0 ""~f "[ 0 I C Aft E :",~J.l:~ ' ~~, C. NURSING PRoaLEM LIST 1. Self-Care Deficit 2. Sleep Pattern ~ Disturbance ~H J) Potential for Violence '',W Directed at Others 4. Altered Nutrition Lsss Than Body Requiremsnts OBJECTIVES 1. Patient will bathe, dress, feed and toilet self to his optimal level of functioning daily. 2. Patient will eleep at least 6 hours per night. J:) Patient will not exhibit , aggressive behavior x 48 hours and will identify aggressive behavior. 4. Patient will eat 50-75\ of each meal daily. ~ Impairsd Social ~;.t,:,ra~ti~ns r.t..,<!. ~:)a. ( /'~l' -I, J/ _ 1 , ~ 4J.. \..1."..(.. f,~.....ttl,t"J..-....., ,,' I . ctU.,LV..hl.aJ ...A F--i...-u ('.n ~~.. z.... .. Patisnt will initiate in one social intsraction daily in an unetructured eetting. b. Patisnt will demonstrate effective social interaction skillo in both 1:1 and group settings. , (' " I'-t ..-I..{'( ,.,,<t't ,\( d,1 ,,;... I" -I 01-- l.l.LlI..:..d...., -..0.1.( ...~L'"~....I.;.;, I (., io~ ~ T S :A;~ :~; T ;~E;:IFicTiTioN-- 05/04/~5 85 SHIIIIIEL wAY IZ/04/1~ CIALISlE. PA IIANFREOI. ROCCO L 110 8SbS21Q 1185~5 MEDlelRE ~' :!i.;l ...~;~~ METHODS ~ Remind Assist as ,~ded Encourage indeP'lndence Allow pt. ample time to perform self-care taoks Relaxation tape Reduce env ironmental distractions Relaxation and stress Increaoe daytime activity and discourage napping Assess pt. for Bigns of increaosd agitation b. Use the leaot restrictive means to assist pt. to mainta in control 1. Verbal redirection 2. Time out in room J. Offer PRN medications 4. Seclude/ restrain ao needed Weigh pt. Jx/wk Provide nutritional eupplemente if not eating meals c. Aooist with menu selectione a. Encourage pt. to remain out of bed b. Asoiot pt. to identify behavior that prevento social relationships c. Encourage attendance and progreoBive participation in a 11 groups 1. Streos managemont 2. Aooertiveneos training J. Relaxation group 4. COlM1unity meeting 5. Medication group d. 1:1 interaction w/staff 15 min. 2x daily 1. a. b. c. d. 2. a. b. c. d. 3'.- a. 4. a. b. TIME FRAME ~<;/,.1 ~ .;< LL"8./,_ J . NURSING CONTINUEDt WEEK 2 Date 3 Date 4 Date 5 Date IN IT . PROBLEM # SIGNATURE .. J <":.. @J~~ INITIAL TREATKENT PLAN AND REVIEWS PSYCHIATRIC UNIT PS 0915 (5/94) REVIEW C. PROGRESS GOALS INTERVENT1'ONS Ole DATE PATIENT IDENTIFICA~. J : .\ ,!' 0';11" ROBUTS. VIOLETTI I. :"', ' OS/C4/Q5 85 SMIRKlL wAY -' 11I04/IQ CARLISLE. Pl "'"FREel. ROCCO L "0 8SbS219 1185'\5 MEOIClRE J .. ....,'. ;'" .,,' ~"".i';f.' , ..:, ' .'.'w:..'~"..:."" D. OCCUPATIONAL THERAPY PROBLEM LIST 1. Suicidal Ideation 2. Depresolon CD Psychosis 4. Mania S. Delirium ~ Family Issues 7. Temper control 8 Disposition Planning ~ Other. OBJECTIVES (i) Increase self-confidence and self-awaroness ~ Plan post-discharge daily routine c. Identify leisure interests d, Improve ADL status e Learn relaxation/stress management techniques f. Select ways to increase or provide outlet for energy level g. Other. REVIEW D. WEEK INIT. PROBLEM # PROGRESS 2 Date 3 Date 4 Date 5 Date ~~ Ibpital INITIAL TREATMENT PLAN AND REVIEWS PSYCHIATRIC UNIT PS 0915 (5/94) '- METI!ODS o successful completion of group tasks TIME FRl\ME Iw~t" b Select discharge planning goals c. Assessment sheet, re-activate old interest d. Functional Assessment ~ Integrate coping methods/values groups f. O.T. therapeutic exercise program, body/mind group g. Other: ~frr..f@'M-Ih GOALS INTERVENTIONS Ole DATE - PATIENT IDENTIFICATION,~~t \""~.. ,,-I.to, l.'~l C51ZU ROBERTS. 'JOLETTE I. 05/0C/QS 85 SHIMMEL wiT 17/0C/IQ CARLISLE. Pl MHFREOI. ROCCO L "0 PQbS21Q 118SQS . '. 't; ~- "EOIClAE E. ACTIVITIES THERAPIST PROBLEM LIST 1. Suicidal Ideation 2. Depres&ion G) Psychosis 4. Mania 5. Delirium ~ Fam~ly Issues 7. Temper Control @ Disposition Planning (2) Other. T'-'lloff.d RJrmJiJid IX iOtJ '- OBJECTIVES ~ Attend and participate in activity for at least 45 minutes. ~ Participate in socialization activities with copatients during free time. c. Walk up and down hall way at least once per day. d. Other. METlloDS ~ Group Therapy (3) Focused activity group or project ~ One. One time ~ Recreational activities o Other. ~oclran'a I LVs:t K' TIME FRAME REVIEW E. WEEK INIT. PROBLEM # PROGRESS GOALS 2 Date 3 Date 4 Date 5 Date INTERVENTIONS DIC DATE PATIENT IDENTIFICATIO~ . O')IZII ROBEIITS. "OllrTl I. ..~ OS/04/QS 85 $HINNEL WAT" IZ/04/1~ CARLISLE. PA MANFREDI. ROCCO L MD 8~bS21q 1185'\5 @/~ I-b;piIal INITIAL TREATMENT PLAN AND REVIEWS PSYCHIATRIC UNIT MEDIClRE 'I' -'1', "I!r INITIALS ,SIGN T RE I' I,' ",:' i' ,)t c ,) r II', \. "\1 b .. ,12 " \,0" ,I' ~0r(IIJ2' ^,:.r iH Ii' . . I. . I' " .1 'r' 'r" ., OVEIlAU. SKIN BOWEL.t BLADDER RElfABlLrrATIVE MENTAL Nl1T1lmOIlAL CIfIlOIlIC DIS1lA58 CONDmoN COtmlOL STATE STATS STATS STATS 0 0 , 0 I 0 I , , . , , , , , " , " !' .. IIp '1 "" , , I. " " " , , . ",' ~I . ......1......... til:-. I.' 1,.,r.ur PE 1908 \1/931 DATE I ~,t~ DATE OF.ADMISSIONI g :Ll:95 , . " i r I' , ! ., r: I I.. , ,I , 6-Aa n""..~ cfYTlJdo PliJdA-ri UCOlD Dr ........IIDTi" ~A J .-tl , . . . . . . , . . ,. II " " II II II " It II .. 21 .. .. .. .. .. " .. .. .. 21 V ....., ''f', PATIENT R1JJJiJ 1- ~ lOw;......, 2. INTERVIEW EDUCATION Highest level completed 8 9 College/Training ~~ Learning Problems -11QYL(_ VOCATIONAL HISTORY P""""y .'p10y.d ____ y" ~~ If not why --21{JYI\DM\5V\!A/ ( flPDr/l If yes, length and type of employm nt ~ 'I @ 11 @GED Past significant job history --1kpt..~ ..{ll'6NPAI ~Nr1cWW1a~. Job satisfaction/problems Future plans for employment I&~ I-bspital - . ~l~, ?f~ fti O~IZW ROBERTS. 'IDLUTE I. >\I:;.;i . 05/04/'15 85 aN I IIMH wn :;,'~" 12104/1'1 CARLISLE. P"" MANFRE D/. ROCCO L 110 i~,..\ SQbS21Q 1185'15 ~;\,~,,~i "EOICAR[ , ,..H,t , , 1oJ.{"; "1"''1'. 4 !t'''IM r... l"'t'" OCCUPATIONAL THERAPY DATA BASE OT 0425 (2/93) '. ;' j. , , " , , I, 2 .' I ; , .. :. ",.:... I f ;1.' I , I J " r I : I' '. , 'J ..I ,"2 J. SOCIAL RELATIONSHIPS .; ,,' Marital status ~ 1.3 I I .' Children ~-1'- - Current living situation ~ (i CORe. In " . !.::. r ',' '.t" rl..rr.lI.E;{. 01ANI 1l1um ~ ~ Social 4. LEISUR INTER S preseqt and past 1eisur~ activities/interests ~l~~ Wor~ Community involvement __V'J&Ybn~~~, Medical limitations ~_______ Financial status Transportation Drug/alcohol use Means of relaxation Recent level of activity/energy --1M:uANYIdv hw.aI. \MlW 5. ACTIVITIES OF DAILY LIVING ~~"~~wtt,r:tin~~~~f1u,iJl DATE: /J."-<( -7,j- BECK DEPRBSSION PROTOCOL l0 This iR a questionnaire. On the questionnaire are groups of statements. Please read the entire group of statements in each category. Then pick out the one statement in that group which best describes the way you feel today, that is, riaht Dowl circle the number'beside the statement you have chosen. TO READ ALL THB STATEMENTS IN EACH OROUP DEFORE MAKINO YOU CHOICE I PATIENT IDENTIFICATION 1;1 r'~, O~IIW ROBERTI. YIOLETTI .t ';' 05/D4/~5 8!1 IHIIIIIEL IIAT "if , IZlD4"~ CULIIU. PI ,! "fllNFRrOI. ROCCO L flO '~ "~I,")'" SQb521Q 118S'fS ,.-:!, \ . ',. .~.. .. t:!l:ii.. , . ~ -'.',; ,',/ j-,~;...;."~~,,,,,\,,,-:, ',' DB SURB 1. ~ J 2. G) 1 2 J J. Cf 2 3 4. ~ 1 2 J 5. 0 1 2 3 6. 0 2 3 . I do not feel sad. I feel sad. I am sad all the time and I can't snap out of it. I am so sad or unhappy that I can't stand it. I am not particularly discouraged about the future. I feel discouraged about the future. I feel I have nothing to look forward to. I feel that the future is hopeless and that things cannot improve. I do not feel like a failure. I feel I have failed more than the average person. As I look back on my life, all I can see is a lot of, failures. I feel I am a complete failure as a person. I get as much satisfaction out of things as I used to. I don't enjoy things the way I used to. I don't get real satisfaction out of anything anymore. I am dissatisfied or bored with everything. I don't feel particularly guilty. I feel guilty a good part of the time. I feel quite guilty most of the time. I feel guilty all of the time. I don't feel I am being punished. I feel I may be punished. I expect to be punished. I feel I am being punished. f 11 . @/~ I-h;pital .. ..." ,PSYCHIATRY I ." BECK, pBP~~SSj~~N ,PR9TOCOL . I .11' I J" , J , ' , ;' I' ,,' , , PS 0203 (4/92) I ' I f1lDICU[ ,\ I 7. Q 1 2 3 8. cp 2 3 9. Q 1 2 3 10. G) 1 2 3 11. G) 1 2 3 12. w) 1 2 3 13. ~ 1 2 3 14. cD 2 3 I don't feel disappointed in myself. I am disappointed in myself. I am disgusted with myself. I hate myself. I don't feel I am any worse than anybody else. I am critical of myself for my weaknesses or mistakes. I blame myself all the time for my faults. ' I blame myself for everything bad that happens. I don't have any thoughts of killing myself. I have thoughts of killing myself, but I would not carry them out. I would like to kill myself. I would kill myself if I had the ~u~nce. I don't cry any more than usual. I cry more now than I used to. I cry all the time now. I used to be able to cry, but now I can't cry even though I want to. I am no more irritated by things than I ever am. I am slightly more irritated now than usual. I am quite annoyed or irritated a good deal of the time. I feel irritated all the time now. I have not lost interest in other people. I am less interested in other people than I used to be. I have lost most of my interest in other people. I have lost all of my interest in other people. I make decisions about as well as I ever could. I put off making decisions more than I used to. I have greater difficulty in making decisions than before. I can't make decisions at all anymore. I don't feel that I look any worse than I used to. I am worried that I am looking old and unattractive. I feel that there are permanent changes in my appearance that make me look unattractive. I believe that I look ugly. ~PATIENT IDENTIFICATION ,;, 0512w ROBERTS, VIOLETTE 05/04/QS 85 SHI"MEL WlY Il/04/1Q CARLI SLE, Pl HANrREOl, ROCCO L MD , R9bS21Q 1185~S .;, 3J@f~~, 'PSYCHIATRY , " BECK'DEPRESSION PROTOCOL " ..,.., t, ".:' -. II f". ' PS 0203 (8/92) PATIBNT IDBNTIFICATION .( 051 ZW ROHRTS. .,y I (llqTE 'II \), . 05/04/Q5 85 SH I NNH wI Y . · ~,.~;, IZ/04/IQ CARLIS,lE, ,PA, . N AN r REO 1.. ROC c,q ; l "0,. ,j,... 8 g bSc19 118 Slf 5 L,' i:. NEOICAAE ~;~~;~ .l~-' :.I.' 15. ~ 1 2 3 16. cV 3 17. 0 <i> 2 3 lB. d> 2 3. 19. & 3 20. LV 1 2 3 ~~ 2 3 - BECK DEPRESSION PROTOCOL (COD't) I can work about as well as before. It takes an extra effort to get started to doing something. I have to push myself very hard to do anything. I can't do any work at all. 1 can sleep as well as usual. I don't sleep as well as I used to. r wake up 1-2 hours earlier than usual and find it hard to get back to sleep. I wake up several hours earlier than r used to and cannot get back to sleep. r don't get more tired than usual. r get tired more easily than I used to. I get tired from doing almost anything. I am too tired to do anything. My appetite is no worse than usual. My appetite is not as 'good as it used to be. My appetite is much worse now. I have no appetite at all anymore. I haven't lost much weight, if any, lately. I have lost more than five pounds. I have lost more than ten pounds. I have lost more than fifteen pounds. I am not more worried about my health than usual. I am worried about physical problems such as aches and pains, or upset stomach, or constipation. I am very worried about physical problems and it's hard to think of much else. I am so worried about my physical problems that I cannot think about anything else. I have not noticed any recent change in my interest in sex. I am less interested in sex than I used to be. I am much less interested in sex now. I have lost interest in sex completely. f31 : @/~~ PSYCHIATRY BECK DEPRESSION PROTOCOL I PS 0203 (4/92) , .'. . . . . e iiJ DATE I 5-~ - 1'..5 - DECK DEPRESSION PROTOCOL Thil is a queeUonnaire. On the questionnaire are groups of statemente. Plea.e read the entire group of statements in each category. Then pick out the one Itate.ent in that group which best describes the way you feel today, that i., riabt DOW. Circle the number beside the statement you have chosen. .1 .va. to .BAD ~L THB STATEMENTS IN EACH OROUP BEFORB MAKINO YOU CHOICB' 1. o <P 3 2. (Q) 1 2 3 3. Q> 1 2 3 4'G 2 3 5.W 1 2 3 6. o 1 6 I do not teel sad. I teel sad. , I am sad all the time and I can't snap out of it. I am so sad or unhappy that I can't stand it. I am not particularly discouraged about the future. I feel discouraged' about the future. I feel I have nothing to look forward to. I feel that the future is hopeless and that things cannot improve. I do not feel like a failure. I feel I have failed more than the average person. As I look back on my life, all I can see is a lot of failures. I feel I am a complete failure as a person. I get as much satisfaction out of things as I used to. I don't enjoy things the way I used to. I don't get real satisfaction out of anything anymore. I am dissatisfied or bored with everything. I don't feel particularly guilty. I feel guilty a good part of the time. I feel quite guilty most of the time. I feel guilty all of the time. I don't feel I am being punished. I feel I may be punished. I expect to be punished. I feel I am being punished. ~PATIENT IDENTIFICATION _ "'0 I' .\< 051tw ROIUU., IOUTrI.'."." " 05/04/~' '5 '"'""IL NAT ',)~ 11/04//9 CARLI.Lr. 'A'" MUrlllOL. 1l0CCO L NO "'1" RQbSc:?1Q 'lB5~5 ',: ( "[Ortur '. ., @/Quiige ~ , , .:: : T l' "PSYCHIATRY BECK DEPRESSION PROTOCOL . : "I j " I . ,. I ' ." I I , , ',.' I " ., I' I' : I PS 020,3 (4/92) o~'f3ENT IDENTIFICATION ROBE 1115, Y I OUTrE O~/04/95 85 SHIRREL WAr I2I041J~ CULl SLE PA HAI"~[OI, Aoeeo L'RO ggbS21Q 1185~5 REDICARE 7'Q) 1 2 3 8. cp 2 3 9. CQ) 1 2 3 10. <to 1 2 3 11. rp 2 3 12. o 1 2 3 13. cp 2 3 14. & 2 . 3 I - I don't feel disappointed in myself. I am disappointed in myself. I am disgusted with myself. I hate myself. I don't feel I am any worse than anybody else. I am critical of myself for my weaknesses or mistakes. 1 blame myself all the time for my faults. 1 blame myself for everything bad that happens. 1 don't have any thoughts of killing myself. 1 have thoughts of killing myself, but 1 would not, carry them out. 1 would like to kill myself. I would kill myself if 1 had the chance. 1 don't cry any more than usual. 1 cry more now than 1 used to. 1 cry all the time now. 1 used to be able to cry, but now 1 can't cry even though 1 want to. 1 am no more irritated by things than 1 ever am. '1 am slightly more irritated now than usual. 1 am quite annoyed or irritated a good deal of the 1 feel irritated all the time now. time. I have not lost interest in other people. ~ am less interested in other people than I used to be. 1 have lost most of my interest in other people. I have lost all of my interest in other people. 1 make decisions about as well as I ever could. 1 put off making decisions more than I used to. 1 have greater difficulty in making decisions than I can't make decisions at all anymore. before. I don't feel that 1 look any worse.than 1 used to. I am worried that I am looking old and unattractive. I feel that there are permanent changes In my appearance that make me look unattractive. I believe that 1 look ugly. ..'. ' ..,..... .. " I'~\ ~I@ll,' ~~I, , '11 i~~;-:'I I. .1 PSYCHIATR~ . BECK..DEPRESSION PROTOCOL , , PS 0203 (8/92) , ',f,' PATIENT IDENTIFICATION t 0512w ROBERTS. VIOLETTE , 05/04/Q5 85 3HI""EL WAr 12I04/1Q CARLI SU ' PA ' MlHfREOI. ROCCO L'MD ,~.." 8'1b5219" ~185~5..._ .~ MEDICARE .H\:Hf' ~fr~~ ' 15. Gi) 1 2 3 16. ~ 2 3 17. ro 2 3 18. CD 1 2 3. 19. cp 2 3 20. ~ 2 3 21. G 2 3 BECK DEPRESSION PROTOCOL (con't) I can work about as well as before. It takes an extra effort to get started to doing something. I have to push myself very hard to do anything. I can't do any work at all. r can sleep as well as usual. I don't sleep as well as I used to. I wake up 1-2 hours earlier than usual and find it hard to get back to sleep. 'I wake up several hours earlier than I used to and cannot get back to sleep. I don't get more tired than usual. I get tired more easily than I used to. I get tired from doing almost anything. I am too tired to do anything. My appetite is no worse than usual. My appetite is not as good as it used to be. My appetite is much worse now. I have no appetite at all anymore. I haven't lost much weight, if any, lately. I have lost more than five pounds. I have lost more than ten pounds. I have lost more than fifteen pounds. I am not more worried about my health than usual. I am worried about physical problems such as aches and pains, or upset stomach, or constipation. I am very worried about physical problems and it's hard to think of much else. I am so worried about my physical problems that I cannot think about anything else. I have not noticed any recent change in my interest in sex. I am less interested in sex than I used to be. I am much less interested in sex now. I have lost interest in sex completely. @I Cartige lb;pital PSYCHIATRY BECK DEPRESSION PROTOCOL PS 0203 (4/92) DATE I S- - S--;P'"..)