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Home My WebLink About11-0205Metzger, Wickersham, Knauss & Erb, P.C. FILED-OFFICE OF THE PROTHONOTARY By: Francis J. Lafferty, IV, Esquire Attorney I.D. No. 84009 2011 J', i 2: 22 P.O. Box 5300 _ 3211 North Front Street Cum i' 1! T Y pp t'1!? Harrisburg, PA 17110-0300 Attorneys foil laintiffs (717) 238-8187 f1(a),mwke.com IN RE: OF CUMBERLAND COUNTY, PETITION FOR APPROVAL OF PENNSYLVANIA SETTLEMENT OF THE CLAIM OF GRACE COLE, a minor, BY NO. Vi Ter M JENNIFER COLE and NATHAN COLE, her parents and natural guardians PETITION FOR APPROVAL OF COMPROMISE AND SETTLEMENT OF MINOR'S CLAIM 1. Petitioners are Jennifer Cole and Nathan Cole, parents and natural guardians of Grace Cole, who was born on April 28, 2001, and who resides at 145 15th Street, New Cumberland, Cumberland County, Pennsylvania with her mother and father. 2. On January 23, 2010, Grace Cole suffered personal injuries when she was involved in a dog bite incident. Ms. Cole was visiting with friends at Kristine and Carol Long's residence. Ms. Cole was upstairs playing with her friends in one; of the bedrooms when Dakota, a Husky/Labrador mix who was approximately 7 months walked into the bedroom and began attacking Ms. Cole. Dakota bit Ms. Cole multiple times on the left leg, left shoulder, back, left arm, left elbow and left side. 3. Grace Cole was transported by her parents from the scene of the accident to Holy Spirit Hospital, where she was treated for the puncture wounds on her left leg, left shoulder, back, left arm, left elbow and left side. She was treated and released on January 23, 2010. The emergency room records of the hospital are attached hereto as Exhibit "A." g) pball%) c? s?,au.s 456653_1 .DOC ? Y 4. Grace Cole had three (3) additional follow-up visits with her primary care physician at Jones, Daly, Coldren & Associates for her injuries. She has since recovered from the injuries. Attached hereto as Exhibit "A" are medical records. 5. Travelers Insurance, the homeowners insurance carrier for Ms. Long, has offered $50,000.00 to settle the claim of Grace Cole against Carol Long. Attached hereto as Exhibit "B" is a letter of December 7, 2010, from Travelers Insurance advising settlement in the amount of $50,000.00. 6. Travelers Insurance has offered to pay the $50,000.00 settlement on a structured basis as set forth in the structured plan attached hereto as Exhibit "C." The proposed settlement agreement provides for payment to the law firm of Metzger, Wickersham, Knauss & Erb, P.C. of the sum of $13,699.67 for reimbursement of attorney's fees, costs and a medical lien. The remaining amount is to be paid to Grace Cole in guaranteed lump sum payments of $12,448.00 on April 28, 2019; $17,448.00 on April 28, 2022; and $22,448.00 on April 28, 2026. 7. All medical expenses have been paid through Grace's private health insurer, Capital Blue Cross. The lien amount of $1,379.42 has been negotiated down to $919.61. See letter dated November 22, 2010, from the PEBTF, the subrogation company for Capital Blue Cross, setting forth the lien. See letters attached hereto as Exhibit "D." 8. Petitioner has entered into a Contingent Fee Agreement with her attorney, Francis J. Lafferty, IV, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C. in the amount of twenty-five percent (25%), which fee agreement is attached hereto as Exhibit "E." 456653-1 i 9. Counsel for Petitioners has incurred expenses in the handling of the claim as follows: Fee for police report $15.00 Photocopies $29.30 Postage $17.03 Facsimile $10.00 Medical Records Costs $116.73 Filing Fee for Petition $92.00 Total Costs $280.06 10. Petitioners wish to accept the offer from Travelers Insurance totaling $50,000.00. 11. Petitioners respectfully request that this Honorable Court approve the minor's settlement and enter a Decree distributing the funds as follows: a. $12,500.00 to be paid to Metzger, Wickersham, :Knauss & Erb, P.C., for counsel fees; b. $280.06 to be paid to Metzger, Wickersham, Knauss & Erb, P.C., as reimbursement for costs and expenses; C. $919.61 to be paid to PEBTF, on behalf of Capital Blue Cross as satisfaction of its lien; and d. The balance of $36,300.33 will be placed in an annuity from Travelers Insurance Company and will be paid to Grace Cole in guaranteed lump sum payments of $12,448.00 on April 28, 2019; $17,448.00 on April 28, 2022; and $22,448.00 on April 28, 2026. 12. The undersigned counsel for Petitioners hereby certifies that the settlement is fair and reasonable, and in the best interests of the minor, Grace Cole, in view of the questionable liability and the successful recovery by the minor. 456653-1 WHEREFORE, Petitioners respectfully request that this Honorable Court approve the settlement and authorize Petitioners to execute all necessary settlement agreements and releases. Dated Respectfully submitted, METZGER, WICI By: Francis J affert Esquire AttornI.D. No. 84009 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 (717) 238-8187 Attorneys for Petitioners AUSS & ERB, P.C. 456653-1 VERIFICATION I, Jennifer Cole, am the Petitioner and parent and natural guardian of the minor, Grace Cole. I have read the forgoing Petition and agree with the contents thereof. I hereby certify that I join in the request for approval of the proposed settlement, which I have discussed with my daughter, Grace Cole, and which we believe is reasonable and in the best interests of Grace Cole. I hereby verify that the facts stated in the foregoing Petition are true and correct to the best of our knowledge, information and belief. I understand that the facts set forth in the Petition are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsification to authorities. r Col as parent and natural Je ffic gu an of ace Cole Dated: /0?, de, 456653-1 CERTIFICATE OF SERVICE I, Francis J. Lafferty, N, Esquire, of the law firm of MetEger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and exact copy of the foregoing document with reference to the foregoing action by first class mail, postage prepaid, this 1.0`h day of January, 2011, on the following: William Smith Travelers Insurance Company P.O. Box 13485 Reading, PA 19612 456653-1 ??iT X HOLY, QB IILU S I lealth System Camp Hill, PA 17011 MEDICALRECORD# 9A-f 'A'3 SURGERY DATE SOCIAL SECURITY NO NURSE STA ROOM/BED ADMIT DATE / TIME HSRV PT TYPE V- CLINI CODE PATIENT-Acc'r 171-80-2816 01/23/10 13:54 ER1 E # ER1 36368.371 FIN CLASS AGE DATE OF BIRTH RACE SEX MS CHURCH / R. PREF AMBULANCE ADM. REG DATE/ TIME CONFID REG BY B 8 04/28/2001 1 F S NO CONNECTION TO ANY O ?MbtRTIFIED OR UNKNO Ejy 01/23/10 14:33 N ADJLS P, COLE GRACE L P A 293 LOCUST POINT RD A M UNEMPLOYED T, I NEW KINGSTON, PA T p I F 17072 I , L EO E O T 717 - 580-4749 PHOTO ID N T: E - R GEO CODE LANGUAGE ENGLISH OCCU TION G COLE , JENNIFER MI M q,& A 293 LOCUST POINT RD UM C_MM, WEA. OF PA AI A NEW KINGSTON, PA 17072 R q,[ G? F N , o 0 717 - 580-4749 NY TE - ?i R OR RELATIONSHIP M 172-62-8768 R ADAMSON CHERYL CAMPBELL PATTY E.C E ,C - MO EN D EN +=Li?: RT ' GA E(' -=LATIONSHIP P N RELATIONSHIP A N Y1 .IOMEPHONE 717 - 756-6571 T Y . 2 HOME PHONE 717 - 329-9528 _ WORK PHONE - WORK PHONE _ PLAN CODE B09 INS CO BLUE CROSS PLAN CODE INS CO 1 POLICY # PFP80046199202 l POLICY # N s GROUP# 005026250000 g GROUP# U# # AUTHORIZATION # u, #I AUTHORIZATION # R All ADDRESS R 2 N PO BOX 779503 HARRISBURG PA 17177 N ADDRESS PHONE # VERIFIED C PHONE # E SUB NAME COLE , JENNIFER MI M Y E SUB. NAME: VERIFIED REL TO PT G PRIORITY 1 MI REL TO PT PRIORITY PLAN CODE INS CO PLAN CODE INS CO I POLICY # I ' POLICY # S GROUP # S GROUP# u* AUTHORIZATION # _ U- AUTHORIZATION # 3 # A ADDRESS 4 ADDRESS C PHONE # VERIFIED C PHONE # E SUB NAME MI E NAME VERIFIED SUB REL TO PT PRIORITY . REL TO PT PRIORITY MI ACC ID ENT DESCRIPTION ACC. DATE / TIME / IND. RIVACY NOTICE DOG BITE J 01/23/10 12:30 0 P 012310 V01 ER NEF COMMENTS DX ACTIVE ALT # 7175804709 FATHERS CELL ADMITTING DX. ADMITTING DR. ATTENDING DR. REFERRING DR. 1 180016 ED GROUP 180018 ED GROUP 149112 " " A? 