- BECK DEPRBSSION PROTOCOL to This is a questionnaire. On the questionnaire are groups of statements. Please read the entire group of statements in each category. Then pick out the one statement in that group which best describes the way you feel today, that is, riaht Dowl Circle the number beside the statement you have chosen. BB SURB TO READ ALL THB STATEKENTS IN BACH OROUP BEFORB MAKING YOU CHOICE I 1. <D 2 3 2. tv 2 3 3. 0 1 2 3 4. (J 1 2 3 5. (i) 2 3 6. If 3 I do not feel sad. I feel sad. I am sad all the time and I can't snap out of it. I am so sad or unhappy that I can't stand it. I am not particularly discouraged about the future. I feel discouraged about the future. I feel I have nothing to look forward to. I feel that the future is hopeless and that things cannot improve. I do not feel like a failure. I feel I have failed more than the average person. As I look back on my life, all I can see is a lot of failures. I feel I am a complete failure as a person. I get as much satisfaction out of things as I used to. I don't enjoy things the way I used to. I don't get real satisfaction out of anything anymore. I am dissatisfied or bored with everything. I don't feel particularly guilty. I feel guilty a good part of the time. I feel quite guilty most of the time. I feel guilty all of the time. I don't feel I am being punished. I feel I may be punished. I expect to be punished. I feel I am being punished. , ./ PATIENT IDENTIFICATI~:, '.- ~ O~IZw ROBERTI. 'IOLETTI'..!, O~/(l419' 85 SHINIIlL lilT ""1,. 1?/04/1~ CARLISLE. PA ,~? "lMrR[ 01. ROCCO L "D '.':.~ "[~~:A~:1q 1185'+5 . '\">:~ i1o~G~1 (il "? @f;~,~",~ "1', PSYCHIATRY' I ".. ", ,'r \ ' ., BECK DBPRBSSION, PROTOCOL r I ' I . ,... J "I "'l:"~' . I. '" 1 .. . ;'1 u;~ I r : f" ':, ' , , PS 0203 ( 4'/92) I don't feel that I look any worse than I used to. I am worried that I am looking old and unattractive. I feel that there are permanent changes in my appearance'that make me look unattractive. 3 I believe that ok ugly. .( 05 12W PATftlltf II1ISSNf:UIU!j(f~~:':':C' Oo;/04/~5 8'5 SIIIIIIIH lilT ,;~ IU04/1~ CaRLISLE. 1'. '," "ANFREDI. ROCCO L 110 '.'''' SQbS21Q 11BSQS 7. G) 1 2 3 9. (J 1 2 3 9. Q 1 2 3 10. G 1 2 3' 11- q 3 12. ~ ,,0 1 2 3 13. 0 @ 3 14. .' MEDICARE ..... - e e e e ." r '" " I don't feel disappointed in myself. I am disappointed in myself. I am disgusted with myself. I hate myself. I don't feel I am any worse than anybody else. I am critical of myself for my weaknesses or mistakes. I blame myself all the time for my faults. I blame myself for everything bad that happens. I don't have any thoughts of killing myself. I have thoughts of killing myself, but I would not carry them out. I would like to kill myself. I would kill myself if I had the chance. I don't cry any more than usual. I cry more now than I used to. I cry all the time now. I used to be able to cry, but now I can't cry even though I want to. I am no mc~e irritated by things than I ever am. I am slightly more ' irritated now than usual. I am quite annoyed or irritated a good deal of the time. I feel irritated all the time now. I have not lost interest in other people. I am less interested in other people than I used to be. I have lost most of my interest in other people. I have lost all of my interest in other people. I make decisions about as well as I ever could. I put off making decisions more than I used to. I have greater difficulty in making decisions than before. I can't make decisions at all anymore. o 1, e> c; 'I . ~1-f~.Ji'lr.J~ll'l '",~ ~?1'?~ ... .,r',: , ":'~ . " I.' i ")1:;) I I PSYCHIATIlY"'~' .:'. BECK DEPRESSI~N PROTOCa~, " ' I" ., PS 0203 ,(9/92) J. . ". 'I>~ Olj1211 ROBERTS. "DUlt! I",lt; 05/04/Q5 85 SHI""lL vAt I2I04/1~ ClRLI&Ll. PA :,\:~;:;i. K'UAlOI. ROCCO L KD SUS. ", "~'t' ggbS21q 118 -. ':+ ," j.:4.:), "E Die ARE i.'\I~"r.'i. ! 15. G;' 1 2 3 16. 0 q> 3 17. 0 1 2 3 18'6) .0 1 2 3. 19. ~ 2 3 20. (i) 1 2 3 0; 0 1 2 3 BBCK DEPRBSSION PROTOCOL (con't) I can work about as well as before. It takes an extra effort to get started to doing something. I have to push myself very hard to do anything. I can't do any work at all. 1 can sleep as well as usual. I don't sleep as well as I used to. I wake up 1-2 hours earlier than usual and find it hard to get back to sleep. I wake up several hours earlier than I used to and cannot get back to sleep. I don't get more tired than usual. I get tired more easily than I used to. I get tired from doing almost anything. I am too tired to do anything. Ky appetite is no worse than usual. My appetite is not as good as it used to be. My appetite is much worse now. I have no appetite at all anymore. I haven't lost much weight, if any, lately. I have lost more than five pounds. I have lost more than ten pounds. I have lost more than fifteen pounds. I am not more worried about my health than usual. I am worried about physical problems such as aches and pains, or upset stomach, or constipation. I am very worried about physical problems and it's hard to think of much else. I am so worried about my physical problems that I cannot think about anything else. I have not noticed any recent change in I am less interested in sex than I used I am much less interested in Rex now. I have lost interest in sex completely. f31 my interest in sex. to be. r', G~ PATIBNT IDBNTIPICATI ,.\ 'j \ - @/~ I-mpital PSYCHIATRY BECK DEPRESSION PROTOCOL PS 0203 (4/92) APPLICATION FOR INVOLUNTARY EMERGENCY EXAMINATION AND TREATMENT Mental Health Procedures Act of 1976 Section 302 leted followin admission.) NAMI LAlT MIDDLE ADE SEll Qo~-\:.":. S- AOORESS <65" ~, ~f1 nO \ ') DIU O. D~ cO. INSTRUCTIONS 1. Part I must be completed by the person who believes the patienl is in need of treatmenl. If lhis person is nol a physicL1n, police officer, the County Administrator or his delegate, he or she must request authorization or a warranllhrough lhe County Administrator. , 2. If the authorizalion or a warrant through the County Administrator is required, call or visit lhe office of the County Administrator. AUlhorization 10 take a patient for examination without a WoIrrant is 10 be documented in Part II, If a warrant is required, Part III must be completed by the County Administrator or a person designated by the Administrator to sign the warrants. ! 3, When lhe patient is laken to the examination facility, the rights described in Form MH 783.A must be explained, Part IV should be signed by the person who explains these rights to the patienl. 4. Pari V is to be compleled by lhe County Administrator (or representative) or by lhe Director of the Facility (or representative) upon arrival of the patient althe facility. 5. Part VIis 10 be completed by lhe examining physician. 6. If additional sheets are required al any point in completing this form, nOle on this form the number of additional sheets which are attached. 7. If lhe patient is subject to criminal proceedings/detention. brieny describe below. PAoe 1 of 7 MH 783 . 7,82 ~-' IMPORTANT NOTICE ."" ANY PERSON WHO PROVIDES ANY FALSE INFORMATION ON PURPOSE WHEN HE COMPLETES nus FORM MAY BE SUBJECT TO CRIMINAL PROSEClTflON AND MAY FACE CRIMINAL PENALTIES INCLUDING CONVICTION OF A MISDEMEANOR. I believe thai Part I APPLICATION \J \tr~~~~ b severely menially disabled:, (Check and complete all applicable Cor thb palient.) A person Is severely meltlally disabled when, as a result oC mental illness, his/her capacity to exercise seIC-con:rol, judgment and discretion in lhe conduct oC his/her aCCalrs and socW relations or 10 care Cor hb/her own personal needs Is so lessened that he/she poses a clear and present danger oC harm 10 others or 10 himselC or herselC. D Clear and present danger :to olhers shall be shown by establbhing lhat wllhln the past 30 days lhe person has inflicted or attemplen to -inflict serious bodUy harm on another and that there b reasonable probabUlty that such conduct-will be repeated. A clear and present danger oC harm to others may be demonSlrated by prooC that the person has made threau or harm and has commiued acu in Curtherance oC the threat 10 commit harm; or ' Clear and present danger 10 himselC shall be shown by eSlablishing that wilhin the past 30 days; D (i) D (ii) D (Iii) the person has acted in such manner as to evidence that he/she would be unable. without care, supervision and lhe conlinued assistance oC olhers, 10 satbCy hb/her need Cor nourishment, personal or medical care, sheller, or selC.protectlon and saCety, and that there b reasonable probabUlty that death, serious bodUy injury or serious physical debUllation would ensue withIn 30 days unless ade,quale treatment were aCCorded under the act; or the person has attempted suicide and thai there b reasonable probabUlty oC suicide unless adequate treatment Is aCforded under thb acl. For the purpose oC this subsection, a clear and presenl danger may be demonSlrated by the prooC thai the person has made threau to commit suicide and has commlued acts which are In Cunherance oC lhe threat to commit suicide; or the person has substantially mutilated himselC/herselC or at templed 10 mutilate himself/herselC substantially and that there b the reasonable probabililY or mullilatlon unless adequale trealmenl b afCorded under this act, For lhe purposes oC thb subsection, a clear and present danger shall be eSlablbhed by prooC that the person has made lhreats to commit mutUatlon and has committed aclS which are In Curtherance of the threat to commit mutilation. PAOE 2 017 MH 713 . 7.12 'Describe in detaU the speciflc behavior within lhe last JO days which suppvrts your beliefs (in...de location, . date and time whenever possible, and state who observed the behavior): - ~~ ~ -e- 7'~ ~.w a-6-~,....e t'~ .... {J..__._ ~ . oJ- ,.. ~ f",'" ~ .&.. ...c..=40<--' ~ ~ --:dJ~p. ~.:,. m......~ ~~~..- , . ~.:(7~ \J1 J;:i~L~'~ ~X ~ (tl.;.~ ~,,'.,L.~~:~~~c- ~~' ~ /',GC ,~." ;: v ~_~ ";.,._ -..e. (}___. ~~ ___ c>.-...e- h f,.... ~ '1f:.' _ " ~ ~.....,cx; .eL ....1..... e.L....u ~ A.c. d-t.., ~ . ~'a. r ~~..<..~ ?!!:;B~~;1.~~ ~~3ii~~~~~:$~~:~~; ~~fi~~~~~ I understand lhal IlIlU. be required to testify at a court hearing concerning the informalion I gave. V;o~ 1(CJb<V-t."} ,PERSON'S NAMEI Is in need of involuntary examinalion and lrealment. I request thai: (Check A or B . Notice that Bcan_ be checked by II physician, a police orncer. lhe County Administrator or his/her delegale). On the basis of lhe informalion I gave above, I believe that A. !Xl The County Administrator issue II warrant authorizing a policeman or some. one represenling the Coumy Adminislralor to lake the patient 10 a facUilY for examinalion and treatmenl. ~~ <- - "'-<:....-.:.-~... ~ :, 7f dJO~'!!~'!.~LICANT ~t:~.<-~~~~~.if1. <,cC (I., WL--' '!..dy- I d(""~~ Uk~ C!....{A.~ _ "- /'7iJ,...3 P T NAME A 0 ADDRESS OF APPLICANT .sTy /9' S- DATE 717-.;}~.s--9P~/ TELEPHONE NO. B, o That lhis facUlty examine the patient to determine his/her need for treat- menl, SIONATURE OF PHVSICIAN. POLICE OFFICER. COUNTV AOMINISTRATOR,OR REPRESENTATIVE OATE PAINT NAME AND TlTl.E OF PHYSICIAN, POLICE OFFICER, COUNTV AOMINISTRATOR OR REPRESENTATIVE TELEPHONE NO. ADDRESS 'AOE 30'7 MH 7113 . 7.82 .----.-.-----.-- PART III .' . WARRANT (CheckAorB) . Ifl~,j ~ A. I X I Based upon representations made 10 me by -1; : ~ R~ 1). - n. -rt- /) n -J(NAME Of APPLICANT1 I hereby order lhal ~ e:.~ shall be taken to ~ .11 ., INAME OF PER80NI and examined at l1.-<<.4 ~J.../J and if required, .. - ;r~lNAME OF FACILITY) shall be admitted to a facUity designaled for treatment for a period of time not 10 exceed 120 hours, Name of facUity designaled for treatmenl if olher lhan the facUhy conducling the examination: c!!J", B. o SIONATURE OF COUNTY ADMINISTRATO 0 HISIHER REPRESENTATIVE c..hlH'/I'S +lo~ ~\ PRINT NAME OF COUNTY ADMINISTRATOR OR HISIHER REPRESENTATIVE DENIAL OF WARRANT The requesl of the pelitiDner for a warrant is denied: SIONATURE OF COUNTY ADMINISTRATOR OR REPRESENTATIVE DATE PART IV THE PATIE~HTS I affum lhat when lhe patient arrived al @( \\~ \'0. ~~',-\,,9 INAME OF FA ILITY) I explained hb righu 10 him/her. These rights are described in Form MH 783-A. I believe lhat he/she: ~ . b~ ~QQ.IU!. -w> llOS~;-c. ~S understand these rights. ~ ~~e1~d. \ D does nOl understand these rights, ;-- 4-91)- DATE ~ SIONATURE,OF ERSON EXPLAIN ~,,~ ~ '^""'" fR TAME 0 PERSO PLA NINO RIOHTS PAOE 8 017 PART V , ACfIONS TAKEN TO PROTECf THE PATIENT'S INTEREST I affirm thai 10 lhe best of my knowledge and belief lhe following actions which were laken constituted all reasonable steps needed to, assure that while the patienl is delalned the health and safety needs of any his/her dependents are mel and thai his/her personal property and the premises he/she occupies are secure, Describe lhe actions taken below. Use additional sheets if required. . t f' J?xJ' .(\Q.... , ~ "~(f l. ~uo~~"'> SIGNATURE OF COUN-T'9 MINISTRATon/R PRESENTATIVE OR THE OIRECTOR OF THE FACILITY OR REPRESENTATIVE c:; - 4-? c:\ DATE '- ,.. T NA E OF COUNTY ADMINlsrnATon/REPRESEN TIVEI DIRECTOR OF THE FACILtTV OR REPReSENTATIVE MH 783 . 7.82 PAGE II 01 7 t: ..... ..I. ,J o:a. - LQ -t ....I .. r- w . " , ..W~ "8;1 " , t-- 0 ,. t, ..-u ..."~U III 0 a- t 0"'''. llII.U .r- "'.- t\J W .-Q U' . ......... .D . :a...,.. u "'00... cr - -......,. Q "'''''''.. 00 =: gQ-a ~~<:h. ~ '. A ... t.l~ ~~ o t.l t.l~ .cH AI-< 'H :z: H n" nJ 1'\1 ...'" ... .' -"",,. ",', '" ..' ,r I I. .... .. ~ \) " ,. ,-, ~ _ \ ,(\I ",...-1fI '.... "'0.. () n n ". " , I,' lA' n I. fU.... ", '" ,.., ,.. ., Ul: .l.- t...- N N~" II.. ,., ... . ;. ."\ rr :~ ~;::... .~ ,,,.. ~1Il ..... ~~ ~ 3~ ": 8t; : I ,~ u n ... U' ,., ~ .... ~J~ !XI nJ ::.- ru .. '" ~ --. " .... 0, H rl' ~~ - .... ~O 0 oJ) 0'" rl 0 0 :z: . e ~ o Cl :z: i t Clt.l ~~ I-< ", Ii! ,: 8 !; o o ~ lol Po >< lol III H III o :z: Cl IC H '0 Cl :z: H i III ....:;1 t.lH - ICI-< OH :z: H , , , , , I ~ ' ~I I , , , I , I . . 05/04/95 OK . ~i\ VIOLETTE t.L NAY . CUHB'CROSSINGS CARLISLE,' PA 01./ 17013 .. 75~ ,F H H !12/04/19 32~-16-28S2 (717)249-1106 RETIRED AUItHT laPOlJ8(/O utR tlM'lOVER M" IPHONE/DO I Co . ROBERTS, VIOLETTE H. 85 SIIIMMEL HAY CUMB CROSSINGS CARLISLE, PA 17013 y y CUMB SOUTH MIDDLETON TWP CCI CN 1327162B82A GNIHM120184 01 01 . al'JDll/9l4l0 1<1''' 0111 ;;l~ Ij ~.;lO~ , 340079010 1BOOCAPPING 10 70 PROB DEMENTIA DI8POOITIOH A.M.A. ""0lCAl.-..-. MEOICARE -. .." , ~ COYLE, JOHNSON COYLE, JOHNSON G MO G MO r..., DIlIaWm OA.IE 5/9/95 ROCCO L MO ~""""""'"' COllE Axis I Paranoid disorder 297.9 ASSOCIATED _II: COllE Senile dementia of the Alzheimer!s type - mild 290.0 No diagnoses ! Macular degeneration 362.50 Petient with frequent moves and change in living situation Globe! assessment of functioning scale at time of admission - 40 ' ; Global assessment of functioning scale at time of , Discharge _ 60 i I Axis II Axis III Axis IV , Axis V OPEAA1lONS: COllE ll;I'J:i.:~.\':'t'l~: HAS B!:~N DTSCLOS~:D '(t',,, :.'!~f"~~ ~l'J"OFnS ~I';'HO:i: CO~lFIDj~:-:rIALITl '" . '''''/''1',1) ;;'{ ~;TAl'E LI"'l. t.;TATj~ ,'.!7r;,::~; Ll!,!IT YOUR llGilT 'ra 1!.If:E ..:,\ :' r:,;!t!:H DlSC!..O.3t!RE C " THIS I!;?Ol\~~A'rI()~j :,1 '. ':l'UI' Tt1E PRIOR .mITT'll CONSEllT OF TilE n:ilsull 1'0 WHOM IT PERT IllS." JJl,.f.. I cerllfy lhal the narretlve descriptions 0' the principal end secondary diagnoses end the major procedures performed are eccursto end complete 10 the best of my knowledge. Signature, Attending Physician Date . .i .. HOLY SPIRIT HOSPITAL COMMUNITY MENTAL HEALTH CENTER CAMP HILL, PENNSYLVANIA PSYCHIATRIC EVALUATION Name: VIOLETTE ROBERTS Date of Eval.: 09/03/1996 Attending Physician: Dr, Nayyar, Medical Record #: 356489 Date of Birth: 12/04/1919 SOURCE OF INFORMATION: The patient, her husband's daughter, Kathy Kee, Eileen Metz, Director of Personal Care at cumberland Crossings, as well as Psychological Evaluation which was done by Bruce Kelly. IDENTIFICATION: Patient is a 76-year-old widowed white woman who lives by herself currently in an independent living oituation at Cumberland Crossings. She's been living in this area for three years, and is a housewife. CHIEF COMPLAINT: Patient presented herself for a psychiatric evaluation for evaluation for patient's capacity to maintain an independent living situation and to assess her for dementia as well as depression. HISTORY OF PRESENT ILLNESS: Patient presented for evaluation along with her lawyer, Mr. Marcus McKnight. The patient was interviewed alone. The patient states that she has been living in this area for the past three years since her husband, Ed Roberts, died. He had had Parkinson's disease and had died about three years ago. Patient had moved up to this area as her son Greg lived here, and she was living at Cumberland Crossings, She was living in Quincy, Illinois prior to this. Patient states that she has macular degeneration and has trouble with her vision, but has been trying to make some adjustments to take care of this. Patient states that her son haS left this area. She feels that her two children, at this point, are trying to take her money away, and feels that ~hey are trying to take away her independence, and feels that this has really been upsetting her. The patient herself is somewhat suspicious. She states 1 "THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE COr'JFIDFNTr",ITY IS PROTECTED BY STAl E LAW STATE I1EGUl.I\- '1.' 'J<: LIMIT YOUR RIGHTS TO Mt,KE ANY FURTHI:I< 1J13 CLOSURE OF THIS INfOHMArION WITHOUT THE PRIOR WRITTEN CONSENT OF THE PERSON 1'0 WHOM IT PERTAINS:' Name: ROBERTS, VIOLETTE that Theresa Kimmel doesn't like her (Theresa Kimmel is one of the staff at Cumberland Crossings), and feels that her house has been searched a couple of times, She is somewhat vague in giving this information. She says that Theresa Kimmel is "in cahoots" with her two children, and that they just want to take her money away. Patient describes a somewhat turbulent relationship with her two children, especially her daughter, and states that they have their financial problems and are interested in her money. The patient denies feeling depressed, stated that she had been depressed for sometime in the past. She states that she's been sleeping fine, has been able to maintain her apartment, states that she spends her day cleaning and enjoys doing this. She states she is able to do her own groceries, and has had some trouble with her banking and her money management, and therefore has the bank take care of it. She states she goes to the bank once a week, and they are able to help her with writing out her checks. She has one CD in carlisle which a friend is taking care of for her. She denies having any suicidal or homicidal ideations, states her energy is good, denies hearing voices, and denies any symptoms of insertion thought broadcasting, or any referential at this po~nt. She also denies anhedonia. Patient states that she has never been a big drinker, and denies any alcohol use at this time. Writer also spoke with Eileen Metz who is the director at Cumberland Crossings, who also confirmed some of the information. She did admit that Mrs. Roberts has been suspicious at times, but states that Mrs. Roberts has had no trouble maintaining herself, that she keeps her cottage immaculately clean, her ADLs are very good, she has been able to get a magnifier to read some of the things that she was unable to read before, and states that she does have some concerns about Mrs. Roberts spending so much time alone, and that there has been some trouble when she's gone grocery shopping, saying that Mrs, Roberts only buys junk food. The patient, though, does buy a lot of ready-made food because it has become harder and harder to cook because of her vision. Patient also has recently been getting her dinner delivered from the cafeteria at Cumberland Crossings at night, and Mrs. Metz has confirmed this, Mrs. Metz denies any agitated behavior, denies any threatening b~havior at this time. Writer also spoke to Kathy Kee, Some of what precipitated this whole issue was the fact that in February, patient had gone up to Chicago with her husband's daughter, Kathy Kee, and according to Kathy Kee, the patient is doing fine. Mrs. Kee stated that she herself wrote the note and left it in management; but according to the management, this was not the right procedure, and they had some concern as to whether 2 .~'j::ti~-ti:.~:.t'-~'.~it.,::: '_> ..~ >:</',':' \, Name: ROBERTS, VIOLETTE Mrs. Roberts knows the right procedure ~ for sometime, no one knew where Mrs. Roberts had gone. Mrs. Kee stated that she has some concerns about the relationship between Mrs. Roberts and her children, and that they've always had a turbulent relationship. She states that the patient has had some short-term memory loss, but otherwise she is very methodical, routine, checks everything. She is able to organize her house really well, to deal with her visual impairment, her hygiene is good, and that she had not noticed anything that was interfering with patient's ability to care for herself at this point. Kathy Kee also denied knowing any history of substance abuse as far as the patient. Mrs. Metz also denied any information as far as the patient's drinking. MENTAL STATUS EXAM: Mrs. Roberts is a 76-year-old white woman, well-dressed, casually groomed, cooperative, making good eye contact. Speech is normal. Patient denies being depressed. Affect is full range. No suicidal or homicidal ideation is noted, Patient is goal-directed, but somewhat circumstantial at times, and does, at times, try to evade an issue when she doesn't know the answer. Patient denied any auditory or visual hallucinations, but has some paranoid delusions though, mostly related with things disappearing from her cottage, and is accusing some people, especially one of the staff at Cumberland Crossings, of doing this. Cognitively, she is alert, oriented x 3. Insight is fair. As far as memory, her short-term memory is impaired, but long-term memory is more intact. On a mini mental status, she got 25 out of 30 with the wri~er, and on an extended mini mental status, she got 87 out of 90 (The two pentagons were not done because of patient'S difficulty seeing,). She was able to read "Close your eyes" which was written in a large script. Patient's attention and concentration are fair. Impulse control and judgment during the interview were intact. Insight is limited. MEDICAL HISTORY: Patient has medical history of macular degeneration, and is legally blind, Denies any other medical history and is currently not taking any medication. 3 , ' . . .' Name: ROBERTS, VIOLETTE PLAN AND RECOMMENDATIONS: 1. Patient requires medical workup including an MRI to assess for any correctable conditions that may be playing a part in her cognitive decline, According to Mr. McKnight, patient is having a workup with her physician, Dr. Willard, and Mr. McKnight will have this information forwarded to the writer. 2. Patient probably requires low dose Haldol because of the paranoid symptoms, and writer shall consider starting that on the next visit after awaiting some of the medical workup. 3. Shall reassess the patient in two weeks, especially for the depressive symptoms. According to neuropsych testing, there were some depressive symptoms, but writer herself was unable to find any. 4. As far as capacity at this point, it was felt that the patient has some cognitive impairment, especially with her short-terms memory, and also with some of the paranoid thoughts, but this has not so far interfered, from the information available, with her ability to maintain an independent living situation and living by herself, Writer does feel that the patient needs some support as far as having some help with her groceries, and probably requires a helper to come in a couple of times a week, who could spend some time with her and help her do some of these things, I agree with the neuropsych evaluation as far as this goes. 5. As far as financial management, and the patient's ability to maintain her finances independently, patient has made some changes as far as having the bank write out her checks, and also having someone else maintain her CD. I think that she does need some help with this, but I think that the patient should be able to determine who will help her manage her finances. I think that the patient should also consider assigning power of attorney at this point so that if later on, as the cognitive impairment may get worse and interfere with her capacity, she will 5 . . . In Re: : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS COURT DIVISION VIOLETIE ROBERTS, an Alleged Incapacitalcd Pcrson : NO, 96- Civil Tenn PETITION FOR ADJUDICATION OF INCAPACITY AND ApPOINTMENT OF PLENARY GUARDIAN OF TilE ESTATE AND PERSON IN ACCORDANCEWITII 20 PA. CONS. STAT. ~ 5511 TO THE HONORABLE, THE JUDGES OF THE SAID COURT: I. Pelitioners are Claudia Davis and Gregg Martin, the daughter and son of Violelle Roberts, the alleged incapacitated person, BOlh are adult individuals, They reside as set forth in paragraph 3 below. 2, Violelle Roberts was born on December4, 1920, is 75 years of age and is a widow. She resides in an independenlliving COllage ut Cumberland Crossings retirement homes. South Middleton Township, Cumberland County, Pennsylvania, Her mailing address is 85 Schimmel Way, Carlisle, Pennsylvania 17013 3, The following persons are the alleged incapacitated person's only living next-of-kin: NAME ADDRESS RELATIONSHIP Claudia Davis Gregg Martin 28 I 9 Kingsridge, Quincy, IL 8000 Steven's Mill Road, Mallhews, NC 28105 Daughter Son The alleged incapacitated person also has two step children, neither of which were adopted by her. 4, To the extenl known by Pelilioners, the assets of the alleged incapacitaled person are valued at approximalely $166,000,00, comprising lhe following: Cumberland Crossings COllage Bank Accounts at Fanners Trust Company Pension $120,000,00 $6,000,00 Value unknown Certificates of Deposit at Farmcrs Trusl Company Total $40,000.00 ~ 166,000.00. 5, Petitioners estimale lhe alleged incapacitatcd person's annual income to be $14,400,00, including monthly Social Securily Benefils and pcnsion benefits of$I,200,OO, 6, The allcgcd incapacitatcd pcrson was not a mcmbcr of thc armcd scrviccs of thc Unitcd Statcs and is not receiving bencfits from thc Unitcd Statcs Vctcran's Administration. 7, The allcgcd incapacitatcd person is belicvcd to suffer from delusional paranoia. S, Bccausc of hcr mcntal condition. the ullegcd incupacitatcd pcrson is totally unablc to manage or cvcn appreciatc thc significance of her financiul uffuirs, propcrty and business and to makc and conununicatc appropriatc decisions rclating thcreto, including thc ability to communicatc hcr nced for assistancc in these ureus, Hcr mcntal condition furthcr makcs hcr Iikcly to becomc thc victim of designing persons. 9, Because of her impaired mentul condition,thc alleged incapacitatcd person lacks the capacity to makc or communicate any responsible dccisions conccrning her medical necds, Shc is, however. ablc to attend to her personal hygienc und to keep herself propcrly nourishcd and hydrated. 10, Thc scverityof the alleged incapucitated person's mental condition mandates that a plcnary guardian of hcr estalc be appointed to manage und handlc all aspccts of thc allegcd incapacitated person's cstatc, specifically including, but notlimitcd to: all issucs relating to her cash, chccks, and any bank or savings accounts hcld in hcr name, hcr stocks and bonds, her pcrsonal propcrty, any insurance of any kind. of which she is a bencficiary, any govcrnmcntal and non-governmental benefit plans to which shc is entitled, fedcral, state and localtaxcs, any claims madc or to bc madc on bchalf of hcr or against her, and thc cxccution of documents, cntry into contracts and payment of rcasonable compensation or costs to providc services for him, II. Thc sevcrityof the allegcd incupacitated person's mentul condition mandatcs that a plcnary guardian of her person be uppointed to handlc ull issues relating to thc person of thc allcged incapacitatcd person, specificully including, but notlimitcd to: her living arrangcmcnts, hcr medical and psychiutric carc, the administration of medication to her, :md the employmcnt and discharge of physiciuns, psychiatrists, dentists, nurses, therapists and other professionals for her physical and mental care, 12, Petitioners arc not awarc that the ulleged incapacitated person signed any powcrs of attorney or advancc health carc directives or in uny other wuy designated anyone to scrvc as her agent ovcr any of her personul or financial urruirs or as her surrogatc ovcr her mcdical care, or that she dcsignated in writing her wishes with regurd to health care, including the usc or rcfusal of Iifc-sustaining treatment. . . 13. The proposed plenary guardians of the person of the alleged incapacitated person are Claudia Davis, the daughter of the alleged incapacitated pcrson. and Gregg Martin, the son of the alleged incapacitated pen;()I1. both of wlll,m ill c Petitioners herein and who reside as aforesaid. 14. The consents to serve as plenary guardians of the person for each proposed guardian are attached hereto. 15. The occupation of Claudia Davis is that of . who graduated with degree. 16. The occupation of Gregg Martin is that of Sales Manager. who graduated with a Bachelor of Sciel cc degree. 17. The proposed plenary guardian of the estate of the allcged incapacitated person is Financial Trust Services Company. I Wesl lIigh Street. Carlisle, Cumberland County, Pennsylvania. The consent to serve as plenary guardian of the estate is attached hereto. 18. The proposed guardians have no interest adverse to the alleged incapacitated person. 19. No other court has ever assumed jurisdiction in any proceeding to determine the capacity of the alleged incapacitated person. 20. No other guardian has been appointed for the estate or person of the alleged incapacitated person. WHEREFORE, Petitioners respectfully requests that this court award a citation directed to Violette Roberts, the alleged incapacilUled person, with notice thereof to be given to the alleged incapacitated person in conformity with 20 Pa. Cons. Stat. ~ 55 II. and to such other persons as this court may direct, to show cause why she should not be adjudged a totally incapacitated person, and Claudia Davis and Gregg Martin appointed plenary guardians of her person, and Financial Trust Services Company appointed plenary guardian of her estate. Respectfully submitted, Frey & Tiley, Attorneys for Petitioners By: Roliert G. Frey, Esquire Supreme Court Number 46397 5 South Hanover Street Carlisle. Pennsylvania 17013 (717) 243-5838 'M;>>~~~...~~,"r'~;-"",,,,-.,,.,,,,,',,.., ",~~''':O''~a':;'jIl:-!h~S' -".~,.,., , ,.. _~ "..,_",__ :;:,!,.JR(!'<'i';;'t:._,,'~-';''-':'.''.',' '-.-, '; f.;"-". ,"''.1_~'1!'-'';,,_ if '~;,-, ,,1::" --; In Re: : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA . : ORPHANS COURT DIVISION VIOLE'ITE ROBERTS, an Alleged Incapaeitated Person . . : NO. 96- Civil Term CONSENT OF GUARDIAN OF THE ESTATE Financinl Trust Services Company, a corporation having iL~ principal office at I West High Street, Carlisle. Pennsylvania, does hereby consent to act as the Guardian of the Estate of Violette Roberts. Financinl Trust Services Company has the ability to act as Guardian of the Estate of Violette Roberts and has acted as guardian of the estates of individuals in Cumberland County previously. Financial Trust Services Company is not aware of any interest adverse to Violette Roberts, the alleged incapacitated person. Financial Trust Services Company In Re: : IN TIlE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA V 1O...;nJo: RtI n.: R TN, . : ORPHANS COURT DIVISION : NO. 21-96-148 an Alleged Incnpacitnted Pcrson PI~l'ITION FOR TIIJ~ APPOINTMENT OF GUARDIAN {)J<' THE ESTATE IN ACCOR))ANCI~ WITH 20 PA. CONS. STAT. ~5513 TO THE II0NORAIlLE, TIlE JUDGES OF THE SAID COURT: Thc petition of Clnudin Dnvis und Gregg Mnrtin respectfully represent that: I . Pctitioners nrc Clnudin Dnvis, nn ndult individual of 2819 Kingsridge, Quincy Illinois, and Grcgg Mnrtin, nu ndult iudividunl of 8000 Steven's Mill Road, Matthews, North Carolina. PClitioncrs nre thc daughtcr und son of thc allegcd incapacitated person 2. Thc nllcged incnpucitutcd person is Violet Roberts, born on December 4, 1920. She is 75 years of nge nnd rcsides in un independent living cottage at Cumberland Crossings retiremenl homes, South Middlcton Township, Cumberland County, Pennsylvania. Her mailing nddress is 85 Schlmmcl Wuy, Curlisle, Pennsylvllnia 17013 3. A hearing on thc Pctition filcd by Petitioncrs was held on June 28, 1996 and a subscqueut heuring wns hcld on Deccmber 9, 1996 At thc time set for the hearing, present were Petitiouers with their counscl, Robcrt G. Frcy, and Respondent with her counsel, Marcus A. McKnight, III. 4, At the limc schcduled for thc hellring in June, 1996. Petitioners and Respondent reuched un ugreement which Agreemcnt was reported to the Court and is as follows: u. TIle purties ngreed to continuc this matter to allow further medical evaluation and trcutmcnt by Rcspondcnt. h. The Respondcnt agreed, as soon as is reasonably possible, to have a Psychiatrist lit Holy Spirit Hospitul, Camp Hill, Cumberland County, Pennsylvania, cxaminc her and mnke recommendations for her treatment. c. The Rcspondent ugrced to cooperate with the Psychiatrist and to comply <"'-----'--'___",',c,.;-," - '.".C. "".,~",-:.c';,i~e;i$'.'';:~~~~~~:'\.1.,;j''_',j.i;,,:,''-'Y-''''':J ......., ,.;.. with the recommendations for treatment. d. The Respondent would turn ovcr to her counsel of record her banking accounts and bank statements received. Respondent would have the use of her checking account for the payment of expcnses as required by her, but would not make significant withdrawals from her saving accounts or time deposits, or sell assets without prior notification to Petitioners. e. The Respondent agreed that all information concerning her medical and psychiatric treatment and any records from any facility where she resides would be provided to Petitioners so that thcy may monitor her condition. f. The Petitioners agreed to continue thc scheduled hearing in order to afford Respondent an opportunity to take the actions set forth above g. The Petitioners and Respondcnt reduced this Stipulation to writing which has been incorporated into an Order of Court, a copy of which is attached hereto and incorporated herein by reference as Exhibit "A". 