'TTING COMPLAINT BROUGHT BY: AMBULANCE SERVICE: ITE/ INJ LT SIDE MR # MEDICAL RECORD ER1 PATIENT FACESHEET i? 640323 COLE,GRACE L PTA T# 36368371 8 F Holy Spirit Hospital r HS ECU DOCIRM t Printing InCW& Correction Historyi 0 -iteriat COLE, GRACE L Emergency Dept 28-Apr-2001 8y8m F 640323 /000036368371 23-Jan-201014:17 Triage Note, ED Extended Arrival Info French, Anne M (RN) [Entered: 23-Jan-201014:211 - Time of Triage: 14:07 - Reason for Visit: Child attacked by friend's dog approx 90 min ago. Child states she was playing with her friends and was attacked by the dog. Child denies provoking dog or any contact with the dog prior to the attack. Bite wounds and scratches to left shoulder, 1 elbow, left flank, 1 knee and 1 calf. bleeding controlled. - Language Spoken/Understood: English - Mode of Arrival: Private auto - Means of Arrival: Carried - Accompanied by: Family; Parent(s)/guardian(s) - Primary Care Physician: Jones, Daley reatment Prior to Arrival Treatment prior to arrival - Treatment prior to arriving No Presenting Complaints Presenting Complaints Chief Complaint Animal bite;. Triage Level: 3. Vital Signs - Temp Fahrenheit: 97.6 degrees F - Temperature: tympanic - Heart Rate: 100 - Systolic BP: 115 mm Hg - Diastolic BP: 88 mm Hg - BP Noninvasive Mean: 97 mm Hg - Reap Rate: 20 - Sp02 (%) : 98 - Respiratory: room air Height, Weight, BSA Measurements (Adult) - (lbs) : 62 lb (kg): 28.1 kg Pain Assessment Requested by: Stoner, Grace E (UQ Printed from: Emergency Dept 23-Jan-2010 20:26 - Page 1 of 3 Holy Spirit Hospital HS ECU Document :Printing Include Correction History: 0 iteria: COLE, GRACE L Emergency Dept 8y8m F 28-Apr-2001 Pain Assessment - Is the patient experiencing Yes... any pain? - Quality Constant Throbbing Aching Burning - Onset Minutes, 90 - Faces Scale Hurts whole lot immunizations - Immunization history: Medical History Medical History Details Does the patient have any medical problems? Medical details LMP 640323 /000036368371 No recent exposure Current - pediatric Yes... seasonal allergies N/A Surgical History Prior Surgical History - Previous Surgeries? No Assessment & Interventions Assessment & Intervention - Airway: Patent - Breathing: Normal - Circulation/Skin: Pink; Warm; Dry ED Advance Directive Advance Directive - Advance Directive No Abuse Screening Abuse Screen - Patient states physically, No emotionally, sexually hurt and/or threatened Additional Question - Do you currently have any No thoughts of hurting yourself or others?: Allergies No Known Allergies riage Requested by: Stoner, Grace E (UQ 23-Jan-2010 20:26 Printed from: Emergency Dept Page 2 of 3 Hal S irit;I?asprtal Y PHS ECU Document Printing Include Correction History.: 0 iteria: COLE, GRACE L Emergency Dept 8y8m F 28-Apr-2001 640323 /000036368371 Triage Disposition - Triage Disposition ER Signatures French, Anne M (RN) [Signed 23-Jan-2010 14:17] Authored: Arrival Info, Treatment Prior to Arrival, Presenting Complaints, Vital Signs, Height, Weight, BSA, Pain Assessment, Immunizations, Medical History, Surgical History, Assessment & Interventions, ED Advance Directive, Abuse Screening, Additional Question, Allergies, Triage 23-Jan-201014:17 1. Vital Signs 2.0 French, Anne M (RN) [Entered: 23-Jan-2010 14:211 T, P, R, Sp02, BP, ECG Temp Fahrenheit (degrees F) : 97.6 degrees F Temperature Site : tympanic 'eart Rate (beats/min) : 100 Systolic BP Systolic : 115 mmHg Diastolic BP Diastolic (mm Hg) : 88 mm Hg BP Noninvasive Mean Mean (mm Hg) : 97 mm Hg Resp Rate (breaths/min) : 20 Sp02 (%) Sp02 (%) : 98 Respiratory Patient On : room air Body Measurements Body Measurements (lbs) : 62 lb Body Measurements (kg) : 28.1 kg Requested by: Stoner, Grace E (UC) 23-Jan-2010 20:26 Printed from: Emergency Dept End of Report Page 3 of 3 Initial Lab & X-Rav Orders: Labs [ ] Acetaminophen ( ] ESR [ ] Acetone (SACE) [ J Glucose ( ] Alcohol (ALCO) [ ] HCGS [ ] Amylase/Lipase [ ] Quantitative [ ) APTT HCGS [ ] BBH [ ] HIV [ ) Blood Cultures [ ] Lithium [ ] BMP [ ] Liver profile [ ] CBCP [ ] Lyles [ ) CMP [ ] ProBNP [ ) CK,CKMB,TNT [ ) Phenobarb [ ] Depakote [ ] PTP [ J Digoxin [ ] Salicylate [ ) Dilantin [ ] Tegretol Radiology [ J Abd./Obstr. Series [ J Ankle R L [ ] Clavicle R L [ ] Cerv. Spine--Routine (3 view) [ ] Cent. Spine--AP/Lat ( ] Cerv. Spine--Portable Let [ J Chest--Routine or Portable [ ] Elbow R L [ ] Facial [ ] Femur R L [ ) Finger R L [ ] Foot R L [ ] Forearm R L [ ] Hand R L [ ] Hip R L [ ] Humerus R L [ ) Theophylline ( ) Thrombolytic Labs [ j Tox Screen [ ] Urine Tox (DOAS) [ ]TSHR [ ) Type&Cross_fl of units (BOR) [ ] Type & Screen [ ] UA: [ ] DIP [ ] DIAG. [ ]Urine C&S [ J Urine HCG [ ] WC Breath Alco Test [ ] WC Drug Screen [ ] Other: J Knee R ] KUB ] US Spine ] Mandible Nasal ] Orbit R ] Pelvis Pyelogram IVP J Ribs R ] Shoulder R ] Skull ] Sternum ] T/Spine ] Tib / Fib R ] Toe -R ] Wrist R [ J Other: Time/CRT/Int. REASON: Special Procedures: Ultrasound: CT: (W=With contrast; WO=Without) [ ] Abdomen [ J Abdomen/Pelvis W WO [ ] VQ Scan [ ] Duplex Doppler [ j Brain/Head W WO [ ] Echo- ( J Gallbladder [ ) Chest W WO cardiogram [ J Pelvis [ ] Spiral chest for PE [ ] Transvaginal ( ) Other: [ ] MRI Scan Time/CRT/Int. REASON: SSecimensJCultures: J Beta Strep AG Rapid J Cervical/Genital ] Chlamydia ] GC Culture ] Monospot (rapid) ] Sputum C & S [ )Stool C&S [ ] Stool 0 & P [ j Stool C. Difficile [ ] Trichomonas [ ) Wound C & S [ ] Other: Billing Classification: PHYSICIAN CHARGE FACILITY CHARGE ( ] Level I [ ] Level I [ ]Accident [ ] Level II [ J Level II [ ] Medical [ ] Level III [ ) Level III [ ] Case 1 [ ] Level IV ( ] Level IV ( ] Extended Hrs. J Level V [ ] Level V Holy Spirit Hospital Camp Hill, PA John R. Dietz Emergency Center Physician Order Sheet 206-ECU 12/04 REV. LLW Cardiac [ j Monitor [ ) EKG [ J 02 Umin. [ 102 Saturation Initials: --Denn CRITICAL CAME-Ad Resniratorv [ ] ABG's [ ] Peak Flows Before/After Resp. Tx. [ ] Respiratory Tx. "t ?X [ 1 Dictated Date: 0 Time: OLE GRACE L 8 F ER1 04/28/2001 ?D GROUP 640323 640323 01/23/10 36368371 RN/MA (MD/DO/CRNP I Initials: Signature:- RN/MA Initial Lab & X-Ray Orders: Labs [ ] Acetaminophen ( J ESR [ j Theophylline [ j Acetone (SACE) [ ] Glucose [ ] Thrombolytic Labs [ ] Alcohol (ALCO) [ ] HCGS [ ] Tox Screen [ J Amylase/Lipase [ ] Quantitative [ ] Urine Tox (DOAS) [ ]APTT HCGS [ jTSHR [ j BBH [ ] HIV [ ] Type&Cross_# of units [ J Blood Cultures [ J Lithium (BOR) [ ) BMP [ ] Liver profile ( J Type & Screen [ ] CBCP [ ] Lyles [ ] UA: [ ] DIP [ ] DIAG. ( ] CMP [ ] ProBNP [ ] Urine C & S [ ] CK,CKMB,TNT [ ] Phenobarb [ ] Urine HCG [ ] Depakote [ ] PTP [ ] WC Breath Alco Test ( ] Digoxin [ ] Salicylate [ ) WC Drug Screen [ ] Dilantin [ ] Tegretol [ ] Other: Radio/ogY [ j AbdJObstr. Series [ J Knee R L [ J Ankle R L [ j KUB [ ] Clavicle R L [ ] US Spine ( ) Cerv. Spine--Routine (3 view) [ ] Mandible [ ] Cerv. Spine--AP/Lat [ ] Nasal [ ] Cerv. Spine--Portable Let [ ] Orbit R L [ ] Chest--Routine or Portable [ ] Pelvis [ ] Elbow R L [ ) Pyelogram IVP [ ] Facial ( ] Ribs R L [ ] Femur R L [ ] Shoulder R L [ ) Finger R L [ ] Skull [ ] Foot R L [ ] Sternum [ ] Forearm R L ( ] T/Spine [ ) Hand R L [ j Tib / Fib R L [ ) Hip R L [ ] Toe R L [ ) Humerus R L [ ] Wrist R L [ J Other: Time/CRT/Int. REASON: Special Procedures: Ultrasound: CT: (W=With contrast; WO=Without) [ ] Abdomen [ ] Abdomen/Pelvis W WO ( ] VQ Scan [ ] Duplex Doppler [ ] Brain/Head W WO [ ] Echo- [ ] Gallbladder [ ] Chest W WO cardiogram ( ] Pelvis [ ] Spiral chest for PE [ ] Transvaginal [ ] Other: [ ] MRI Scan Time/CRT/Int. REASON: Specimens/Cultures: [ ) Beta Strap AG Rapid [ ) Stool C & S ( ) Cervical/Genital [ ) Stool 0 & P [ ) Chlamydia [ ] Stool C. Difficile ( ) GC Culture ( ] Trichomonas ( J Monospot (rapid) [ ] Wound C & S [ ] Sputum C & S [ ] Other: Billing Classification: PHYSICIAN CHARGE FACILITY CHARGE [ ] Level I [ ] Level I [ )Accident [ ] Level II [ ] Level II [ ] Medical [ ] Level III [ ] Level III [ ] Case 1 [ ] Level IV ( ] Level IV [ ] Extended Hrs. [ ] Level V [ ] Level V Holy Spirit Hospital Camp Hill, PA John R. Dietz Emergency Center Physician Order Sheet 206-ECU 12/04 REV. LLW Cardiac [ ] Monitor [ ] EKG [ ] 02 Umin. [ j 02 Saturation RMLratou ( ] ABG's [ J Peak Flows Before/After Resp. Tx. [ ] Respiratory Tx. Ma_rlicatinne / Me / AA'IM-1 n.A DOCTOR Orde Tinne r PHYSICIAN ORDERS -NURSE Given Time IV: NSS/ D5W/ LR/ D57.45NS/ -579NS WO/KVO/infuse at mis/hr [ ] Obtain old records [ 1 Td [ ] Protocol initiated for: t ,i Ov.o. read back Time: []DISCHARGE i' ] ADMIT []OBSERVATION- [ ] REGULAR [ ] TELEMETRY [ ] CRITICAL CARE ADMITTING PHYSICIAN / GROUP: DIAGNOSTIC IMPRESSION: Initials: Signature: RN/MA Initials: Signature:. RN/MA CRITICAL CARE hr . (] Dictated Date:l COLE , GRACE L 3 F ER1 04/28/20CI CROUP 6403233 x40323 01/23/10 36368371 ZI C operative - Awake - Alert ? Appropriate 0Warm;R6ry []?I?orm. Color dented-Person words/ response OCool []Diaphoretic meted-Place []Consolable, []Hot OTenting Y nted-Time E inappropriate []Pale []Flushed 7 Agitated words []Dusky ?Mottled ? Uncooperative ? Persistent ?Cya tic OJaundice ? Verbally Abusive ? Combative inappropriate M US MEMBRANES ? Anxious ? Crying crying/ screaming Pink / Moist ? Confused 0 Moans to pain []Pale is []Skin Intact (visible) ?symmetricaV unlabored Extremity "??? u.vm []Abrasion []Rash []clear ?stridor OE chymosis OBurn Olabored []retractions Extremity color.?WNL Wound []wheezing L / R ?Mottled []Cyanotic Laceration/ Avulsion ?rales/rhonchi L / R Skin Temp OWarm []Cool []cough Distal Pulses[]Present ONot palp []Bleeding ?Na []productive . Edema []Yes ONo OControlled ?02_Umin via Deformity []Yes ?No []Nol t Controlled Ecchymosis []Yes ONo []headache UPERL R L EYES MOTOR RE ON$E RBAL []denies s/s ?stiH neck Size_mm mm q Spontaneous 6 Obeys 5 Oriented Ufrequency []neck pain Pinpoint ? ? 3 To verb command 5 Localizes pain 4 Disoriented Ourgency Ufacial droop Dilated ? ? 2 To pain 4 Flexion-withdrawal 3 Inappropriate ?Dysuria []numbness: Fixed ? O 1 No response 3 Abnormal Flexion words ?Hematuria Sluggish ? ? 2 Abnormal Extension 2 Incomprehensible []retention Uweakness: non-reacliveU ? 1 No response sounds []Other: 1 No Response []Denies pain /sympto(n []Duration/ intensity Last BM []Abdomen []nausea []diarrhea ? miting ?constipation?Hematemesis Bowel Sounds []distended EENT denies s/s ?N/A EYES Llal / R Acuity: L_/_ []blurred vision L / R R []double vision L / R []with lenses ?Photophobia L/R IV condition oond : 0=no inflammation/com lication 1 Date Start Stop Ami Solution Ears Nose Throat []Pain UR []congestion []sore CP'M []discharge []drainage []drooling []Call bell []Other: ?Epistaxis L / R []dysphasia ?SR up x2 !ma 2=e hema 3=ecch mosis 4= pain 5=hardness 6=warmth 7=leaki Sz. Site Rate Attpt Cond Initial Notes U' ! Time 13 'Holy Spirit Hospital Camp Hill, PA 17011 John R. Dietz ECU Nursing Assessment/ Notes 205-ECU 6/06 11th Rev. LLW Cl,A.RT ^OPY Uurethral []Monitor/rhythm: hest pain discharge are ?vaginaldischarge Severity /10 []vaginal bleeding Upacer []constant []sharp Ofoley Oedema: []intermittent Odull present -# []burning []pressure LMP ?JVD []SOB []heavy :1 N/A Ucapillary r fill: []nausea []pleuritic Urepid []non-radiating []delayed []radiating oft []calf tender R / -13N Time: each Com anion with patient Procedure explained Time Drug/ Dose Site I Initial Signature Initial ZdU15UMARGE [JADMIT [JOBS []TRANSFER 4 l 1.s awGED / accompanied by:OSelf []Family []Other yia: bulatory ?w/c []ambulance To: me []nursing home []AMA ?OR []other: -- Disch r instructions given to: P atient []Family []Parent []Other OBS Report called @ to oom# old records sent to floor TRI?NSFER TO: []clothing sheet done Condition: []transfer checklist complete )6Satisfactory []Critical []Deceased to morgue []Improved; pairnscale .11M RN Si nature: A COLE GRACE L 8 F ER1 04/28/2001 :D GROUP 640323 F 640323 01/23/10 36368371 DATE A.M. P.M. MEDICATION AND/OR TREATMENT SIGNATURE &IIIJ ?tulL? v )-vu !` ,-.,? V`im`'' -?=?'? E'er. t?E' ?? ? ? 1 'l-?,?% ??; '?_?-.?..?s?l_ ---- =? i ?,?? f -: y ` t LEI I L--}j ??• 1 /? 1 6 r . ?-?,? J ?-( ?J Ul._a_ )_?'\ /` l"?-L'v??l..? 1. ? ?" ? `-??L? I? _. 1 , _ \ ` _ - _ - - _ 7 1 ?,\ '"1 ( %??.M i/?yw?/• ?-^l/v ?/?ilV LUV'l/l..V..' HOLY SPIRIT HOSPITAL CAMP HILL, PENNSYLVANIA 17011 EMERGENCY AND OBSERVATION RECORD PATIENT CARE NOTES COLE ,GRACE L ER1 ED GROUP 640323 01/23/10 8 F 04/28/2001 640323 36368371 FORM NO. 190 (2/95) CONSENTTO MEDICAL TREATMENT ' I HEREBY CONSENT AND AUTHORIZE Holy Spirit Hospital, its agents, and employees, to the rendering of medical care, which may include routine diagnostic procedures and such medical treatment as my attending or consulting physician considers to be necessary. I also under- stand it is customary, absent emergency or extraordinary circumstances, that no substantial procedures will be performed upon me unless or U have had an opportunity to discuss them with a physician or other health care professional to my satisfaction. If I am a competent adult, I h,. the right to consent or refuse to consent. I understand that the practice of medicine and surgery is not an exact science and that diagno- sis and treatment may involve risks of injury or even death and acknowledge that no guarantee has been made to me as to the results of any examination or treatment in this Hospital. I understand many of the physicians on the staff of Holy Spirit Hospital are not employees or agents of the Hospital, but rather are independent contractors who have been granted the privilege of using these facilities for the care and treatment of their patients. Further, I realize this Hospital is a teaching Hospital and at the Hospital are health care personnel in training who, unless expressly requested otherwise, may participate or may be present during my care as part of.their education. Still or motion pictures and closed circuit monitoring of patient care may also be used for educational purposes, unless I expressly request otherwise. I understand that in order to ensure a safe environment for patients, visitors and staff all property on the premises of Holy Spirit Hospital is subject to reasonable search and/or seizure at any time without further notice. Initials RELEASE OF MEDICAL INFORMATION I authorize Holy Spirit Hospital to release to requesting health insurance carrier(s), their representatives and auditors, and any referring health care providers, such diagnostic and therapeutic information (including any information relating to treatment for alcohol and substance abuse and/or treatment of psychiatric disorders and/or confidential HIV related information as may be necessary for them to determine benefit enti- tlement; to process payment claims for health care services provided during this hospitalization/treatment episode, for continuing care/treat- ment, and hospital operations. A photocopy or carbon copy of this authorization shall be considered as effective and valid as the original. The undersigned also authorizes Medicare, when applicable, to release to another insurance carrier, upon their request, medical information need- ed to make payment upon that claim. I understand and consent that the manufacturer of any implantable device inserted by my physician during the course of -mrsurgery/procedure may be provided with my identification information, including social security number, as mandated by Federal Law. f l Ini'tials ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I