6. Subsequently, Respondent was examined by a Psychiatrist pursuant to the Stipulation and the Psychiatrist made recommendations for the treatment and handling of financial affairs of the Respondent. 7. Petitioners filed a Petition on October 29, 1996 secking that guardians be appointed for the purpose of carrying out the recommendations of thc Psychiatrist and for the furthcr purpose of supervising the Respondent's financial affairs. 8. As set forth in the original Petition filed, the proposed guardians of the person arc your Petitioners and the proposed guardian of the estate is financial Trust Scrvices Company (formerly Farmers Trust Company). 9. After a hearing held on Dccernber 16, 1996, thc rcqucst for appointment of a guardian of the person for thc Respondent was denied, and the request for appointment of Financial Trust Services Company as limited guardian of thc estate the Respondent was granted. Acopy of this Order of Court is attached hereto as Exhibit "B". 1 O. It has now come to the attention of Petitioners that Respondent has rctained her checking account and is not using thc scrvices of farmers Trust Company to assist her in writing checks as she had been doing at the time of the hcaring. Instead. Respondent is relying on an acquaintance who sometimes drives her to write checks for hcr. In Re: : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY. PENNSYLVANIA : ORPHANS COURT DIVISION : 2/-9<"1...,. : NO. -96- IT IT VIOLETIE ROBERTS, an Alleged Incapacitated Person ORDER OF COURT ..J oLl-s-:sr AND NOW, this /:J 11. day of-.1996, on consideration of the Stipulation presented by counsel for the Petitioners and Respondent. it is ordered and decreed as follows: a. Consideration of the Petition of Claudia Davis and Gregg Martin is continued to allow further medical evaluation and treatment of Violette Roberts. b, Violette Roberts shall, as soon as reasonably possible, have a psychiatrist at Holly Spirit Hospital, Camp Hill, Cumberland County, Pennsylvania, examine her and make recommendations for her treatment. c. Violette Roberts shall cooperate with the psychiatrist and comply with recommendations for treatment made. d. Violette Roberts will turn over to her counsel of record her banking accounts and bank statements received. Violette Roberts shall have the use of her checking account for the payment of expenses as required by her, but will not make significant withdrawals from her savings accounts or time deposits, or sell assets without prior notification to the Petitioners, e, Violette Roberts agrees that all information concerning her medical and psychiatric treatment and any records from any facility where she resides will be provided to Petitioner so that they may monitor her condition. BY THE COURT: 1..s:wJ~'Ll>C!{~ 2..S~J.~ ' Harold E. Sheely, P.J. (?"'~\~"n'"'' . .;, . In Re: : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS COURT DIVISION : No. 21.96.148 VIOLE'ITE RbBERTS, an Alleged Incapacitated Person SETTLEMENT STIPULATION THE UNDERSIGNED, being the attorneys of record for all of the parties to the above captioned action, do hereby enter into a Settlement Stipulation, as follows: I, Petitiol1ers are Claudia Davis of2819 Kingsridge, Quincy, Illinois, and Gregg Martin, 8000 Steven's Mill Road, Matthews, NC 28105, the daughter and son of Violette Roberts, the alleged incapacitated person. Both are adult individuals. 2. Respondent is Violette Roberts who resides in an independent living cottage at Cumberland Crossings retirement homes, South Middleton Township, Cumberland County, Pennsylvania. Her mailing address is 85 Schimmel Way, Carlisle, Pennsylvania 17013. 3. A hearing on the Petition filed by Petitioners was scheduled for June 28, 1996 at 10:00 a.rn, in Courtroom No. I, Cumberland County Courthouse, Carlisle, Pennsylvania. At the time set for the hearing, present were Petitioners with their counsel, Robert G. Frey, and Respondent with her counsel, Marcus A. McKnight, UI. 4. At the time scheduled for the hearing, Petitioners and Respondent reached an agreement which Agreement was reported to the Court and is as follows: a. The parties agree to continue this matter to allow further medical evaluation and treatment by Respondent. b. The Respondent agrees, as soon as is reasonably possible, to have a Psychiatrist at Holy Spirit Hospital. Camp Hill, Cumberland County, Pennsylvania, examine her and make recommendations for her treatment. c. The Respondent agrees to cooperate with the Psychiatrist and to comply with the recommendations for treatment. d. The Respondent will turn over to her counsel of record her banking accounts and bank statements received. Respondent shall have the use of her checking IEXH!lllT "A.' . . IN RE: VIOLETTE ROBERTS an Alleged Incapacitated IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-96-148 PETITION FOR THE APPOINTMENT OF GUARDIANS OF THE ESTATE AND PERSON BEFORE: SHEELY. P.J. AND NOW, hearing held ~R OF COURT this -IS r day of DECEMBER, 1996, after a on December 9, 1996, Petitioners' request that they be appointed limited guardians of the person of Violette Roberts is REFUSED at this time. However, Respondent is directed to immediately make contact with her psychiatrist Dr. Amita Nayyar, M.D. of Holy Spirit Hospital, to begin treatment. Respondent shall follow the recommendations of Dr. Nayyar, or whoever is in charge of her treatment. If Respondent fails to follow the prescribed treatment, the Court will entertain another petition for appointment of a limited guardian. Petitioners' request that Financial Trust Corp. be appointed limited guardian of the estate of Violette Roberts is GRANTED with the following conditions: 1) Respondent's Social Security check and pension check shall continue to be automatically deposited into her checking account at Financial Trustl 2) Financial Trust shall write out checks to be signed by Respondent for payment of her monthly bills, and if Respondent is unable to sign her checks, the bank shall do sOl 3) Financial Trust shall fliHlllIY"R" , . . . . , distribute cash to Respondent from her checking account for reasonable purposes; what is reasonable shall be determined by the bank should there be a dispute between the bank and Respondent; 4) Harris Savings Bank of Carlisle shall turn over and deliver Respondent's Certificate of Deposit to Financial Trust; it shall then be the decision of Financial Trust whether to retain the money in the C.D. or to make another type of investment with the funds, if deemed advisable; and 5) Should Respondent decide to sell her cottage at Cumberland Crossings, Financial Trust shall receive the net proceeds from the sale and shall have the authority to invest the funds. By the Court, Robert G. Frey, Esquire Marcus A. McKnight, III, Esquire :sld EXHIBIT "B" . _. _.-'.,,,...~.- In Re: : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA VloletJe Roberts, an Alleged Incapacitated Person . : ORPHANS COURT DIVISION . : NO. 21-96-148 PETITION FOR THE APPLICATION OF PRINCIPAL OF THE ESTATEOF AN INCAPACITATED PERSON FOR EXPENSES UNDER SECTION 5536(0) OF THE PROBATE, ESTATES, AND FIDUCIARIES CODE, 20 Po. C.S.A. ~5536(a) TO THE HONORABLE, THE JUDGES OF SAID COURT: The petition of Financial Trust Services Company, Guardian of the Estate of Violette Roberts, an incapacitated person, respectfully represents as follows: I. The Petitioner is Financial Trust Services Company, I West High Street, Carlisle, Cumberland County, Pennsylvania. 2. The Petitioner is Guardian of the Estate of Violette Roberts, an incapacitated person, being duly appointed by this Court by Decree dated August II, 1997. A copy of the Decree is attached hereto as Exhibit "A", 3. The only person interested in the Violeue Roberts' estate are as follows: a son. Grcgg Martin and a daughter, Claudia Davis. Both persons are aware of the expenses contemplated and are in agreement with the expenditures. 4. Violette Roberts is residing at a Cottage located at Cumberland Crossings where she receives no medical treatment or supervised care. Because of her condition, she is no longer able to live in the cottage independently and arrangements have been made for her to live in closer proximity to her son, Gregg Martin. In fact, Cumberland Crossings has notified Petitioner that Violette Roberts must vacate her cottage for the reason that her health condition makes continued residency at the cottage dangerous to herself or others. Attached hcreto and incorporated herein as Exhibit "B" is a copy of the notification from Cumberland Crossings. 5. Petitioner has receivcd estimates of expenses necessary to move Violette Roberts and her belongings of $1,344.68. Attached hereto liS Exhibit "c" are copies of estimates received. 6. The move of Violelle Roberts out of the jurisdiction of the Commonwealth of Pennsylvania will necessitate the securing of a new guardian of the estate for her. Petitioner has received a statement for a required retainer of $4,000.00 to be paid, a copy of which is allached as Exhibit "D", 7, The assets of the Estate of Violelle RoberL~ consist of thc following: $87,094.94 held in Trust funds at Financial Trust Services. 8, The estimated annunl income of the Estate of Violelle Roberts is a~ follows: $14,400.00 consisting of social security and pension income. 8, Petitioner has already expended sums in excess of the income of Violelle Roberts for her normal living expenses. There exists no anticipated sources of income to pay for the extraordinary costs of moving Violelle Roberts and having the guardianship establishcd in another jurisdiction. 9. As stated above, the income received and anticipated to be reccived will be insufficient to pay the accrued and anticipated expenses as set forth in Paragraphs 5 through 9. 10. Petitioner, as Guardian, desires to pay expenses outlined below for which it has received estimates and which it now seeks approval: Retainer to Smith Helms Mullis & Moore, guardianship proceedings $4,000.00 Moving truck rental to Gregg Martin 594.68 Costs of labor in move to Gregg Martin $750.00 II. Petitioner also seeks approval for payments out of principal of such other expenses of Violelle Roberts as arc necessary for hcr care and relocation and for her expenses of this Petition. 12. Petitioner is unaware of any other income. assets, or sources of income in existence or likely to develop. 13. Section 5536(a) of the Probate, Estates and Fiduciaries Code, 20 Pa. C.S.A. ~5536(a), authorizes, with court approval, the approval of expenses incurred by a Guardian and the expenditure of principal of an incompetent's estate. , ~ IN REI I IN THE COURT OF COMMON PLEAS OF I CUMBERLAND COUNTY, PENNSYLVANIA I ORPHANS' COURT DIVISION VIOLETTE ROBERTS, an Alleged Incapacitated Person I No 21-96 -148 IN RE I APPOINTMENT OF GUARDIAN ORDER OF COURT AND NOW, this 11th day of August, 1997, the Court set a hearing today to consider the request to have the two children of Violette Roberts appointed plenary guardians of her person. Appearing today on behalf of Violette Roberts is Marcus McKnight, Esquire. Appearing today on behalf of the two children is Robert G. Frey, Esquire. The parties appeared and took the deposition of Douglas P. Dionne, M.D., on June 5th, 1997. Dr. Dionne is a licensed psychiatrist in the Commonwealth of Pennsylvania. I'm satisfied from his testimony that there should be a guardian of her person appointed. Both children have agreed to serve as co-guardians of the person of their mother, and from the remarks of counsel today, it would appear that appointing both children would be the proper way to proceed rather than just appointing one. Therefore, the Court does appoint the daughter of Violette Roberts, Claudia Davis, residing at Quincy, Illinois, and her son, Gregg Martin, residing at North Carolina a~ co-guardians of the person of Violette Roberts, and the Court will appoint tham as plenary guardians of her person at this time. There has been previously a tamporary appointment of both children as guardians of her person. The Court would EXHIBIT "A" CARLISLE RETIREMENT COMMUNITY CORPORATION doing business as CUMBERLAND CROSSINGS RETIREMENT COMMUNITY DETERMINATION OF JUST CAUSE FOR TERMINATION OF COTTAGE RESIDENCY AGREEMENT It has been determined in good faith that Vioktte Roberts, a cottage resident of the Cumberland Crossings Retirement Community, has developed a health condition making continued residency in the cottage dangerous to the resident and/or others. Therefore, Cumberland Crossings Retirement Community has chosen to terminate the Cottage Residency Agreement. Documentation supporting this determination has been placed in the resident's file, The resident will be sent a notice by certified mail informing himlher of the termination and will be given thirty (30) days from the date of the notice to vacate the cottage. This determination has been made in accordance with requirements specified in Section l4(d} of the Continuing-Care Provider Registration and Disclosure Act, Act of June 18, 1984, P.L. 391, as amended, 40 P.S. ~ 3214(d}. Dated: 2/23/98 J;;;s D!!J:#-- Dated: ~,(4/. Executive Dir cto /) 1 2/23/98 Dated: 2/23/98 Duu1/rn r, 1)7tJW?-.<-- Resident's Physician Mfd , IID..IS\DA T AftLI\HOSPrr AL DOC\I6I.ICD OHIOIT "0" ;~ t ~.~ '---~ J -- CUMBERLAND CROSSINGS --- \....c~-"'~......._--- I February 23, 1998 CLAUDIA DAVIS AND GREGORY MARTIN RE: Termination of Cottage Residency Agrt:ement Dear Ms, Davis and Mr. Martin: This letter eonstitutes notice that the Carlisle Retirement Community Corporation ("Cumberland Crossings") will terminate the Cottage Re~idency Agreement ("Agreement") of your mother (of whom you are the coUrt appointed plen::uy guardians of the person) on March 25, 1998 in accordance with the Agreement. Cumberland Crossings has decided to terminate the Agreement because your mother has developed a health condition which endangers her health, safety, and welfare if she were permitted to remain in her cottage. Specifically, your mother exhibits the following: · Decline in cognitive function · Increased delusional behavior · Inability to comply \vith recommended medical management of her disease · Diminished nutritional state resulting in progressive weight loss · Threats of elopement from the cottage that would endanger her safety. Your l1111ther's con.sulting ph}'3iciall. Dr. Dfllll!lns Dionne, agrees that re:nainillg in the cottage would be dangerous to her health. Because your mother must be able to live independently in order to live in the cottage, Cumberland Crossings has decided to terminate the Agreement for the reasons listed above. Under the Agreement, your mother must vacate her cottage by the date indicated above and transfer to another facility consistent with her health condition, which condition Cannot be accommodated within the Cumberland Crossings community. Cumberland Crossings stands ready to assist you and your mother in making this transition. Cumberland Crossings Retirement Community 1 LonRsdorfWav . Carlisle. PA 17013 . 