have received a copy of the Notice of Privacy Practices. The Notice describes how my health information may be used or disclosed. I under- stand that I should read it carefully. I am aware that the Notice may be changed at any time. I may obtain a revised copy af. the Notice con- tacting this Organization's offices or on this Organization's website at www.hsh.org. '?y ?lnh ah URANCE ASSIGNMENT OF BENEFITS ,?. I ?..,norize payment directly to Holy Spirit Hospital and my treating physicians of all benefits payable under my insura pejj1des I n trstand I am responsible to the Hospital and physicians for all charges not covered by this assignment. (W f? Initials I STATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDERS, PHYSICIANS AmnM TIENT I request payment of Authorized Medicare benefits to me or on my behalf for any services furnished me by or in Holy Spirit Hospital including physician services. I authorize any holder of medical and other information about me, to release to Medicare and its agencies any information needed to determine these benefits for related services. Initials MEDICAL ASSISTANCE RECIPIENT My signatures certifies that I received a service or items from Holy Spirit Hospital and Dr. _ on the date listed below. I understand that payment for this service or item will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of material may be prosecuted under applicable Federal and State Laws. I understand that certain tests and procedures may not be reimbursed by Federal and State funds and that I may be responsible for non covered charges. Also, I agree that if at the time of service, if I am not eligible for Medical Assistance, I will be responsible for balances owed to Holy Spirit Hospital. Initials I have read and understand each of the sections contained above. I understand that by signing this document, I am agreeing and providing t authorization/ consent ontained in each of the above sections where my initials are located. I have had the opportuni- ty to ask k-q es ions reg ina ea thes sections and all such questions asked have been answered to my satisfaction. ( Signature, Witness Relationship t atient . f Time Date HOL17 SPIRIT HOSPITAL CAMP HILL, PA 17011 CONSENT FOR TREATMENT/ RELEASE OF INFORMATION INSURANCE ASSIGNMENT COLE ,GRACE L ER1 :'D GROUP 640323 01/23/10 8 r 04/28/2001 640323 36368371 MR 166 E.D. (3103) CHART COPY Please List All Current Medications: (Include all over-the-counter, vitamins, samples, herbs & other supplements). Please keep any medications with you and show them to the nurse. Name of Medication Dosage, Route (by mouth, cream, etc.), Freque y Medication is Taken Time Medication Taken Last time you took this medication. L Patient has ought a legible, complete medication list that is copied and attached to this form. ALLERGIES? No ? Yes, list all allergies and reactions: Allergic to Latex? Pl?,,No ? Yes Source of Data: ? Patient ? Family ? EMS ? Bottles ? List Patient's Pharmacy: Patient's Family Physician: Patient's Signature: Family Signature and Relationship if patient unable to sign: _ ? Patient unable to sign and family not available ? Unable to Practitioner Name Printed, Name Stamp, (MD/DO/PA/CRNP/ Practitioner Signature (MD/DO/PA/CRNP/RN): Date/Timi! L dose, route or frequency at time of interview M-1off HOLY SP IRIT HOSPITAL Camp Hill, Pennsylvania 17011 The Spirit of Caring Medication History Form Form MR 204 Rev. 10/07 FMC-10/07 v ^ / F COLS , Gg,ACE L 04/26/2001 64p323. ER]. 35358371 1D GROUP _ 640323 01/23/10 White: Chart Yellow: ER 01 Pink: Patient D4*TMENTOF PLEASE FAX '1,'Q: (717) 243-3171 HEALM Cumberland County State Health Center 43, L. North- St. Carlisle. PA 17013 ?y Phone: (717) ?43-51 51 CON Dt11?j??M CONFDE M ANIMAL WIFE REPORT /''_ Victim's Name (Last name, First "me, Middle Inirial): JA_gge: Parent (p?mt or child) W Grp eo /L %i) I l _ ?/ l - ddress. (Street) Ln, - J 7,Tr?kncl County: Home Phone: Wo Address and phone number of victim for the next 10 days if different than above Q w er's Name Last name, First name, Middle Initial): Address: veer Iql i ' ounty u H e Phone: Mel Q K K Q PA % rk Phone- PA ork Phone: Type of Animal: Dog Cat [ ] Other [ ) (If other; what type of animal): Pet ] Stray [ ] Wild [ ] I Breed ?? /, I I a, Sex: A Date of last rabies vaccination: l5 Was animal vaccinated prior to that date? Yes [ ] No [ ] `7ete_rinarian's N2mP' . /1 _1/11 e, .,. _. T X_ 22/7 7 1 Address: v I 1w111/., r V P F-' ? vL.1 r I VV yr C,_r / ( + -1-- DATE OF INCIDENT (Indicate the date bite/se atch occurred): / 93 1 / Cl Place bite/scratch occurred: Owner's Home Victim's Home [ ] Other [ ] (lfother, what location?) What caused animal to bite: (Described circumstances) / 0 C a This is a: Bite X Scratch 7: Other[ ] Part of Body Affected?, / Describe wound: Skin Broken? Yes No If yes; Superficial ) [ ) Deep Other [ ] DATE OF TREATMENT: / Facility where treated: 3bo Q ame of Physici ,,/,/ ? Telephon : 3 -7 Type of Treatment ()`Wound cleansed 01 Antibiotic [ ) Tetanus [ ] HRIG Cho [ ] HDCV (Rabies vaccine) [ ] PCEV (Rabies vaccine) [ ] Other Continents: , cam- y?C ?fl.r??-d? u; Y11 14 L 7) ,?c,? F, Le 69?*7z4Qv1 d S Person completing form: C?e Phone: jI,///2-SOU- Address: 1 SHC USE ONLY Log No. Date: JSM-BLAIRSHC -? A. REASON FOR. F0LLC-'NY-UP GOitTkC"I" B. Abnormai Blood Results Positive culture results (Type) _ Check on patient status - Missed X-Ray - Other (specify): Planned action (as per provider) sau;,- Patient. TELEPHOIV ` COt TACT: Phone N!umb? y Date: Person Co :tacted: ?Relationshik?: _ Outcome of Phone Conversation: jC_:71- -- -.?z°-? -? icy. IF UNABLE TO CONTACT PATIENT LETTER TO PATIENT, Date Sent: Receipt Retuned Date: STERED Letter Returned Date: Family Physician contacted (if known): By Vkfho :: D. RESOLUTION DATE: (Date definitive contact/treatment occurred) MD/ i Stamp P009092 Signature R I 4 pate ; ime iOHOLY SPIRIT Holy Spirit Hospital I C Hill ? amp , PA 17011 i 7 h, Spin: qi C -n Emergency Center Follow-up Form ER-215 Version 04/07 FMC 04107 -, !7 % k wru t t Fracture WOUND CARE r-)_+A8y gently wash over wound in 24 hours with soap and water or peroxide. _._., (.).Change dressing'"-Times daily. Redress with Bacitracin'/Neosporin and sterile dressing or leave it open if advised. ( ) Keep wound clean, cry O covered O uncovered SPRAINS, STRAINS, BRUISES, FRACTURES Elevate the injured part for_ days to reduce swelling. ( ) Apply ice packs intermittently for- days to reduce swelling. ( ) Ace wrap for support for_ days. ( ) Wear splint ( ) At al times until follow-up. ( ) For activity as needed ( ) Use sling for support. ( ) Use crutches: O As needed, weight bearing as tolerated. ( ) At all times. NO WEIGHT BEARING NECKIBACK ( 1 Wear cervical collar for support for days. ( ) Rest, avoid bending, lifting, strenuous activity for days. ( ) Apply moist heat for minutes times daily beginning in hours. ADDITIONAL INSTRUCTIONS ( ) Encourage fluid intake ( ) Clear liquid diet. Advance to regular diet as tolerated ( ) Off work/school from to ( ) Return to work on ( ) Light Duty until: Restrictions: ( ) No gym/sports until ( ) Follow instructions on Workmen's Compensation Form. ( ) Wear eye patch for hours. ( ) If nose bleed recurs, pinch nose firmly for 5 minutes continuously, return if bleeding not controlled. ( ) The interpretation of your X-Rays are preliminary reading. Your films will be reviewed by a radiologist. You or your Physician will be contacted if there is a change in the diagnosis. nvl, r JrIKI I HOSPITAL JOHN R. DIETZ EMERGENCY CENTER ?- 503 NORTH 21ST STREET CAMP HILL, PA 17011-2288 (717) 972-4300 Salvatore Alfano. MD 025502E Ramesh Arora MD 016727E t I Kevin-Sean McGann. DO 010969 David Zimmerman. MD 005636E . Pushpa Mudan. MD 051514L Nik l 1 B D o as . . aran. O OS004697L Aaron Palmer, MD 423830 t , Lorraine Bock NP TF 0034096 I Luke Chetlen. DO 0313145 Nicolau DaCosta. MD 053288L t ? Lawrence Paul, MID Ericka Powell MD 424145 L . 4B i n ) Jon Dubin. DO 053288L Robert Ettlingei MD 027460E . Ranjana Sharma. MD 031265E Pa n Da de . NP P0 606 B Selena DiPaolo. NP VP005264B . Amy Fajardo. MD 420942 Christine Sheridan. DO 009537L Barry Spector MD 032793E ) Natalie Gillis. NP TP006082B Philip Maguire. MD 015063E . 't .? ,flan Teplis. MD 030018E c ) Michelle Hale. NP VF005355B J Dennis MacDougall. NP SP009092 DATE' i SIGNATURE - M,D./D.O./NP DEA# IN ORDER FOR A BRAND NAME PRODUCT TO BE DISPENSED. THE PRESCRIBER MUST HAND WRITE "BRAND NECESSARY" OR "BRAND MEDICALLY NECESSARY' IN THE SPACE BELOW. uuus ivieoia t / Suture Care & Removal MEDICATIONS ( ) Continue present medications except: ( ) Use Advil (Ibuprofen) orinst Tylenol as needed for pain, fever according to package ructions for age and weight, etc. ( ) Use the following medicines according to package instructions: 1: 2: 3: ( ) The following medicines may cause drowsiness: DO NOT DRIVE OR OPERATE MACHINERY WHILE TAKING: The prescribed antibiotic/medication, may reduce the effectiveness of medicationwith consult youPharmacistare currently taking. Check package instructions or. FOLLOW-UP This is our recommendation for follow-up. If your insurance (HMO) requires a physician referral for specialty consultation. IT IS YOUR RESPONSIBILITY TO OBTAIN THE NECESSARY APPROVAL. (_) Follow-up with: ( ) Urgi Center ( ) Occ. Health/Company Doctor (`-)Family Doctor or in days for: -4 )-Follow-up ( ) Suture removal ( ) Take the following test results to your physician: O CBC O CMP O EKG O X-RAY REPORT O OTHERS IF YOU DO NOT HAVE A FAMILY PHYSICIAN CALL 763-2900 FOR PHYSICIAN REFERRAL. ( ) Call as soon as possible for appointment ( ) Pick up your X-Rays from the Radiology Department prior to your follow-up appointment. Call 763-2696 to have films ready. ( ) See-your physician or specialist if not improved in days. -)Return to Emergency Center if you feel your condition is worsening, especially if ( ) Your blood pressure was elevated. Check with your physician. A copy of your dictated Emegency Room Report is available to your Physician from Medical Records (763-2660), if not already sent. Clinical Impressions: I hereby acknowledge receipt of these instructions and understand them. I understand that I have had emergency treatment only and that I may be released before all of my medical problems are known or treated. I will arrange for follow-up care as I have been instructed. It is my responsibility to notify my Primary Care Physician of this visit. SIGNATURE: _ Physician MD/DO/c NP _ W SIGNATURE: u., a' ? .•t ' •Pa?erit "r, Responsible:Pecson Date ( ) PATIENT/RESPONSIBLE PERSON VERBALIZES UNDERSTANDING SIGNATURE: " Nurse RN _ ' Date Theresa Williams, NP TP006126B I? Denise Beltowski, PAC MA0018761 William Buckner. PAC MA052332 Matthew A. DiRodio. PAC MA000969L Jeffrey Horan. PAC M,A051306 Michele Kaiczewski. PAC MA002955L REFILL =?_TIMES COLE , GRACE L 8 F 21 Animal Bite (4) DATE: 3 TIME: p on arrival ROOM: - EMS Arrival EMS treatments ordered HISTORIAN: dra lent spouse paramedics AGE M /(F d?-HX /-EXAM LIMITED BY: HPI chief complaint: Bite occurred: where: just prior to arrival home school a or park yesterday work street do er: ei hborhood anima unknown animal Appearance of animal eared wel appeared ill unknown Description: Animal's Immunization status UTD unknown not immunized Observation/copture... mal is no a observed for 10 s animal unknown; not captured animal control notified context of atta "unprovoked" attack "provoked" attack see a ow approached animal entered animal's domain animals fighting playing with or teasing animal ether aeveri of in'u s tche ucous membrane c ntact location of in'u head face neck Id R 10 chest me hip R/ c mid lower) RUE UE RLE LE 3e ursing Assessment Reviewed ,tals Review e Tetanus immun. UTD PHYSICAL EXAM GENERAL APPEARANCE -no acute distress -mild/ oderat evere distres alert anxious a argic SKIN see diagra -intact NEURO/VASCULAR /TENDON fro vascular compromise oriented x3 o'-sensation intact CCN's nml as tested FROM nml abnml color / warmnth / cap refill- .pulse deficit disoriented to person / place / time- sensory / motor deficit facial droop ROM limited by pain / tendon injury PSYCH depre sed affect mood/ affect nm anxious -------------•-- HEAD/EENT --------------------- ---- " ------- see diagram ? -normocephalic, -EOM palsy/ anisocoria atraurnatic -TM obscured by cerumen (R / L ) PERRL -eye lids / conjun. -post-surgical pupillary defect ( R uninjured -ENT nml external ' inspection NECK 06ninjured, see diagram ' nml inspection CHEST -see diagram -uninjured, -wheezes / rales / rhonchi nml inspection , GI (ABDOMEN -- see diagram ' ROS - uninjured, , " " loss fei ' g / po r arms /legs tr-ou- nml inspection e: reathing /chest pain -non-tender ess loss Z?f ftdder function eadac(t? eckytain suspehed FB (skin lac) ; _nml bowel snds* doubltwcsion / he3Sing loss- recer fever / illness 'BACK -see diagram - ' nause,?/ vomic`g ` -uninjured, ; \ - - " - - - ' nml inspection - - - - - - - - - - - - - - - - - - - - - SOCIAI,WX sr------'----- ' E er drug use /abuse recent EXTREMITIES OH lives alone I uninjured rsing ? ?- I-AMILY HX -negative nml inspection suspe lives in nu home , 4-_jointpenetrationsu no infection -'--------- ---------------spected ------------- ------------ AST HX -negative urses note for Meds and Allergies HTN heart disease C S - 2006 T-System, Inc. Circle or check a rrmatives, backslash /I 7nne-alfinvesHoly Spirit Hospital Camp Hill. PA John R. Dietz Emergence Center EMERGENCY PHYSICIAN RECORD Rev. 06 / 22 / 06 Pa,ge 1 of 2 Underline indicates organ system * equivalent or mininntm required for orgon system exam COLE ,GRACE L 8 F ER1 0.1/28/2001 :D CROUP 640323 1 646323 Oi/23/10 36368371 o ?'1v /.l J n? ?JN ?? Ul)Uf) UOOtl L R L R PROCEDURES ----------------------`? v-- ------------ length / Repair length Sn location / " ,t f {r superficial ub r muscle linear puncture stellate irregular ? clean contaminated moderately/ *heavily ' al NVT: neuro & vascular status intact no tendon injury J,V anesthesia: local digital block mL ' lidoc 1% 2% epi / bicarb marcaine 0.25% 0.5% LET ? conscious sedation required; see attached 23d template prep: Betadine / nor irrigate washed w/ debrided extensive minimal l *mod. / * 1 ^extensive wound explored undermined o materia removed minimal/mod./extensive ' partially completely "wound margins revised ' pd. /"'extensive multiple flaps aligned foreign y identified repair: Wound closed wit wound adhesive / Dermabond / steri-strips SKIN- # --?=-'0 ny in / prolene / staples / , et ilon ' *SUBCUT- # -0 vicryl ' MUSCLE/FASCIA- # -0 vicryl_ *may indicate intennedia[e repair_? a indicate complex repair- - _ _ - - C PROGRESS Time u changed imp oved re-examined ies vac s m mented initi acture care provided: follow-up on given -Discussed with Dr. -Time will see patient in: office I ED 1 hospital imal head R / L forearm face R / L hand Puncture Wound ch O domen R / L wrist R ! L thigh Cat Bit S t h bac R L le e cra c R / arm R / L ankle - . I R / L foot DISPOSITION- ? home ? admitted ICU/ CCU ? transferred- [:] stable (DENT / PA / NP SIGNATURE -Resident / PA / NP's history reviewed, patient interviewed and examined. Briefly, pertinent HPI is: - My personal exam of patient reveals: __-- Assessment and plan reviewed with resident / midlevel. Lab and ancillary K L I confirm the diagnosis of -Care plan reviewed. Patient will need:- Please see resident / midlevel note for details. T=Tenderness PtT=Paint Tenderness S=Swelling E=Ecchymosis B--Burn C=Contusion Lac=Laceration A=Abrasion M=Muscle spasm PW=puncture wound Physicign_ Signature RTl # turned care over at (0wiu+neu m=mild mod=moderate sv=severe) 1~rumple• Tsv = Tenderness un pulputiou (.revere) _ ^? C ?)