717-245-9941 f:'KHlOlT "8" INVOICE DUE UPON RECIEPT! DATE 313MB MOVING COSTS: LABOR, AND PER DIEM FOR GREGG MARrnv. MICHAEL MART/lV. AND PATRlClC MARTIN MOVE FOR VlOLETIE ROBERTS FROM CARLISLE, PA TO CHARLOTTE, NC FOR DATES APRIL 9,10, AND 11, 1998. LABOR SIOO.OO PER DAY PER PERSON: PER DIEM (FOOD &; MOTEL)S50.00 DAY TOTAL S600.OO S150.OO 5750.00 AIL FUEL AND MISCEllANEOUS EXPENSES WILL BE BILLED AFTER THE FACT. .-IJ~ f rl(HnJIl "C" .-- 03/30/~8 1~:26 tt704 786 6176 HALE TRAILER fiI 003/005 SMITH HELMS MULLISS & MOORE, L. L, P. ATTORNUS AT LAW CHARLOTT!:, NORTH CAROLINA O"I:CN'.O"O .oa, O'''ICI: .0. ..." a..'''''''OIlO, tit. c. ".'0'..' "'''''''IIIIG -oDIIl.. "OA' orrl,., IIWl .II'.' cM.....lonE. H_C ""11'.' ."'.'1' Aga.... .al "a."" 'ltTo.. an":I:" cH......~Qn'. N. c. ...lI. NALIIGH "ou ot"Cc. liD. .".. IIAt..IUh4, N. C. 'Ntl."" TU'''HOlllC. 11""'4100 'loCal MIL' ,u.,......,. WfU"tllt'. OIIlI;CT DIAL ,,~."o..c .N"".fCO '1oC....'..r 1I'.'''.rw.a TIU,lfOHO'" ro.'J.~"OQQ I'ACtlMlll '0413:" ._., 00-) 343.2102 March 19, 1998 Mr. Gregg Martin 8000 Sb:vcns MIll Road Matthews, North Carolina 28105 VIA FFnF.1Ul. F.YPRF.gl;: Ms. Claudia Davis 709 Woodbridge Quincy, illinois 62301 Rc: Guardian5hip Proceeding Dear Mr. Martin and Ms. Davis: As I have discussed in telcphone conversations with each of you, you have engaged us to represent you in seeking an appointment of a guardian of the person and the estate of your mother, Violette Roberts, by the Superior Court of Mecklenburg County, North Carolina. Further, you have engaged us to take whatever action is nc:cesSll'Y to terminate the appointment in 1997 of the current guardian of your mother's estate, Financial Trust Services Company, by the Court of Common Pleas of Cumbe:rland County, Pennsylvania, which may include association and compensation of legal counsel in Pennsylvania. This representation is tmminable at will by either you or us, subject to your payment of all fees for services Ialdercd and com advanced through the date of termination. We will bill you fuc our legal =vie>eS perfo:m:d (on an hourly basis), out-uf-p.---t"tt disbursements made and reasonable charges for ancillary services provided on your behalf during our representation of you. Payment is due in full when you receive the statement. Customarily, if payment is not received within forty-five days of the date of the statement, we bill for an interest charge at the rate of one percent per month from the forty-fifth day after the date of the invoice until paid. In addition, it is our firm's policy to require an advance deposit of $4,000.00 in this type of case. This deposit will be applied in chronological order against any outstanding statements, and any sums not used to apply against outstanding statements will be returned to you upon the termination of our services. When selccting law firm pcrsonncI to perform tasks in this matter we will gme:rally select lawyers having the lowest hourly rates consistent with the skills, time demands and other factors influencing the professional responsibility required for each Wk. Also, we charge for EXH!a!T "D" .. e ~ .. IN REI IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION VIOLETTE ROBERTS, an Alleged Incapacitated Person No 21-96-148 IN RE I APPOINTMENT OF GUARDIAN ORDER OF COURT AND NOW, this 11th day of August, 1997, the Court set a hearing today to consider the request to have the two children of Violette Roberts appointed plenary guardians of her person. Appearing today on behalf of Violette Roberts is Marcus McKnight, Esquire. Appearing today on behalf of the two children is Robert G. Frey, Esquire. The parties appeared and took the deposition of Douglas P. Dionne, M.D., on June 5th, 1997. Dr. Dionne is a licensed psychiatrist in the Commonwealth of Pennsylvania. I'm satisfied from his testimony that there should be a guardian of her person appointed. Both children have agreed to serve as co-guardians of the person of their mother, and from the remarks of counsel today, it would appear that appointing both children would be the proper way to proceed rather than just appointing one. Therefore, the Court does appoint the daughter of Violette Roberts, Claudia Davis, residing at Quincy, Illinois, and her son, Gregg Martin, residing at North Carolina as co-guardians of the person of Violette Roberts, and the Court will appoint them as plenary guardians of her person at this time. There has been previously a temporary appointment of both children as guardians of her person. The Court would ., ..... ;-., .,,' trl r:,:-:( '0 I.' ':'i .~o. ,~1~; ~ z , . :~.~' N ~) . ..~'-. '. .- gg Xi ~ ;:uE 08 In Re: : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS COURT DIVISION : NO. 21-96-148 Violette Roberts, an Alleged Incapacitated Person PETITION FOR THE APPOINTMENT OF GUARDIANS OF THE ESTATE AND PERSON IN ACCORDANCE WITH 20 PA. CONS. STAT. ~5513 TO THE HONORABLE, THE JUDGES OF THE SAID COURT: The petition of Claudia Davis and Gregg Martin respectfully represent that: I. Petitioners are Claudia Davis, an adult individual of 2819 Kingsridge, Quincy Illinois. and Gregg Martin, an adult individual of SOOO Steven's Mill Road, Matthews, North Carolina. Petitioners are the daughter and son of the alleged incapacitated person 2, The alleged incapacitated person is Violet Roberts, born on December 4, 1920. Shc is 75 years of age and resides in an independent living COllage at Cumberland Crossings retirement homes, South Middleton Township, Cumberland County, Pennsylvania. Her mailing address is S5 Schimmel Way, Carlisle, Pennsylvania 17013 3. A hearing on the Petition filed by Petitioncrs was scheduled for June 28. 1996 at 10:00 a.m. in Courtroom No. I, Cumberland County Courthouse, Carlisle, Pcnnsylvania. At the time set for the hearing, present were Petitioners with their counsel, Robert G. Frey, and Respondent with her counsel, Marcus A. McKnight, Ill. 4. At the time scheduled for thc hearing, Petitioners lInd Respondent reached an agreement which Agreement was reported to the Court and is as follows: a. The parties agreed to continue this matter to allow further mcdical evaluation and treatment by Respondent. b. The Respondent agreed, as soon as is rcasonably possible, to have a Psychiatrist at Holy Spirit Hospital, Camp Hill, Cumberland County, Pennsylvania, examine her and make recornrncndations for hcr treatment. c, The Respondent agreed to cooperatc with the Psychilltristllnd to comply with the recommendations for treatment. d, The Respondent would turn over to her counsel of record her banking accounts and bank statements received. Respondent would have the usc of hcr checking account for the payment of expenses as required by her, but would not make significant withdrawals from her saving accounts or time deposits, or scll asscts without prior notification to Petitioners. e. The Respondent agreed that all information concerning her medical and psychiatric treatment and any records from lIny facility where she residcs would be provided to Petitioners so that they may monitor her condition. f. The Petitioners agreed to continue the scheduled hearing in order to lIfford Respondent an opportunity to take thc actions set forth above g. The Petitioners and Respondent reduced this Stipulation to writing which has been incorporated into an Order of Court, a copy of which is attached hereto and incorporated herein by reference as Exhibit "A". 5, Respondent was examined by a Psychiatrist pursuant to the Stipulation and the Psychiatrist made recommendations for the treatment and handling of financial affairs of the Respondent. 6. Petitioners filed a subsequent Petition on October 29, 1996, seeking that guardians of the person and estate be appointed to carry out the recommendations of the Psychiatrist and for the further purpose of supervising the Respondent's financial affairs. 7. As set forth in the original Petition filed, the proposed guardians of the person are your Petitioners and the proposed guardian of thc estate is Financial Trust Services Company (formerly Farmers Trust Company). 8. After a hearing held on December 16, 1996, the request for appointment of a guardian of the person for the Respondent was denied, and the request for appointment of Financial Trust Services Company as limited guardian of the estate of the Respondent was granted. A copy of this Order of Court is attached hereto as Exhibit "B". 9, Petitioners filed a further Petition seeking plenary guardianship of the estate of the Respondent for the reason that Respondent had retained control of her checking account and for the reason that the proposed Guardian of the Estate had indicated an unwillingness to assume the limited guardianship responsibilities. A hearing is scheduled on the hcreinmentioned Petition for --:-.~"-........,-'._~-~---~.._,...,~-~....,.._-_.._,.._--_..~ .1.,l;'..., , .... , . _..---- - - -....-..- - ---- -. .~- 2:30 P.M, on April 15, 1997, 10. On Tuesday. April 8, 1997, Robcrt G. Frcy. allorney for Pctitioners, was informcd by Cumberland Crossing staff that Respondent was no longcr taking thc medication prescribed by her Psychiatrist and that she had dismissed the aid lIrranged by Cumberland Crossings to supervisc and assist Respondent in taking hcr daily medication. II, On Wedncsday, April 9, 1997, Robert G. Frcy, allorney for Pctitioners, received a copy of the most recent Report of the Psychiatrist for Rcspondcnt, dated April 3. 1997, a copy of which is attached hereto and incorporated herein as Exhibit "C". 12. The diagnosis indicatcs increased "delusional distortion - from eithcr mcd. non- compliance or adverse (stimulation) reaction to rned," 13. Among the recommendations made by the psychiatrist is that Rcspondcnt "will nced guardianship assignment - and will be at increased risk of morbidity if shc continues to response to delusional beliefs," The recommendations also increased the dosage of Respondent's prescription medication. 14. As stated above, Respondent has refuscd to comply with the changed prescription and has refused to take prescriptions. 15. Petitioners believe that the risk of increased morbidity as stated by the Psychiatrist is an ernergcncy and that a Guardian of the Person is required so that thc Rcspondent clln be required to take necessary medication and receive appropriate care to treat her condition. 16. Due to the emergency nature of these circumstances, it is rcquested that the court waive the requirement that twenty (20) days notice of this proceeding be given to the alleged incapacitated and that instead only notice be given to her along with service of thc citation for consideration of these mallcrs at the hearing scheduled for TucsdllY, April, 15. 1997. WHEREFORE. Petitioners respectfully request that this court award a citation directcd to Violette Roberts, the alleged incapacitatcd person, with notice and servicc thereof to be given to her of the hearing scheduled for April 15, 1997 at 2:30 p.m., to show cause why Pctitioners should not be appointed emergency guardians of her person for thc purpose of consenting to the admission of Violette Roberts to Cumberland Crossings Nursing Home, with thc emcrgcncy guardianship to be in effect with respcct to the guardianship of the person for a period of scventy- two (72) hours from the date of this court's decree. Respectfully submitted, Frey & Tilcy, Attorneys for Petitioners By: ---0~L'=1-d :z~ Robert G. Frcy, Esquire Suprernc Court Nurnbcr 46397 5 South Hanovcr Street Carlisle, Pennsylvania 17013 (717) 243-5838 I verify that both Petitioners are outsidc the jurisdiction of the court and the verification of neither of them could be obtained due to the crnergcncy nautre of the within Petition. I furthcr verify that 1 have either personal knowledge of the statements herein or I have verified thc statements made herein as true and correct by consultation with the Petitioners and I understand that false statements herein are made subject to the penalties of 18 Pa. C, S. A. ~ 4904 relating to unsworn fnlsification to authorities, Dated: April 9, 1997 \ ~~\ , :-\~ ~--\ ..,"'. G. Frey · J . .' In Re: : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYL VANIA : ORPHANS COURT DIVISION , : No. 21.96.148 VIOLETfE RbBERTS, an Alleged Incapacitated Person SETTLEMENT STIPULATION THE UNDERSIGNED, being the attorneys of record for all of the parties to the above captioned action, do hereby enter into a Settlement Stipulation, as follows: I , Petitioners are Claudia Davis of 2819 Kingsridge, Quincy, Illinois, and Gregg Martin, 8000 Steven's Mill Road. Matthews, NC 28105, the daughter and son of Violette Roberts, the alleged incapacitated person. Both are adult individuals. 2. Respondent is Violette Roberts who resides in an independent living cottage at Cumberland Crossings retirement homes, South Middleton Township, Cumberland County, Pennsylvania, Her mailing address is 85 Schimmel Way, Carlisle, Pennsylvania 17013. 3. A hearing on the Petition filed by Petitioners was scheduled for June 28, 1996 at 10:00 a.m. in Courtroom No. I, Cumberland County Courthouse, Carlisle, Pennsylvania. At the time set for the hearing, present were Petitioners with their counsel, Robert G. Frey, and Respondent with her counsel, Marcus A. McKnight, m. 4. At the time scheduled for the hearing, Petitioners and Respondent reached an agreement which Agreement was reported to the Court and is as follows: a. The parties agree to continue this matter to allow further medical evaluation and treatment by Respondent. b. The Respondent agrees, as soon as is reasonably possible, to have a Psychiatrist at Holy Spirit Hospital, Camp Hill, Cumberland County, Pennsylvania. examine her and make recommendations for her treatment. c. The Respondent agrees to cooperate with the Psychiatrist and to comply with the recommendations for treatment. d. The Respondent will turn over to hcr counsel of rccord her banking accounts and bank statements receivcd. Respondent shall have the use of her checking l.:XHIRn "t\." .........- IN RE: VIOLETTE ROBERTS an Alleged Incapacitated : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS' COURT DIVISION NO. 21-96-148 PETITION FOR THE APPOINTMENT OF GUARDIANS OF THE ESTATE AND PERSON BEFORE: SHEELY. P.J. ?R OF COURT AND NOW, this -f S"r day of DECEMBER, 1996, after a hearing held on December 9, 1996, Petitioners' request that they be appointed limited guardians of the person of Violette Roberts is REFUSED at this time. However, Respondent is directed to immediately make contact with her psychiatrist Dr. Amita Nayyar, M.D. of Holy Spirit Hospital, to begin treatment. Respondent shall follow the recommendations of Dr. Nayyar, or whoever is in charge of her treatment. If Respondent fails to follow the prescribed treatment, the Court will entertain another petition for appointment of a limited guardian. Petitioners' request that Financial Trust Corp. be appointed limited guardian of the estate of Violette Roberts is GRANTED with the following conditions: 1) Respondent's Social Security check and pension check shall continue to be automatically deposited into her checking account at Financial Trust; 2) Financial Trust shall write out checks to be signed by Respondent for payment of her monthly bills, and if Respondent is unable to sign her checks, the bank shall do so; 3) Financial Trust shall EXHI9IT "8" REPORT OF CONSULTATION f l" Nome t'h', .. Mlddl. Nam. Room No. HC)lp. No. To: Conlulling PhYlicion Dolo r.,/' /, '3//1 R01<-uPO" ,oquo.'od ,egording i). 0/..: ( ('(t tt';.rl 7'/,;,h" f--'~ < ~"..J ;"Ac",,-: eo (JIJ.- ??f..ct,le J /.. (I Ii _\. . /' cAJ-... Jlcl.Ai.,J I1H InlJ '" \J f/l './..,f";111". I Ptl."C...IIC'IC,' ." (j,~ " 7Jur-fh..u, mo.'- l\i", to.-1\...( C ~ .J 1.L j~. ,).- .i~l' t!. /)("'11 ,.IJ UJ .-::>k.L...., d ('cJ /u.........' .' vd....,1.- r' rl\... . Slg "'U': of "'!fI:ding phv.lclln " ' -no 'Y'/)(l,u I /1'1/111 ~>(X L. cf-tv . REPORT .e c~ I t.L J ;.f. cI 'l/J..., . Finding- Nt) CkOA ~b 1\wJ\ev.). CClAe d~ ~ e Pm n \V\ Cl~ +- (J h'I'U O~Vwo.~~ (l.UleweJ ' M~\t~ a. <,-all- to ~t\", &CW-f"tj, . ~tkrL l1vwil'. J.11- 214 ~~207.. t ltj? Y~1: ::~t~' ~ ",t a.vrJoJ.\,; ~ ...lliVJ,^" ~,..Q) ~PrV\6\r.) ~. Q\O"c:vv-o~(\ -I MCvv.l'r~h--<2' M~ ~ on~, mOCl.~w~ -h '\tv\ciV..dU '{y$N. ~H11l -W^J ~(N,o crY', OM!\;) VV' w~d,. HWVo ~ t(M~. z\J t ~ 'i' tt~ } ~I CUl \... Ct ( t~ - ,,,..... l\M~~ ~ t d.k.