? -` •----------------------------------------------, hysicianSignature P RTI# assumed care at XRAYS ?Interp. by me ?Reviewed by me ?Discsd w/ radiologist , mplate Complete ? Additional T-Sheet ? Dictated Addendum _nml / NAD -soft tissue swelling / deficit _no fracture -fracture / dislocation _nml alignment _ COLE •, GRACE L 8 F _nml soft tissue _ 04/28/2001 OTHER =- - - - - - - - - - - - ?See separate report -; =R1 640323 t -------------- ,D GROUP 3636 1 Animal Bite - 21 Rev. 06 / 221 06 Page 2 of 2 64033 01/'11/10 01/25/10 JONES, DALY, COLDREN ASSOCIATES Acct: 3921 Grace Cole DOB: 04/28/2001 Sex: F Age: 8 years Nurse Note: F/U DOG BITES SYMPTOMS: ER F/U FROM SATURDAY, PT WAS ATTACKED BY DOG. PT HAS 11 SUTURES. 01/23/10 - Holy Spirit Urgi-Care-Dog Bite Labs: []Refer to HRQ FORM: []Completed []Paid []Mailed []Picked Up Subjective CC: See above M.A./Nurse note. dog bite - at friends home-bit by bog - lab / huskey mix adults were downstairs: dogs were given a bath. - After bath, dog sw door ope and Grace was in ther and came in a bit her is several places. Grace was not able or unwilling to discuss the specifics- did not push . dog - was -rescued- not sure of initial hx - may have a fighting dog hx. had receive 11 stitches i the ER and was tod so fu in 2 days in primary MD office. HPI: I have reviewed and agree with the history above. Any additions are detailed below. ROS: Y N YN YN YN ? ® Fever ? ® Runny Nose ? ? Cough ? ? Difficulty Breathing ? ®Sore Throat ? ® Ear Pain ? ? Congestion ? ? Poor Eating ? ® Poor Drinking Items not checked did not ? ® Vomiting ? ? Diarrhea apply to this com l i t d ? ? Decreased UOP p a n an , t herefore, were not asked. Current Meds: No Current Medications Allergies: NKDA Objective Wt: 671b Wt Prior: 611b 2oz as of 11/06/09 Wt Dif: +51b 14oz Wt%: 66th T: 98.2 Normal Comments General: Nontoxic, NAD Eyes: No lesions noted ? Grace Cole DOB 04/28/2001 Page #2 Ears: TMs normal ? Nose: No congestion ? Throat: Tonsils symmetric ? No erythema Neck: Supple, min LAD ? Lungs: CTAB ? CV: RRR s1s2 ? no m,r,g GI: SNDNT no HSM ® several -small areas of laceration - closed with several - total of 11 sutures - no sige of infection or swelling .- bies a re located on her left side - over thr shoulder , laeral thorax and left elbow area. Skin: No rashes Neuro: No focal deficits Extrem: Nontender, no edema NOTE: All checked items indicate normal findings. All unchecked items were deferred unless abnormal findings are noted. Assessment #1: E906.0 Bite Dog Comments : multiple dog bit wounds with hx of unprovoked injury, has been seen in the ER with several sutures - no sign of infection at this time. need t monitor closely and FU if any sign of infection - is on augmentin - outlined that needs to be on at least 500 BID for > +5 days. return friday for appointment and probable all or partial suture removal, sooner PRN Plan: Follow Up .(Follow up) Correspond's Letter - Misc Plan Other: Med Current No Current Medications Seen by: JONES, DALY, COLDREN ASSOCIATES 2025 TECHNOLOGY PKWY,STE 108 MECHANICSBURG, PA 17050 (717)-791-2680 January 25, 2010 Patient Name: Grace Cole Date of Birth: 04/28/2001 To Whom It May Concern: Recent dog bite at multiple sites. Please excuse school absence. May return when feeling well. Please excuse from gym and modify recess to avoid physcial exertion or physical contact. If you have any further questions or concerns, please do not hesitate to call me. Sincerely, 01/29/10 JONES, DALY, COLDREN ASSOCIATES Acct: 3921 Grace Cole DOB: 04/28/2001 Sex: F Age: 8 years Nurse Note: F/U DOG BITE SYMPTOMS: F/U VISIT FROM DOG BITE, AND SUTURE REMOVAL. Labs: ? Refer to HRQ FORM: ?Completed ?Paid ?Mailed ?Picked Up Subjective CC: Patient presents for an injury. follow up visit to check sutures from dog bite 6 days ago and see that wound is healing- has been on antibotics and appears to be healing well no fever, no significant pain HPI: Injury. Date of Injury: last sunday dog bite - attack left side and shoulder and lower upper arm Symptoms have improved since onset. Aggravated by movement. wounds have healed pretty well less pain and appear to be healing ROS: Const: Denies constitutional symptoms. General health stated as good. ENMT: Ears: Denies ear symptoms. Nose and Sinuses: Denies nasal symptoms. Mouth and Throat: Denies sore throat. Resp: Denies SOB GI: Denies gastrointestinal symptoms. Musculo: Denies symptoms other than stated above. Skin: Denies bruises and rash. Current Meds: No Current Medications Allergies: NKDA Objective Wt: 671b Wt Prior: 671b as of 01/25/10 Wt Dif: Olb Wt%: 66th T: 98.6 Pediatric Exam: Const: Appears healthy, well nourished and well developed. Weighs within the normal range. No signs of acute distress present. Head/Face: Normal on inspection. Musculo: Skin: Warm and dry with no rash, induration, nodularity or tightening Grace Cole DOB 04/28/2001 Page #2 several small lacerations most with edges well approximated- most sutures removed easily though Grace very fearfull and crying. Has a single area on the anterior lateral chest with a single suture wher the woudn appears to have pulled apart and the sutrue is emmeshed in hte healed crust - is dried but open appearing left arm with a single area with a curved laceration the has 2 sutures still in place that question removal vs leaving an additional few days Neuro: Bright and interactive. Speech is appropriate for age. Sensation to light touch is intact. Reflexes are present and symmetric. Finger to nose was normal. Motor activity is symmetric. Cranial Nerves: Cranial nerves II-XII intact. Psych: Mood is appropriate for encounter. Assessment #1: 879.8 Open Wound (s) (multiple) Unspec Site(s) W/o Comp Comments several sutures removed - initially very fearful but gradually coaxed into allowing removal. has a single area on the back wher the sure appear to hav separated bu is crusted in the scab - soaked but was unabel to remove due to poor cooperatin . has a cresennt shaped cut on the arm that appeared partially healed - left the 2 stitche in and will chec and hopefullly remove on monday -seemed a bit too soon today original antibiotec sompleted will DC for now MS close fu ifworse in any way MS Plan: Assessment #2: E906.0 Bite Dog Plan: Follow Up .(Follow up) Plan Other: Med Current No Current Medications Seen by: 02/01/10 JONES, DALY, COLDREN ASSOCIATES Acct#: 3921 Grace Cole DOB: 04/28/2001 Sex: F Age: 8 years Nurse Note: FOLLOW UP DOG BITE SYMPTOMS: PT HERE FOR DOG BITE FOLLOW UP DOING MUCH BETTER PER MOM, NEEDS TWO SUTURE REMOVER FROM LEFT ARM 01/25/10 - F/U Dog Bites 01/29/10 - F/U Dog Bite 01/25/10 -.JDC O.V. (Checkboxes) Labs: ?Refer to HRQ FORM: ?Completed ?Paid ?Mailed ?Picked Up Subjective CC: Patient presents for an injury. dog bite left side and is healed - here for reassessment and suture removal- is off antibiotics MS HPI: Injury. Date of Injury:1/24- saturday dog bite left side , shoulder and left upper arm Symptoms have shown no change since onset. Aggravated by movement. (Alleviating). (Functionality). ROS: Const: Denies constitutional symptoms. General health stated as good. ENMT: Ears: Denies ear symptoms. Nose and Sinuses: Denies nasal symptoms. Mouth and Throat: Denies sore throat. Resp: Denies SOB GI: Denies gastrointestinal symptoms. Musculo: Denies symptoms other than stated above. Skin: Denies bruises and rash. Current Meds: No Current Medications Allergies: NKDA PMH: Immun/Inj. Record: 90744-Hepatitis B Vaccine Pediatric/Adolescent 01/16/02 06/28/01 04/30/01 90716-Varicella (Chicken Pox) Vaccine 02/23/09 04/17/02 90713-Poliovirus Vaccine Subcutaneous 06/08/06 10/24/02 09/06/01 06/28/01 90707-MMR Vaccine, Live, For Subcutaneous Use 05/02/03 07/24/02 90700-DTaP Vaccine Younger Than 7 06/08/06 10/24/02 11/12/01 09/06/01 06/28/01 90669-Prevnar Vaccine Under 5Yrs 04/17/02 11/12/01 09/06/01 06/28/01 90647-Hib (3 Dose)PRP-Omp Conjugate 07/24/02 11/12/01 09/06/01 06/28/01. Medical Problems: Urinary Tract Infections - Left hydronephrosis Seasonal Allergies - 7/09: Dr H Wang : mild asthma, allergic and perenial rhinitis Grace Cole DOB 04/28/2001 Page #2 Accidents: Dog bite - 1/10: attack at friends home- left side, shoulder, arm Reviewed and updated. Objective Wt: 691b Wt Prior: 671b as of 01/29/10 Wt DR: +21b Wt%: 71st T: 98.5 Pediatric Exam: Const: Appears healthy, well nourished and well developed. Weighs within the normal range. No signs of acute distress present- Is alert and comfortable Head/Face: Normal on inspection. Musculo: SKIN: wounds appear to be healing left anteriior chest has area 7 x 4 mm that was not initially sutures or that suture spontaneously was expelled. is healing by 2 ary intention. Has a similiar more shallow area on the back that is - 10x5mm. left side most anterior area- the area where sutures were removed ther is a separationg of wound of5x3mm remainder of lesions - healing well. removed 2 sutures from medial left upper arm - dressing left inplace on the left side and band aide applied to left upper arm. Neuro: Bright and interactive. Speech is appropriate for age. Sensation to light touch is intact. Reflexes are present and symmetric. Finger to nose was normal. Motor activity is symmetric. Cranial Nerves: Cranial nerves II-XII intact. Psych: Mood is appropriate for encounter. Assessment #1: E906.0 Bite Dog Comments : - removed sutures from arm - at 9 days post injury all sutures Out - no evidence of infection has area on upper left anterior shoulder that is healing by secondary intention see above - recommended avoiding gym and cheer leading until Monday 2/8, shower - not bath and fu pm mother is aware of consideration got plastics visit once well healed MD. Plan: Follow Up .(Follow up) Correspond's Letter - Misc Plan Other: Med Current No Current Medications Correspond's May Return To School Seen by: JONES, DALY, COLDREN ASSOCIATES 2025 TECHNOLOGY PKWY,STE 108 MECHANICSBURG, PA 17050 (717)-791-2680 February 1, 2010 Patient Name: Grace Cole Date of Birth: 04/28/2001 To Whom It May Concern: Healing dog bite. Sutures are now out but stretching may cause wound disruption. Please excuse from gym this week. May return to full activities 2/8/10. If you have any further questions or concerns, please do not hesitate to call me. Sincerely, JONES, DALY, COLDREN ASSOCIATES 2025 TECHNOLOGY PKWY,STE 108 MECHANICSBURG, PA 17050 (717) 791-2680 Today's Date: February 1, 2010 This is to certify that Grace Cole has been under our professional care. Grace was seen in our office on 02/01/2010. She has been out of school 02/01/2010 through 02/01/2010 and will be able to return on 02/01 /2010 . ? was NOT SEEN in our office but parent reports that the patient is ill and has been out of school 00/00/0000 through 00/00/0000 . Physical Education: ® may take ? may not take ? limited: Comments: Physician: ?? ?'$I? 5147 TRAVELERS The Phoenix Insurance Company P O Box 13485 Reading, PA 19612 (800)842-9897 _.? 12/07/2010 P1385 2/06 Frank Lafferty Metzger Wickersham 3211 North Front Street, P.O. Box 5 Harrisburg, PA 17110 Insured: Carol Long Claimant: Grace Cole Claim/File #: 278 LR HCA7242 T Date of Loss: 01/23/2010 Reference #: Settlement Confirmation Dear Frank Lafferty: This letter follows up our conversation of 11/17/2010, at which time 1 made an offer to settle your client's bodily injury case for $$50,000. Please take this offer to your client and advise of a decision as soon as possible. If you have any questions or concerns, please call me. Sincerely, William B Smith Tech Spec (610)736-2512 Fax: (866)418-6923 Email: WSMITH50travelers.com F3162C1d10341005147 00001 N / X?h'31 STRUCTURED FINANCIAL ASSOCIATES 0 Proposal GRACE COLE (4-28-2001) OPTION II Total Deposit: $50,000 Proposal Date: 11-24-10 Purchase Date: 12-15-10 Upfront Cash Benefit Cost Counsel fees & Liens $13,699.67 $13,699.67 Deferred Lump Sum Benefits Age 18 (4-28-2019) $12,448.00 $10,005.43 Age 21 (4-28-2022) $17,448.00 $12,248.50 Age 25 (4-28-2026) $22,448.00 $14,046.40 Structured Settlement Totals: $66,043.67 $50,000.00 Please note that the cost of the attached structured settlement quote is not representative of retail annuity rates and therefore cannot be used as the basis for a cash settlement. Doing so is a misrepresentation of the attached quote and is prohibited. Rates subject to change and require reconfirmation after seven (7) days from the proposal date. Periodic payments guaranteed and tax-free pursuant to IRC 104 to claimant or named beneficiary. `G X ?Bl? 0000 Nov, 1j. 1UIU 1.7UAM rLbli rINMIAL 6tKVIlt6 No, 5509 N. 1 PEBTF Pennsylvania Employees Benefit Trust Fund 150 South Ord Street • Suite 1 Harrisburg, Peruvylvania 17111.5700 ovember 22, 2010 VIA F'ACSIMXLE 234-9478 ONLY Melanie L. Kirk, Paralegal Metzger Wickersham 3211 North Front Street Harrisburg, PA 17110 RE: Grace Cole (minor) Date of Injury: January 23, 2010 ePEB00060017-03 Dear Ms. Kirk: Local 717.561-4750 Toll Free 8=522.7279 www.pebtf.org In response to your two letters to our office dated November 19, 2010, the PEBTF agrees to accept $919.61 to satisfy our lien for the above mentioned case. Also, per your request I have enclosed a copy of the PEBTF Summary Plan Description which details our subrogation rights. There is no Erisa funding therefore we would be unable to provide your office with proof. The PEBTF is a self-funded employee benefit plan that follows Erisa guidelines. If you have any questions, or need additional information, please do not hesitate to contact our office at (717) 565-7442. Sincerely, P Manager, Financial Services Enclosures PEBTF Pennsylvania Employees Benefit Trust Fund 150 South 43rd Street • Suite 1 Harrisburg, Pennsylvania 17111-5700 ®93 March 30, 2010 Melanie L. Kirk, Paralegal Metzger Wickersham 3211 North Front Street Harrisburg, PA 17110 RE: Dear Ms. Kirk: Grace Cole (minor) Date of Injury: ePEB00060017-03 January 23, 2010 Local 717-561-4750 Toll Free 800-522-7279 www.pebtf.org The Pennsylvania Employees Benefit Trust Fund (PEBTF) has identified a subrogation interest in the above-referenced case in the amount of $1,379.42. Enclosed please find the PEBTF Claims Utilization report indicating the medical benefits paid on behalf of Ms. Cole and in support of our subrogation lien. Please advise us if you are prepared to represent the PEBTF's subrogation interest on the basis of a 1 /3 contingency fee arrangement with litigation costs and expenses to be apportioned proportionately. If you have any questions, or need additional information, please do not hesitate to contact me directly at (717) 565-7312. Sinc ely, Phylli . Ulsh Manager, Financial Services Enclosures ro H q 0 00 00 00 00 00 00 00 00 00 00 00 000 H 0 0 w 00000000000000 q 00000000000000 C H (V N NN N N N N N N N N N N o a U ? 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CONTINGENT FEE AGREEMENT I, Nq.A,..A ilk individually and as parent and natural guardian of am m ak , retain and authorize the law firm of Metzger, Wickersham, Knauss & Erb, P.C., to do whatever they deem necessary or desirable in order to represent me and my in all claims for compensation and reimbursement for personal injuries, wage loss, medical expense and other damages resulting from an InA that occurred on .? o - Li 1. ATTORNEY'S FEES: The fee of the attorneys shall be contingent as follows: (a) Twenty-five percent (25%) of gross recovery; (b) SHOULD THERE BE NO RECOVERY BY SUIT OR SETTLEMENT, SAID ATTORNEYS DO NOT HAVE ANY CLAIM AGAINST US OF ANY KIND FOR LEGAL SERVICES RENDERED. 