~, c\v,\n~'" . \r.- L-",^ ""'fA, V\ll\'\ '~\(CtM.uv V\: (l~{/LA..(J (S~,OC1k.--) I\.Qr~ b \MvL. j'-::ff ~~\ I;~~~~~~ -4Ji1l~~r ~)--OMd lAlv~oJ-v..~Jlt4k ---1"\ W-l11h,,~ /Jk C~ h 1lM~~ tn ~ ~ . @~, (4.1>o~~~~i"> IOwj. ~d. X ZwiA. ~ s x 1 - $ I cu -r cw,,\1i, . \ . q <tis-. _ (C /1vW-? cuP. lJ- Oo'e a' con.ull.,lon, 01 U Dr. y _ ~ ~ igntlllr. of Conl\lll.nl Form (~~.:: o.~M2'~.~: . (It) ~I C1tit~uiLec~'t r I CrW. ~ ( d~~~~C~l~~~ EXHIBIT "e" \ .r '," --~- ----- ~- ._--- . , ~.. '~~. IN RE: IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Violette Roberts, an alleged: Incapacitated Person : NO. 96-148 ORPHANS' COURT ORDER OF COURT AND NOW, this 15th day of April, 1997, a hearing was held today on two issues, one, whether Farmer's Trust Company should be appointed a plenary guardian of the Estate of Mrs. Roberts, and two, whether or not the Court at this time should appoint either a limited or plenary guardian of her person. Mr. McKnight, who represents Mrs. ROberts, was present in court today. Mrs. Roberts was not present. Mr. McKnight, on behalf of Mrs. Roberts, agreed to the appointment of Farmer's Trust Company as plenary guardian of the estate, and I have read in the petition why Farmer's Trust wants to be appointed plenary guardian of the estate. I believe that's a reasonable request, and therefore the prior Order of Court is amended, and it is ordered and directed that Farmer's Trust Company, Carlisle, Pennsylvania, be appointed plenary guardian of the estate of Violette Roberts. A deposition will be taken of the present psychiatrist for Mrs. Roberts this Thursday. If he recommends that a guardian of the person be appointed and gives adequate reasons, I will consider that request. Therefore, upon .- t~ ~ ':\-.;.:;1'0-":' ,"-." 1 In Re: C2 1 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA 2 Violette Roberts, ORPHANS COURT DIVISION 3 an Alleged Incapacitated NO. 21-96-148 Person 4 5 6 7 8 16 (')('j S0" \Ci _J FREY & TILEY BY: ROBERT G. FREY, ESQUIRE FOR - PETITIONER ,<:. '-- c...-: r- I N -:J '" 17 APPEARANCES: 18 19 20 21 22 23 -0 \ 24 . ,I, 1~. ...... 25 0 '- .t:. IRWIN, MCKNIGHT & HUGHES BY: MARCUS A. MCKNIGHT, III, ESQUIRE FOR - VIOLETTE ROBERTS :0 :-7'.., ''--' .- -- ORIGINAL C.P.C.R.S. @ pacourt@kns.net (717) 258-3657 or (800) 863-3657 2 Q 1 INDEX TO TESTIMONY 2 WITNESS DIRECT CROSS REDIRECT RECROSS 3 Douglas P. Dionne 3 14 4 5 6 7 8 9 10 11 INDEX TO EXHIBITS 12 NO. DESCRIPTION PAGE 0 13 1 Report of Consultation 8 14 15 16 17 18 19 20 21 22 23 24 0 25 C.P.C,R,S. @ pacourt@kns.net (717) 258-3657 or (800) 863-3657 3 o 1 STIPULATION 2 It is hereby stipulated by and between the 3 respective parties that signing, sealing, certification 4 and filing are waived; and that all objections except as 5 to the form of the question are reserved until the time of 6 trial. 7 8 DOUGLAS P. DIONNE, M.D., called as a witness, 9 being duly sworn, was examined and testified as follows: 10 DIRECT EXAMINATION 11 BY MR. FREY: 12 Q. Dr. Dionne, I'm going to ask some questions of o 13 you. If I'm unclear with any of the questions, or if I 14 ask it in a way that you don't know how to answer, ask me 15 to repeat it, clarify the question. And please use 16 whatever documents, notes or records that you have in 17 answering any of the questions which you think might be 18 helpful, 19 Could you state your name and business address, 20 please? 21 22 23 24 0 25 A. Douglas Paul Dionne. My business address is Phil Haven, 283 South Butler Road in Mount Gretna, M-o-u-n-t, G-r-e-t-n-a, Pennsylvania 17064. Q. And what is your license to practice? A. I am a licensed physician with additional C.P.C.R.S, @ pacourt@kns.net (717) 258-3657 or (800) 863-3657 4 C\ 1 training in psychiatry. And I'm certified with the .. 2 American Board of Psychiatry and Neurology. 3 Q. And how long have you been practicing? 4 A. I've been practicing since 1982. 5 Q, Have you treated or examined Violette Roberts? 6 A. Yes, I have. 7 Q. Do you know what dates you have seen her? 8 A, I have four consultations. The first initial 9 evaluation was conducted on the 10th of January of this 10 year. There were three subsequent assessments. 11 Unfortunately, two of them were in the absence of the 12 patient who was noncompliant in participating in the o 13 interview. 14 Q. Essentially, she did not show up? 15 A. she was unwilling to make the appointment, so I 16 had to obtain information from the family, feedback from 17 the staff at Cumberland Crossings. 18 Q. What is the date of your most recent 19 evaluation? 20 A. Most recent evaluation in which I had access to 21 the patient was on the 3rd of April, 1997, 22 Q. Did you also have the opportunity to review her 23 medical records? 24 A. I did, I was particularly able to focus on the \;.I 25 consultation which was conducted by a Dr. Nayyan, C,P.C.R.S. @ pacourt@kns.net (717) 258-3657 or (800) 863-3657 a 12 0 13 14 15 16 17 18 19 20 21 22 o 5 1 N-a-y-y-a-n, a psychiatrist who performed a previous 2 psychiatric evaluation, And also a neuropsychological 3 evaluation by Mr, Martin, who conducted a form of 4 psychological testing, 5 Did you also have an opportunity to discuss her Q. 6 history with any of the staff at Cumberland Crossings? 7 Yes. I received a full report from Ann Moser, A. 8 who is the clinical social worker at Cumberland 9 Crossings, I was also able to talk to the resident's 10 daughter on a long distance telephone call for 11 corroborating history. Q. And from these evaluations and the consultation, what did you observe about her mental and physical condition? A. Mrs. Roberts shows evidence of cognitive decline consistent with a dementia, probably Alzheimer's type, along with clinic~l depression which appears to have increased substantially since the death of her husband four years ago. She's also experiencing significant delusional and paranoid distortion in her perception of her environment, which I think is exacerbated by vision 23 problems, or diagnosed as macular degeneration, as well as 24 perhaps building on a previous personality; paranoid 25 personality style. C.P.C.R.S. @ pacourt@kns.net (717) 258-3657 or (800) 863-3657 0 1 2 3 4 5 6 0 13 14 15 16 17 18 19 20 21 o I'm even suspicious that perhaps there is evidence of what is called a Korsakoff psychosis which is experienced by individuals who consume alcohol, who subsequently experience significant deficits in memory which they compensate for by what we call confabulation. It's like they kind of make up history as they go along; 7 and a fair amount of paranoid defense. 8 Q. Based on those observations, what have you 9 recommended or attempted to treat those conditions? 10 A, I was responsive to a court order which 11 indicated that Mrs. Roberts would participate in 12 psychiatric treatment and a trial of medications. What I had recommended to her initially was the use of an antipsychotic medication called Risperidone, R-i-s-p-e-r-i-d-o-n-e, in a very low dosage, along with possibly a trial of an antidepressant, Prozac, P-r-o-z-a-c, The resident was not pleased with these recommendations because of her fear of having symptoms like her husband's, who died of Parkinson's disease, And one of these medications can be associated with 22 Parkinson's symptoms. She was also resistant to taking 23 medication because there is a significant amount of denial 24 of her clinical depression and of her memory deficits, 25 Her rationale is, why should I take medication if I'm not C.P.C.R.S, @ pacourt@kns.net (717) 258-3657 or (800) 863-3657 6 r o . . 12 0 13 14 15 16 17 18 19 20 21 22 o 9 1 These are my progress notes on the patient 2 based upon a follow-up discussion, 3 Q. And that would have been the last 4 A. The last contact in reviewing her case with the 5 Cumberland Crossings staff. 6 Q. Under the recommendations portion it states in 7 part that, it is evident that the patient will need 8 guardianship and will be at increased risk of morbidity. 9 A. Yes. 10 Q. Can you explain in some detail if you believe 11 that conclusion is still accurate. And if it is, what guardianship services will be needed? A. I'd be glad to elaborate. Because of the increasing paranoid content of her thinking and exclusion of people who are significant supports to her, I have concerns that she will make decisions of impulsive elopement from the facility or possibly unwise financial decisions if she concludes that there are family members or Cumberland Crossings staff who are attempting to take her money; that she may make an unwise decision as to the management of her financial resources, The risk of harm is that she does form 23 alliances at times that seem unwise, There is a history 24 in the past also of her having talked about her fears of 25 being killed. I would have concerns that her defensive C.P.C.R.S. @ pacourt@kns.net (717) 258-3657 or (800) 863-3657 . . 10 ~ 1 maneuvers in avoiding that would be to possibly isolate 2 herself from support or potentially to harm others because 3 she's not made consistent decisions that are in her best 4 interest. I'm concerned even about her living 5 independently at this point where an increased level of 6 structured care or personal care should be afforded to 7 her. 8 I'm trying to think of specific examples for 22 A. It did not. The patient has consistently 9 you where she has acted rashly. I believe when she fir3t 10 received evaluation, this lady had gone to Chicago without 11 notifying the staff of her intention to do so, and 12 utilized people who may otherwise have taken advantage of o 13 her in order to achieve that. Since her cognitive 14 functions have declined progressively since that time, my 15 concern is this would be repeated or other incidents that 16 we can only imagine can occur. 17 Q. This next question is just a point of 18 clarification for me. The recommendation number three, 19 can you tell me what that says? 20 A. Number three is follow-up in two weeks, 21 Q, And that didn't occur? 23 declined consultation with me based upon the fact that she 24 believes that I'm, quote, not a real doctor, unquote. 0... ~.._- 25 It's also based upon a previous history, a fairly C.P.C,R.S. @ pacourt@kns.net (717) 258-3657 or (800) 863-3657 f....\ 1 ~.'. . 2 3 4 5 6 7 8 9 10 11 12 Also Mrs. Roberts has stayed in touch with them; unfortunately, sometimes very early in the morning telephone calls to describe a number of delusional incidents occurring. My notion is that they have acted responsively in keeping informed and have been active participants in attempting to lead her to appropriate decisions. I have no reason to doubt that they would be effective as guardians given at least their recent performance or my awareness of what they've done. Q. But it would be your feeling that a move of her 12 closer to one of them would be advantageous? 0 13 A, Because she's had a number of losses, I think 14 her children are important to her. If they're not part of 15 her delusional system and she is able to tolerate living 16 closer to them, that would be one strategy or one o 17 possibility. It's also possible that she's made a 18 sufficient number of casual acquaintances and friends in 19 this area that she would choose to remain in this area. 20 I'd like to explore that with her, 21 specifically, given an either-or kind of choice, Perhaps 22 she would make -- give us some guidance on that. 23 Q. Are you aware of anyone with whom Mrs. Roberts 24 has close ties who could act as guardian for her other 25 than her children? C.P.C.R.S. @ pacourt@kns.net (717) 258-3657 or (800) 863-3657 13 o 1 A. Unfortunately, I'm not. She is not very 2 disclosing of her social contacts here. I would recommend 3 that Ann Moser would probably have better knowledge of 4 that, specifically people that she trusts or that she has 5 worked with; perhaps legal counsel, perhaps an appointed 6 counsel that she has worked with. 7 Q. From your discussions with Mrs. Roberts' B children, do you believe they understand her condition as 9 you've explained it? 10 A. I've only spoken with her daughter. And she 11 seems quite aware of the situation, and is quite 12 distressed at the further deterioration and her o 13 ineffectiveness in being able to help her mother. The 14 son's involvement at times has been reduced because of, 15 again, Mrs, Roberts paranoia in which she's projected onto 16 their selected spouses that they're hostile or bad or 17 evil. So that it's really strained the relationship that 1B she's had with her son and daughter. 19 Nonetheless, they have responded not as if she 20 were motivated by a bad intent, but simply that she is 21 ill. with dementia and depression, they need to 22 accommodate some of her commentary. 23 Q. Do you believe that her daughter, since that's 24 the one you've spoken with, concurs with your feelings as o 25 to what would be the best treatment for her? C.P,C.R.S. @ pacourt@kns.net (717) 25B-3657 or (BOO) B63-3657 14 ~ 1 A. Yes, I do. 2 Q. And going back to, I think you stated earlier, 3 concerns regarding her paranoia. Does that make it 4 possible for her to be taken advantage of by unscrupulous 10 Q. If further hearings in court are necessary, 5 or designing persons? 6 A. That is possible. It is also possible for her 7 to make independent decisions in which she excludes 8 appropriate help and guidance. And that, in fact, is my 9 greater concern. 11 would Mrs. Roberts presence at court be harmful to her 12 physical or mental condition? o 13 A. That's a difficult one to answer since she is 14 not fully reality based in terms of insight as to why 15 people are doing this. It's difficult to predict how she 16 would interpret this action other than more and more 17 people are against her. 18 I believe she -- her interests would be best 19 served if she were not a participant. 20 MR. FREY: Thank you. That's all the questions 21 I have. 22 CROSS-EXAMINATION 23 BY MR. MCKNIGHT: 24 Q. I have a few. o 25 I am Marc McKnight. I am personal counsel for C.P.C.R.S. @ pacourt@kns.net (717) 258-3657 or (800) 863-3657 16 ~ 1 A, It is a diagnosis of exclusion, short of being 2 able to do a specific biopsy procedure, which is usually 3 postmortem. Alzheimer's being the most common cause for 4 dementia changes, it's a diagnosis of presumption. 5 Progression in the dementia changes and increased 6 intensity of paranoia are commonly associated with this. 7 And over time, it tends to confirm the diagnosis. But 8 initially the diagnosis of dementia -- at least as I read 9 both Mr, Martin's and Dr. Nayyan's report -- was that she 10 qualified in a level four of impairment. 11 I would say currently her impairment has 12 progressed even in the last five months further o 13 reinforcing my inspection of an Alzheimer's dementia. Two 14 other things I would speculate would be the potential for 15 damaging effects of the use of alcohol, and that history 16 is not clearly established. There is also some evidence 17 for pseudodementia, p-s-e-u-d-o, dementia, in which her 18 clinical depression since the death of her husband 19 probably exacerbates her short-term memory deficits. 20 Q. Did you see the evaluation done by Bruce Kelly 21 at our request? 22 A. I did not. 23 Q. I show you a copy at our request. We had -- my 24 request -- Bruce Kelly came and did a full psychological v 25 evaluation of her. C.P.C.R.S. @ pacourt@kns.net (717) 258-3657 or (800) 863-3657 12 13 have, 14 15 16 17 18 19 20 21 22 23 24 25 o o e '~...l..;..; ~,.# 19 1 loss, I think it would be extremely difficult for her to 2 make that decision for herself. But because of increase 3 in deficits and judgment and insight, I really feel at 4 least at the level of personal care in which there was 5 structure, monitoring with medication use, monitoring diet 6 would be wise, 7 Also, I would expect her clinical depression to 8 intensify. She's very isolated and lonely and only 9 interacts selectively. This has become more and more of 10 an apparent problem. And I would expect if the depression 11 is left untreated, her dementia will accelerate. MR. MCKNIGHT: Thank you, Doctor. That's all I MR. FREY: Thank you. (Whereupon, the deposition was concluded at 1:25 p.m.) I C,P.C.R.S, @ pacourt@kns.net (717) 258-3657 or (800) 863-3657 20 (") 'l.__..' 1 2 COMMONWEALTH OF PENNSYLVANIA SS. 3 COUNTY OF CUMBERLAND 4 5 I, JILL L. ROTH, a Court Reporter-Notary Public 6 authorized to administer oaths and take depositions in t.:L 7 trial of causes, and having an office in Carlisle, 8 pennsylvania, do hereby certify that the foregoing is the 9 testimony of DOUGLAS P. DIONNE, M.D. 10 I further certify that before the taking of 11 said deposition the witness was duly sworn; that the 12 questions and answers were taken down in stenotype by the J 13 said Reporter-Notary, approved and agreed to, and 14 afterwards reduced to computer printout under the 15 direction of said Reporter. 