2. EXPENSES OF LITIGATION: I acknowledge responsibility for all expenses incurred on our behalf to pursue our claim/case and my attorney shall be reimbursed out of the balance, after deduction of attorneys fees, of any recovery for all legal expenses which have not already been paid by me. I do hereby agree to pay all expenses incurred by our attorney in the preparation and presentation of this case and do understand that these expenses include, but may not be limited to, costs of medical reports and records, stenographic expenses connected with depositions, expert witness fees, photocopying charges, and mileage charges connected with the rendering of legal services. I understand that I am responsible for payment of these expenses regardless of the eventual outcome of the case and further understand that if our attorney deems it necessary, I may be asked to advance these costs prior to the incurring of any such expenses or the scheduling of any deposition. Page 1 of 3 3. APPEAL: I hereby further agree that our attorney may charge us reasonable additional compensation if it is necessary to try the case more than once, if the case is appealed, or if proceedings in other courts are necessary because of the change of circumstance of a party or for other reasons. 4. AUTHORITY: I hereby further agree that our attorney is hereby authorized to bring suit or to settle and compromise the claim, to execute all documents pertaining thereto, and to do all lawful acts requisite for effecting the claim on our behalf. 5. MEDICAL EXPENSES AND LIENS: I further authorize my attorney to pay out of any proceeds of settlement or trial any unpaid medical bills or liens for treatments or services or workers' compensation liens made necessary by the injuries sustained in this accident, or back child support payments owed to Pa.SCDU. I understand that my attorney is not guaranteeing the payment of any medical bills or liens, and they remain solely my responsibility. 6. INVESTIGATION OF MERITS OF CASE: I agree that our attorney accepts this employment on the condition that he will investigate this claim, and if it appears to be a recoverable claim, he will proceed to handle the claim; but if, after investigation, the claim does not appear to be recoverable, said attorney shall then have the right to rescind this Agreement. 7. EARLY TERMINATION: I hereby further agree that if I decide to terminate this authority before any settlement is offered or any award is obtained the firm shall be entitled to reasonable compensation for all work done on the case up to that point. I agree that reasonable compensation for Francis J. Lafferty, IV, Esquire, or any other attorney involved in the handling of this case, shall be Two Hundred Dollars ($200.00) per hour, and other employees One Hundred Dollars ($100.00) per hour, or such higher rate as shall Page 2 of 3 constitute his/her standard billing rate at the time that the work is performed, or the agreed upon percentage fee in paragraph one of this Agreement, whichever is greater. 8. WITHDRAWAL: I agree that our attorney may withdraw from this case at any time after reasonable notice to us, and I agree to keep him advised of our whereabouts at all times and to cooperate at all times in the preparation and trial of this case, to appear upon reasonable notice for depositions and Court appearances, and to comply with all reasonable requests made of us in connection with the preparation and presentation of this case. 9. CONFLICT: I also understand that if the investigation reveals that a parent is contributorily negligent in causing the accident the attorney's representation will solely be limited to representing the injured minor and there will be no representation of the parent. I also waive any conflict of interest that may arise by my meeting with the attorney to discuss the case. IN WITNESS WHEREOF, I have signed below on thiseX day of 2010. CLIENT: ?- METZGER, RSHA & ERB, P.C. ATTO : Franci ferty , Esquire Page 3 of 3 s ' OF THE PROTOHONOTARY 2011 x l% 12: 52 CUMB`EP,L r0UNTY PEA;,, la rl Q Metzger, Wickersham, Knauss & Erb, P.C. By: Francis J. Lafferty, IV, Esquire Attorney I.D. No. 84009 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 Attorneys for Plaintiffs (717) 238-8187 f 1(i?mwke.com IN RE: CUMBERLAND COUNTY, PETITION FOR APPROVAL OF PENNSYLVANIA SETTLEMENT OF THE CLAIM OF GRACE COLE, a minor, BY JENNIFER COLE and NATHAN COLE, her parents and natural guardians NO. go)(- DOS C-1Vi lTeeW DECREE AND NOW, this ? day of --r ? #77. , 2011, upon consideration of the Petition for Approval of Compromise and Settlement of minor's claim, it is hereby ORDERED that proposed settlement consisting of up front cash and future periodic payment with a present cash cost to Carol Looney's and Kristi Long's insurer, The Phoenix Insurance Company (hereinafter "Insurer"), of Fifty Thousand Dollars ($50,000.00) is hereby approved and that Jennifer and Nathan Cole, as Parents and Natural Guardians for Grace Cole, a minor, is hereby authorized to enter into a compromise of the minor's cause of action upon the following terms: ORDERED that Insurer pay the following amounts: 1. $13,699.67 payable to Jennifer and Nathan Cole as parents and natural guardians of Grace Cole and Frank Lafferty, Esq., their attorney, which will be distributed as follows: a. $12,500.00 to be paid to Metzger, Wickersham, Knauss & Erb, P.C., for counsel fees; 456653-1 b. $280.06 to be paid to Metzger, Wickersham, Knauss & Erb, P.C., as reimbursement for costs and expenses; c. $919.61 to be paid to PEBTF, on behalf of Capital Blue Cross as satisfaction of its lien; 2. The balance of $36,300.33 will be placed in an annuity from Travelers Insurance Company and will be paid to Grace Cole in guaranteed lump sum payments of $12,448.00 on April 28, 2019; $17,448.00 on April 28, 2022; and $22,448.00 on April 28, 2026. ORDERED that Insurer make future periodic payment(s) payable to Grace Cole ("Payee") in the following amount on the following date: 1. $12,448 lump sum payable April 28, 2019; 2. $17,448 lump sum payable April 28, 2022; 3. $22,448 lump sum payable April 28, 2026. The precise future periodic payment amounts may vary slightly when the future periodic payments are ultimately funded, due to interest rate fluctuation and the time sensitivity of the investment. ORDERED that Insurer shall execute a "Qualified Assignment" in compliance with IRC 104 (a) (2) and Section 130 of the Internal Revenue Code of 1986, as amended, to MetLife Tower Resources Group, Inc. ("Assignee") of Insurer's future periodic payment obligation. The Assignee shall fund the obligation for the periodic payments by the purchase of annuity contract from Metropolitan Life Insurance Company. The Assignee shall be substituted as obligor of such payments for Insurer, which shall be released from any further obligation to make said future periodic payments. Assignee shall be the sole owner of the annuity contract. None of the periodic payments (including the Claimant's or Payee's rights to such payments), or any portion thereof, may be accelerated, deferred, increased or decreased, anticipated, sold, assigned, pledged or encumbered by the Payee (or by any other person who becomes a recipient of periodic payments pursuant to the terms of the Qualified Assignment Agreement or by operation of law), except as authorized pursuant to a qualified order under IRC 5891. 456653-1 ORDERED that all parties shall cooperate fully and execute any and all supplementary documents and to take all additional actions which may be necessary or appropriate to give full force and effect to the basic terms and intent of this settlement, including but not limited to the necessary structured settlement documentation. cc William Smith, Travelers Insurance Company, P.O. Box 13485, Reading, PA 19612 led P 1118! l1 K8 V L", Arancis J. Lafferty, Esquire, Metzger, Wicker sham, P.O. Box 5300, Harrisburg, Pa 17110 456653-1