16 I further certify that the proceedings and 17 evidence are contained fully and accurately in the notes 18 taken by me on the within deposition, and that this copy 19 is a correct transcript of the same. 20 In testimony whereof, I have hereunto 21 subscribed my hand this 17th day of June, 1997. 23 NOTARIAL SEAL JILL ROTH CARLISLE BOROUGH, CUMBERLAND COUN MY COMMISSION EXPIRES NOV. 13. 2000 '-" . ~~~r-. Notary Public 22 24 My Commission Expires November 13, 2000. :J 25 C.P.C.R,S. @ pacourt@kns.net (717) 258-3657 or (800) 863-3657 -... -" In Re: Violette Roberts, an Alleged Incapacitated Person : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA , : ORPHANS COURT DIVISION , , : NO. 21-96-148 PRELIMINARY DECREE AND NOW, this I si" day 0~97, upon consideration of the annexed petition and deposition and upon consideration of the testimony previously presented, it is hereby ORDERED and DECREED that Claudia Davis and Gregg Martin are a appointed Temporary Guardians of the Person of Violette Roberts for a period not to exceed 30 days, pursuant to 20 Pa.C.S,A, fi 5513 and a citation is awarded directed to Violette Roberts, to be served upon her counsel of record, Marcus A, MeKnight, III, Esquire, to show cause why Respondent should not be found to be incapacitated and Petitioners appointed plenary guardians of her person. The hearing thereon to be held in Court Room No. I, Cumberland County Courthouse, I Courthouse Square, Carlisle, Cumberland County, Pennsylvania, on A u~ldf 11.1997 at I :~() 'I o'elockf.M, ttd:f~ZL-' f;J, . ' In Re: : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA Violette Roberts, an Alleged Incapacitated Person . : ORPHANS COURT DIVISION , , : NO. 21-96-148 PETITION FOR THE APPOINTMENT OF GUARDIANS OF THE ESTATE AND PERSON IN ACCORDANCE WITH 20 PA. CONS. STAT. A5513 TO THE HONORABLE, THE JUDGES OF THE SAID COURT: The petition of Claudia Davis and Gregg Martin respectfully represent that: I. Petitioners are Claudia Davis, an adult individual of 2819 Kingsridge, Quincy Illinois, and Gregg Martin, an adult individual of 8000 Steven's Mill Road, Matthews, North Carolina. Petitioners are the daughter and son of the nlleged incapacitated person 2. The alleged incapacitated person is Violet Roberts, born on December 4. 1920. She is 75 years of age and resides in an independent living cottage at Cumberland Crossings retirement homes, South Middleton Township. Cumberland County, Pennsylvania. Her mailing address is 85 Schimmel Way, Carlisle, Pennsylvania 17013 3, By Order of Court dated April 15, 1997, Farmers Trust Company was appointed plenary guardian of the estate of Respondent. Said Order further stated that upon deposition of Respondent's psychiatrist, if the psychiatrist recommended the appointment of a guardian of the person for Respondent, giving adequate reason therefor, the Coun would consider the request for appointment of a guardian of the person. A copy of said Order is allachcd hereto and incorporated herein as Exhibit "A". 4. A deposition was taken of Douglas p, Dionne. M.D. on June 5, 1997. Dr. Dionne is a physician certified by the American Board of Psychiatry and Neurology who has examined Respondent and reviewed her medical history. (N.T.3-4) Present at the deposition was Robert Q, Frey, attorney for Petitioners and Marcus A. McKnight, III, attorney for respondent. A cenified lranseript of the deposition is filed herewith and incorporated herein as Exhibit "B". 5. Dr. Dionne has concluded that the Respondent suffers from cognitive decline consistent with dementia of the Alzheimer's type. (N.T. 5, 16) Respondent may additionally , . suffer from Korsakoff psychosis caused by alcohol consumption. (N.T.6) 6. Dr. Dionne has noted that Respondcnt's condition has declincd in the last 5 months causing her to be more paranoid and more delusional in her thinking. (N.T.7, 10, 16) 7. Dr. Dionne has allernpted to treat Respondent but she has been uncooperative and noncompliant and has rcfused treatment. (N.T. 7, 8, 10) She is unable to make informed decisions concerning her medical treatment. (N.T.7-8) 8, Respondent's failure to treat her condition a~ prescribed by Dr. Dionne ha~ rcsulted in weight loss, possible misuse of alcohol, and isolation from others. (N.T. 18-19) 9, Respondent also faces the risk that beclluse of her paranoia, she mllY leave the facility without adequate preparation for her safety or seek help from person who may take advantage of her (N.T. 9-10) or may avoid appropriate assistance (N.T. 14). 10. Dr. Dionne has recommended that a guardilln be appointed for her because of her "increasing paranoid thinking" (N.T. 9) and because of her inability to make informed medical decisions (N.T. 8), II, Dr. Dionne has recommended an increased level of structured care is necessary for the Respondent. This structure should include monitoring of medication use, monitoring of diet, and assistance in personal care. (N.T. 10, 18-19) 12. If a Guardian of the person is not appointed to make medical decisions on her behalf, her dementia and depression will accelerate (N.T. 19), she will be in greater risk of placing herself in dangerous situations (N.T. 10), and there will be greater risk of harm to others (N.T. 10). 13. Petitioners have kept informed a~ to Respondent's condition (N.T. II), have kcpt in contact with Respondent (N.T. 12), have allernpted to assist Rcspondent to make decisions on her own (N.T. 12), one of the Petitioners has consultcd directly with Dr. Dionne (N.T. 13) and are in agreement with Dr. Dionne's rccommendations for Respondent (N.T. 13-14). and would cffective guardians for her, (N.T. 12) 14. Dr. Dionne is unawarc of anyone else who could act as guardian for Rcspondent (N.T. 13). Petitioners are also unaware of anyone who could act as guardian of the person of Respondent, other than Petitioners. 14. Petitioners believe that Respondent's psychiatrist ha~ recommended the appointrncnt of the Guardian of the Person of Respondent and hilS provided convincing testimony documenting the need for the appointment. r" ,....__.."_._-,,.._.~... 15. The Probate, Estlltes, and Fiduciaries Code, 20 Pa.C.S.A.~ 5518 provides: To establish incapacity. the petitioner must present testimony. in person or by deposition from individuals qualified by training and experience in evaluating individuals with incapacities of the type alleged by the petitioner, which establishes the nature and extent of the alleged II1capacities and disabilities and the person's mental, emotional and physical condition, adaptive behavior and socilll skills. The petition must also present evidence regarding the serviccs being utilized to meet essential requirements for the alleged incapacitated person's physical health and safety, to manage the person's financial resources or to develop or regain the person's abilities; evidence regarding the types of assistance required by thc person and as to why no less restrictive alternatives would be appropriate; and evidence regarding the probability that the extent of the person's incapacities may significantly lessen or change. 16, Petitioners believe that the testimony of Dr. Dionne filed hcrewith represcnts testimony by an individual qualified by training and expericnce in evaluating individuals with incapacities of the type alleged by Petitioners. 17. Petitioners believe that the testimony of Dr. Dionne and tcstimony at prior hearings by Petitioners and by others familiar with the Respondent establish that the Respondent is totally incapacitated, unable to make responsible decisions conccrning hcr medical needs, personal care, or financial well being, based on a mental condition dillgnosed as dementia of the Alzheimer's type coupled with paranoia which condition is exaccrbated by physical limitations of visual impairment caused by macular degeneration. 18. Petitioners believe the testimony of Dr. Dionne and testimony at prior hearings by Petitioners and by others familiar with the Respondent establish that Respondent has at various times utilized services at Cumberland Crossings to assist hcr in meal preparation, tllking of medication, and medical evnluation but because of Respondent's incapacity she has tcrminated all of these services which are necessary to mect her essential needs. 19. Petitioners believe the testimony of Dr. Dionne and testimony at prior hearings by Petitioners and by others familiar with the Rcspondent establish that the Respondent is in need of supervised care through an inpatient nursing carc facility to provide Respondent with a~sistance for her personal care and meal preparation and to providc medication to Respondent as prescribed by treating physicians. 20. Petitioners believe the testimony of Dr. Dionne and testimony at prior hearings by Petitioners and by others familiar with the Respondent establish that less restrictive rnellsures have been attempted to provide Respondent with scrvices needed to meet her essential requirerncnts for physical health and safety, but that these less restrictive measures have all failed because of Respondent's refusal to cooperate, which refusal is caused by her incapacity. 21. Petitioners believe that the record, including the two previous hearings and the Deposition of Dr. Dionne filed hercwith presents clear and convincing evidencc, without further hearing, to establish the total incapacity of the Respondent. 22, The Probate, Estates and Fiduciaries Code, 20 Pa.C.S.A. ~55 13 permits the appointment of an emergency guardian or guardians of the person "when it appears that the person lacks capacity, is in need of a guardian and a failure to make such lIppointrnent will result in irreparable harm to the person...ofthe allegcd incapacitated person.... An crnergency order appointing an emergency guardian of the estate shall not cxceed 30 days." WHEREFORE, Petitioners rcspectfully request that this Court appoint Pctitioners Temporary Guardians of the Person of Violelle Roberts for a period not to cxceed 30 days and award a citation directed to Viole lie Robcrts. thc alleged incapacitated person, with notice and service thereof to be given to her, to show cause why Respondent should not be found to be incapacitated and Petitioners appointed plenary guardians of her person. Respectfully subrnilled, Frey & Tiley, Allorneys for Petitioners By: Robert G. Fr ,Esquire Supreme Court Number 46397 5 South Hanover Street Carlisle, Pennsylvania 17013 (717) 243-5838 I verify that both Pctitioners are outside thc jurisdiction of the court and the vcrification of ncither of them could be obtaincd due to the urgent nature of the within Petition. I further verify that I have either personal knowledge of the statements herein or I have verified the statemenL~ made herein as true and correct by consultation with the Petitioners und I understand that false statements herein are made subject to the penalties of 18 Pa. C. S. A. ~ 4904 relating to unsworn falsification to lIuthorities. Dated: June 20, 1997 ~Sv;j -4 .~ Robert G. Frcy (J .' ----- IN RE: IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA violette Roberts, an alleged: Incapacitated Person NO. 96-148 ORPHANS' COURT ORDER OF COURT AND NOW, this 15th day of April, 1997, a hearing was held today on two issues, one, whether Farmer's Trust Company should be appointed a plenary guardian of the Estate of Mrs. Roberts, and two, whether or not the Court at this time should appoint either a limited or plenary guardian of her person. Mr. McKnight, who represents Mrs. Roberts, was present in court today. Mrs. Roberts was not present. Mr. McKnight, on behalf of Mrs. Roberts, agreed to the appointment of Farmer's Trust Company as plenary guardian of the estate, and I have read in the petition why Farmer's Trust wants to be appointed plenary guardian of the estate. I believe that's a reasonable request, and therefore the prior Order of Court is amended, and it is ordered and directed that Farmer's Trust Company, Carlisle, Pennsylvania, be appointed plenary guardian of the estate of Violette Roberts. A deposition will be taken of the present psychiatrist for Mrs. Roberts this Thursday. If he recommends that a guardian of the person be appointed and gives adequate reasons, I will consider that request. Therefore, upon fXHIBIT "A" "jJ"~""" , ''':j''~'" ,c.', "'Y"",:\' , .' .' submission of this deposition to the court, I will render an appropriate order. By the court, Robert G.Frey, Esquire For Petitioner Marcus A. McKnight, Esquire For Respondent :lkt EXHIBIT "~,r' .~ g ~ ...... .'.0 . - .....\10' ' ...,'....,.....~. 71 ~ ..~ . ~. -. .' .. . ",.,.;;:,., ~ql,(9 ... d Q H"'.""" peqOI ~"""J' ,-i\'i,:r ".' PIIIO PIIOcloJlI q UOllnq/ fD\/.:F ;,;:'cc ,_,,, 'P uo qU* JIIIP ,r..'.,. '. .-wUUOO IInq/lll/ 10Ulp /O'rn ~;;:,. .. P PUI 10001 ",.;,: . ,(/'1 U/ ,!:';'" ,. Olql ~~t:;_~..;. ~'k,.:,:":- f.~;..:.; 1~,jF: m~{~~'~ <{:,-x','<'; I,~~tt- . , ;:;'::";'- .,.~,e ,,' ~"."'.' .. \ii' ...', ~~~,:' . ~'.:'" t>i,.<' ~-;'-/ ;:,,' ~~(: &,i, i, ~~,..-' " ~L: ' ~A..:.:.'{ ~.""-'-' . ~." " ~\ ~!~;" , ~l:~::':':} ';~, - ii' ....,,- 'tS~ 0- N ~~ ~3: "" () Q.. ,',J :" ~ ,3 00 ~ -o~ 1) ~* ~ ,ij )1 -r; ..: Q) ~ ~~ ! !;l ra.5 ~ ~ ~~ ra.~ ~ ii!1ii 0 ra.... ;~~ ~~~~ ~g~ ~~~a 0813 ~t:ai 13g8 ~era..i!i 8Bin~g~OU~ ~d;~lm . . ... 0\ 0\ ... co 0\ 0\ ... . ~ .ri N ... ~ ~ =; ~ .. .. ~ ~ ~ Q <II ~ ~ ~ 8 Q !;l ~ .:" c '\J'" . Co Q) CD ,- C ~ "c,Ell~iO c c'G ::I:S~ .!1l15.~ ~ c -5.8 l! .8 'O;::;,i511i '" i .. 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COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANtA ORPHANS' COURT DIVISION No, 96-148 Estate of VIOLETTE Q, ROBERTS, An Incepacltated Person FIRST AND FINAL ACCOUNT OF FINANCIAL TRUST SERVICES COMPANY Guardian Date of Decree: Account Stated to: April 15, 1997 July 24, 1998 SUMMARY & INDEX ~ PRINCIPAL Receipts 2 $ 213,057.64 Net Gain on Conversions Adjusted Balance $ 213,057.64 Less Disbursements 2 (93,232.36) Balance before Distributions $ 119,825.28 Distributions to Beneficiaries 3 Principal Balance Remaining $ 119,825.28 INCOME Receipts 3 $ 19,157.71 Less Disbursements 3 (16.791.40) Balance before Distributions $ 2,366.31 Less Distributions to Beneficiaries 3 Income Balance Remaining 2.366.31 COMBINED BALANCE REMAtNING $122.191.59 COMPOSITION OF NET BALANCES Principal Market Value Julv 16. 1998 Account Value Cesh $ 119.825.28 $ 119.825.28 Income Cash $ 2,366.31 $ 2,366.31 PRINCIPAL RECEIPTS 6/2/97 FTC Savings Account 14-035174 $ 9.980.91 6/2/97 FTC Checking Account draw down 5.000.00 10/22/97 FTC Checking Account draw down 6,000.00 7/24/97 Harris Savings Bank CD #1754255031 70.801.73 4/21/98 Proceeds Sale of Cottage @ Cumberland Crossings 121,275.00 TOTAL PRINCIPAL RECEIPTS $ 213.057.64 PRINCIPAL DISBURSEMENTS 09/29/97 Phllhaven Hospital. Consultation Service $ 65.00 10/29/97 GPU Energy. Electric Service 60.50 10/29/97 Robert C. Calms. Tax Collector, Personal Taxes 14.70 11/21/97 Transfer of Funds to Income 1,000.00 03/13/98 Lawyers Glen Retirement Living Center. deposit 5,100.00 04/07/98 Gregg Martin. Moving expense 750.00 04/07/98 Taylor Rental. Truck Rental Expense 594.68 04/20/98 Intemal Revenue Service. 1997 Personal Income Tax 2.329.00 04/20/98 Commonwealth of PA. 1997 Personal Income Tax 121.00 04/28/98 Smith, Helms. Mulllss & Moore LLP, deposit 4.000.00 05/05/98 Lawyers Glen Retirement Living Center, Balance Entrance Fee 49.336.00 05/13/98 Time Wamer Cable 17.87 TV Cable of Carlisle. Service 6/4/97 to 10/22/97 8.10 UGI Corp., Gas Service 6/4/97 to 4/9/98 298.92 United of PA. Telephone Service. 6/4/97 to 4/24/97 71.70 Cumberland Crossings. Monthly Maintenance 6/17/98 to 4/15/98 3.021.25 Cumberland Crossings. First Call Service. 8/19/97 to 12/16/97 375.00 Sprint. Telephone Service 7/23/97 to 10/21/97 162.69 Irwin. McKnight & Hughes. Professional Services 8/27/97 to 4/15/98 430.95 Reserved: Financial Trust Services Company 275.00 Miscellaneous Closing and Filing fees 200.00 Advance Distribution to Lincoln Bank of North Carolina 25.000.00 Guardian of the Estate of Violette G. Roberts $ 93.232.26 -2- PRINCIPAL DISTRIBUTIONS TO BENEFICIARIES None INCOME RECEIPTS 10/15/97 AFTRA Heallh Fund. Refund $ 21.93 11/21/97 Transfer from Prlnclpal 1.000.00 11/24/97 Harris Savings Bank CD Interest 1.763.17 04/28/96 County Meadows Association, Refund of Deposit 502.16 06/02/96 Sprlnt Telephone SelVlce, Refund 35.82 07/06/96 Cumberland Crossings Retirement Center. Refund 292.70 Fed Fund. Temp Fund Interest 7/2/97 to 4/1/98 1,953.26 Social securlty 11/3/97 to 7/9/98 11.695.00 KeyPremler Prlme Money Market Interest 411/98 to 7/1/98 1.893.67 TOTAL INCOME RECEIPTS $ 19,157.71 INCOME DISBURSEMENTS 10/24/97 Key Travel. air travel for Thanksgiving $ 1,042.40 12/12/97 Phllhaven. Balance Due 85.28 02/06/98 Allstate Insurance, Premium on Policy #0011204580118 162.00 02/25/98 CountlY Meadows Association, Deposit 500.00 04/20/98 PA Department of Revenue, 1998 estimated Stale Personal Taxes 31.00 04/20/98 IRS, 1998 Estimated Federal Personal Taxes 583.00 04/28/98 Gregg Martin. Reimbursement for Wallpaper 327.50 05/01/98 Gregg Martin. Reimbursement for Medication 524.54 OS/28/98 Gregg Martin. Reimbursement Eckerd Prescrlptlons 120.79 OS/29/98 Momlngstar MaUhews. Storage Rent 306.00 06/09/98 Robert G. Bookholl. Professional SelVlces 112.00 06/18/98 Indian Trail Pharmacy. Medical Supplies 12.57 Cumberland Crossings. First Call Aide 7/22/97 to 12/16/97 314.00 Cumberland Crossings. Room and Board 9/18/97 to 4/7/98 627.13 TV Cable of Carlisle. SelVlce 8/26/97 to 4/14/98 14.98 Rodney K. Hough. M.D. 11/12/97 to 7/1/98 79.81 Cumberland Crossing, Nursing Expense 11113/97 to 6/19/98 561.50 Cumberland Crossing, Nursing Home Expense 11/13/97 to 6/18/98 2,330.00 UGI Corp., Utilities Expense 12/2/97 to 4/21/98 471.95 Sprint. Utilities Expense 12/2/97 to 4/28/98 2136.05 GPU Energy. Utilities Expense 12/3/97 to 4/21/98 219.84 Irwin. McKnight & Hughes. Legal Expense 1/16/98 to 3/18/98 93.75 Lawyers Glen Retirement Center. Care Expenses 5/5/98 to 7/8/98 7.098.75 Financial Trust Department Fee 8/6/97 to 5/14/98 906.56 TOTAL INCOME DISBURSEMENTS $ 16.791.40 INCOME DISTRIBUTIONS TO BENEFICIARIES None -3- In Re: : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS COURT DIVISION : NO. 21-96-148 Violette Roberts, an Alleged Incapacitated Person PETITION FOR THE APPLICATION OF PRINCIPAL OF THE ESTATE OF AN INCAPACITATED PERSON FOR EXPENSES UNDER SECTION 5536(n) OF THE PROBATE, ESTATES, AND FIDUCIARIES CODE, 20 Pa, C.S.A. ~5536(a) TO THE HONORABLE, THE JUDGES OF SAID COURT: The petition of Lincoln Bank of North Carolina, Guardian of the Estate of Violette Roberts, an incapacitated person, respectfully represents as follows: I. The Petitioner is Lincoln Bank of North Carolina, a North Carolina corporation, having its office and principal mailing address at P. O. Box 657, Lincolnton. North Carolina 28093. 2, The Petitioner is Guardian of the Estate of Violette Roberts. an incapacitated person. being duly appointed by decree of Court dated July 21, 1998. A copy of the Decree is attached hereto as Exhibit "A". Petitioner is the successor Guardian to Financial Trust Services Company, I West High Street, Carlisle, Cumberland County, Pennsylvania, which was appointed Guardian of the Estate by this Court by Decree dated August II, 1997. 3. Petitioner was appointed Guardian of the Estate for the reason that the incapllcitated person is now a resident of North Carolina and is no longer a rcsident of thc Commonwealth of Pennsylvania. 4. The only persons interested in the Violette Roberts' estate are as follows: 1I son, Gregg Martin and a daughter, Claudia Davis. Both pcrsons are awarc of the expenses contemplatcd, are in agreement with the expcnditures, and were parties to the North Carolinll proccedings.. 5, Because of Petitioner assuming the dutics, effcctive July 21, 1998, fornlUlly handlcd by Finuncial Trust Services Company. Financial Trust Serviccs Company intends to file 1I first lInd final account on Friday, July 24, 1998. 4 ._-~_"'_"__. _ _'_ 6. Petitioner has been informed by Financial Trust Services Company that it will be unable to make any disbursements for expenscs after the filing of the first and final Account until the account is confirmed. Confirmation of the account is expected to be made on August 25. 1998. 7. Petitioner anticipates that it will be required to make payment for regulllr expenses of the care of Violette Roberts prior to the confirmation of account. 8. Petitioner further believes it prudent to have available a reserve to be used. if necessary, for unanticipated expenses or in the cvent that confirmation of the account is unexpectedly delayed. 9. Pctitioner has conferred with financial Trust Services Company and both agree thllt a distribution to Petitioner in the amount of $25,000.00 would be sufficient to pay lInticipated expenses and provide a prudent reserve until the final accounting of financial Trust Scrvices Company is confirmed. 10. Financinl Trust Services Company has been made aware of the contents of the within Petition, has included a reserve for the payment to Petitioner upon Court approval in its final account, and does not object to the requested payment to Petitioner. II. Petitioner is unaware of any other income, assets, or sources of income in existence or likely to develop other than those under the Guardianship of Financial Trust Services Company. 12. Section 5536(a) of the Probate, Estates and Fiduciaries Code, 20 Pa. C.S.A. ~5536(a), authorizes, with court approval, the approval of expenses incurred by a GUllrdian and the expenditure of principal of an incompetent's estate. WHEREFORE, pursuant to Section 5536(a) of the Probate, Estates and fiducillries Code, 20 Pa. C.S.A. ~5536(a), Petitioner rcspectfully prays Your Honorable Court to approve the payment by financial Trust Services Company of $25,000.00 out of principal of thc Estate of Violette Roberts in the to Lincoln Bank of North Carolina. ~\~r Robcrt G. Frey Attorney for Petitioner (' 5 South Hanover Strect Carlisle, Pennsylvania 17013 (717) 243-5838 County IN THE MATIER OF: N'''l~AndAddr''~R:_' ~'iP S'Z.7- VIOm.('/:iI:YUiS 10 :x> ~ R.i. uc- ZlrZZ7 0,,, Of BIffII 0tMrI Ul:enH No lZ-l./--/Cof AT O'ClOtK II. - ':-liribj(~lff FoIoNo Cfg-&- 3~5" In The General Court Of Justice Superior Court Division Before The Clerk STATE OF NORTH CAROLINA JUl 2!" ORDER ON PETITION FOR ADJUDICATION OF INCOMPETENCE o.s. 35A.1112. 35A.1113. 35A.1116. 35A.1120 This matter Is before the Court on a Petition for an adjudication of the Incompetence of the respondent. This Court has jurisdiction of the subject matter of this proceeding and of the person of the respondent; a copy of the Petition and a notice of this hearing were properly served on all persons entitled thereto; and this county is a proper venue. o A hearing was held before the Clerk of Superior Court and a jury and after hearing the evidence and the instructions of the Court. and upon deliberation. the jury 0 did 0 did not find by clear. cogent. and convincing evidence that the respondent is incompetent. ~ A hearing was held before the Clerk of Superior Court and, after hearing the evidence. the Court r)i does 0 does not find by clear. cogent, and convincing evidence that the respondent is incompetent. o The nature and extent of the respondent's incompetence are as follows: (Use only when respondent may retain any legat rights or privileges. See G.S. 35A.121S(b) and lorm AOC.E-406.} Therefore: i;&!t is ADJUDGED that the respondent named above is incompetent; and ORDERED that: rM a guardian be appointed by this Court. IT for good cause shown. the proceeding for the appointment of a guardian is transferred to Icounty To WIlIell Gu."'"n'!lIp Prtx;'''..g Tfln,f.rred o This proceeding is dismissed. Pursuant to G.S. 35A-1116. costs are r!'J taxed to 0 petitioner. [Jwaived. DI'e 7-Z(-9~ NOTE TO CLERK: o CIeri' 01 SU,,","'" coun /I the respondent is adjudicated incompetent. then in all cases send a cerlilied copy or this Order to the Division or Motor Vehicles. G.S. 2D-17.1(a}. /I the respondent resides in another county, also send a cerlilied copy of/his Order to the Clerk of/he county of/he respondent's tegat residence to be fited and indexed as in a special proceeding in that county. G.S. 35A.1112(/}. CERTIFICATION I certify thai this Order On Petition For Adjudication Of Incompetenc . a true and complete py of the original on file in this case. 0.,. 7- '2.1- Cl! , o ChI" 01 Suponor Coun AOC-SP.202 Rev. TillS IXItIBlT "A" C STATE OF NORTH CAROLINA r - . ,1m No. !V}~~U.4 county? A4. t. ~ _~.Mm #34 .' I 21" ORDER ON APPLICATION FOR APPOINTMENT OF GUARDIAN In The General Court at Justice Superior Court Division Bel r Th I Ii< IN THE MATTER OF THE ESTA Name ij,u/errE ~T'S M. rt;(1 I 10M' DaleOIApp" ~ - ~ ;;~~~e en /flor cLERl<oF"s1.jn iolifl5ill'l'f G.5. 35A-1213, 35A.1214. 35A-1215. 35A-1226 'fj~"1!::.,''L~ ~ N~.,",,,,,,,m "'G"""~ ~ e:K)~~J . .if/tJ;,)_/wCL:Jf"m;w, Aie.. 'ct;~ 01 The Estate 0 01 The Person 0 General Guardian 0 01 The Estale D 01 The Person 0 General Guardian This maller is before the Court on an application for the appointment 01 a guardian for the incompetent person or minor named above. This Court has subject maller jurisdiction over this proceeding and personal jurisdiction over the incompetent person or minor, and this county is a proper venue. 1. Upon due notice and hearing, or upon waiver of notice and hearing by all parties entitled thereto and upon their consent. the Court determines that a guardian: ~ must or should be appointed, and the Court further finds that each person appointed by this Order is T\. entitled. and Is not in any way disqualilled to serve as guardian. and that it is in the best Interest 01 the Incompetent or minor that he do so. D should not be appointed. D 2. Based on the findings as to the nature and extent of the ward's Incompetence made in the original incompetence proceeding, which are incorporated by relerence. the Court further finds that it is in the best Interest of the incompetent person that he retain certain rights and privileges as set forth below. Ills ORDERED that: rM each person named above is appointed as guardian of the incompetent or minor to serve In the capacity 't\. designated. and lellers of appointment shall be Issued to each such person when he properly qualifies to serve. D the ward shall retain the following legal rights and privileges: D the statutory powers and duties 01 the guardian(s) are modified by adding the following special powers or duties or by Imposing the following limits: o the application Is denied. Dale 7-"2-/-q8 . J\ TRUE COpy D Clerk 01 Superior Court AOC.E-406 Rev. 5/90 :f)&H1mi' "A" ~ B STATE OF NORTH CAROLINA F/IoNo. 98-E-1988 RIm No. Mecklenburg County In The General Court Of Justice Superior Court Division Before the Clerk IN THE MATTER OF THE ESTATE OF: ,.'"_ Of Wmt Violette Roberts LETTERS OF APPOINTMENT GUARDIAN OF THE ESTATE ~/ncom".t."r PInon OM- G.S. 35A.1203, .1206. .1251: 34.2.1 The Court in the exercise of Its Jurisdiction for the appointment of guardians of Incompatent persons end minors. and upon proper application, has eppointed the person named below as Guardlen of the Estate of the ward named above and has ordered that these Lellers Of Appointment be Issued. ~~:~ ....;:.:':::=c:rA-r-z:- '~" g~ .(\~t. ;:;:. J ~ O,c-~ .':"':1' ,"< ~ ....---......... ,t "", hi'. ~ ~A'{ :,:' ,;-.~,. '1.:.......'....'\ The guardian of the estate Is fulry'l!Uthdrized Ii ifentltled under lhe I~s O.l~orth Carolina to receive, manege end administer the property, esta,te'8nd'~~srnti~ffalis'of the werd. :x~ '\\ /' ~, ;f.....L ~ ~~~' f,' - ~r"'" .:~, ;.) ,. ^- .~ v,} :..--cU"1 r... _ I 11 ,.... . ~j~""'/: \1 i 't. ,r.:- \, .,,1 fAr. "'~"'-~^':""-"--' 1(. ~~.\ (i ,\ '. >::!'" {-- "'11 '-. l--=."" '.':17._ I j -. ,':'.1/ ,.t.~,-. -' -1,' fj 1.\ l-:...l . . ..-7/1 il'~ . _ .... ~. > ~j " , . )',.' . -I ~ .-.- ~ I . ...i . C::" ",-:;' ',//i,' ..<-........ ;\' - ;:;:J,,~, .\ , "'"" , ".' I' I 1'" \\ ,:, These Lellers ere Issued to allest to thai~tI1dritY'l!nd to.O ,t~' Gs:r;;w)n full force and effect. \,\,.~\-:;\lD:\--:' (#:i ~/i,'l1 j"..,~..,; lit... .....:~ ~ ~~7 " \,; ..".. --"~'........,.c ~ ,,, -;, ..-" ._,..... .w 'o.,,~ . /"" .;';. . "'1;)..... ........0 .'.// .~" ~ ' t\~L 12. \, , .::( /k ~,.:, ..... .. .., \. ::.,1 I....~ ~_l...... Ot:....~ /..r Witness my hand and the Seal of th~'S~P~~~~~.-&.# .........::::::...:;-~ N,m. And Add,." Of G~rd~n Of Th. EJr.,. Lincoln Bank of NC PO Box 657 Lincolnton NC 28093 O,r. Of O~1ifkllion Jul 21 1998 CI"t Of SUlHrlor Court Martha H. Curran EX OFFICIO JUDGE OF PROBATE SEAL O,t. 01 I"~nc. July 21, 1998 / SlQfYruto 0<..../i / .'" lQ9 D.pury CSC o AuiJt.nt CSC / AOC.E.407 Rev. t 0/96 ~m<<r "Pi" "'l"'II'w;......._~y"''''_.-.~-' ___<.-.,~.~__.......c~._. _ - - (- STATE OF NORTH CAROLINA -13:6 ~ ( ~IJ~ ilmNo. In The General Court at Justice Superior Court Division B f r Th I rI< IN THE MATTER OF THE ESTA Name l/J'O/e:;re. 1<dJ~,,-7S '. ORDER ON APPLICATION FOR APPOINTMENT OF ... GUARDIAN Incompetent D Minor Person Na~ndAddress 01 Guardian l'fJAftniJ , tVJill /ZR., /y} 1YrrA'WIS I Ale- 'Z$/ocf- o 01 The Estate 01 The Person 0 General Guamian G.S. 351..1213. 35A.1214. 35A.1215. 35A.1226 ame And Address 01 Guardian CJt:kAJ.l~ ..g~ 'il1'f ~~E. (W./~ If/,A.i 'r bZ~1 o 01 The ~state 01 The Person 0 General Guamian This matter is before the Court on an application for the appointment of a guardian for the incompetent person or minor named above. This Court has subject matter jurisdiction over this proceeding and personal jurisdiction over the incompetent person or minor, and this county is a proper venue, 1. Upon due notice and hearing. or upon waiver of notice and hearing by all parties enlitled thereto and upon their consent. the Court determines that a guardian: ~ must or should be appointed. and the Court further finds that each person appointed by this Order is entitled. and is not in any way disqualified to serve as guardian, and that it is in the best interest of the Incompetent or minor that he do so. D should not be appointed. D 2. Based on the findings as to the nature and extent of the ward's incompetence made in the original incompetence proceeding, which are incorporated by reference. the Court further finds that it is In the besl interest of the incompetent person that he retain certain rights and privileges as set forth below. It Is ORDERED that: rtt each person named above is appointed as guardian of the Incompetent or minor to serve In the capaCity "'-designated. and letters of appointment shall be Issued to each such person when he properly qualifies to serve. D the ward shall retain the following legal rights and privileges: D the statutory powers and duties of the guardlan(s) are modified by adding the following special powers or duties or by imposing the following limits: D the application Is denied. Date 7- 2-/-'1 f A TRUE COpy D Clerk 01 Superior Court AOC.E.406 Rev. 5190 ~. C.~S?a.. :"~ B .' . . ~:huk !.l.'';':' 'I L,,!'rt IXHItIIT HA'- i' I I If STATE OF NORTH CAROLINA File No. 98-E-1986 Film No. Mecklenburg County In The General COurt Of Justice Superior Court Division I r Th I rI< TA E F: Violette Roberts LETTERS OF APPOINTMENT GUARDIAN OF THE PERSON rn Inctlmpelenl Person o Minor a.s. 35A-1203, 35A-1206, 35A-1251 The Court In the exercise 01 Its jurisdiction for the appointment 01 guardians of Incompetent persons and minors. and upon proper application. has appointed the person named below as Guardian 01 the Person of the ward named above and has ordered that these Lellers Of Appol!l!m~nt be 'Isstiijd; '~" , .~-: " ('"-J" -- '- ~/ . ': ~ ...~\ r _ ~::.. . ~~'0\..o -'" J ... l~. '-. ..~~.' r~\ ~~-~- -,~-.~- -'-'. . " r -..-' .', <. v/' ",\." ' .' The Guardian of the Person Is fuUy aUlhorized.a(ld entitled under the laws 01 North Carolina to have the custody, care and control 01 the ward. but hss:no sutho;'tv to receive. msnsae or sdmlnlster the orooerlv. estste or business sffalrs of the ward.,' ./ ~ i t' "t'" ,'. ,', .. . ""....... _.f" J,'" ...... '. ,"', ':' , ! ~! I ~r~!;,., ' . --. . .- , ~) \ ,"' ~ :'~ .. ~\ of)...,' - These Lellers are Issued to allesno'that a~!hOrity ~nd to certify thalll is now In luli lorce and ellect. -" \ : -' \ . ," .. ....~J~ . .. . . ~ "', ~ '. ...,,~ '. ., . '.~;." - ,-' ':: ..\,(' "'..,- , ...~, .,.....: ::J-.,., _ Witness my hand and the Seal 01 the Supenor Court.~ -~~_.:, - '. '-:~~"....~.':':~E: ':~~I_... ," "'~7..:'. _ '.. Ne\?8 tc%'liE"M Of Guarcfian Of The Person ~h~S~vN8s2~6! Road Claudia Davis 709 Woodbridge Quincy IL 62301 Date Of Qualification July 21, 1998 Clerk Of Superior Court Martha H. Curran EX OFFICIO JUDGE OF PROBATE SEAL Date Of Issuance July 21, 1998 Signaturef/ I . 'I r U ,\ '\.vl\, r", [I Deputy CSC DAsslstanl CSC / AOC.E-408 New 5/88 mtIB8T "f:..'