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12-1189
L?12?E824 A???' ?? ?? VA? Ad`s CUMg?R gY4. IN RE: BENJAMIN SHEARS, A PE?? IN THE COURT OF COMMON PLEAS MINOR, BY NICHOLAS AND ANDREA CUMBERLAND COUNTY, PENNSYLVANIA SHEARS, AS PARENTS AND NATURAL GUARDIANS NO.: r,,? ?PETITION FOR APPROVAL OF COMPROMISE SETTLEMENT AND DISTRIBUTION OF PROCEEDS FOR CHILD, A MINOR Petitioners, Nicholas and Andrea Shears, as Parents and Natural Guardians of Benjamin Shears, a minor, aver as follows: The Petitioners are parents and natural guardians of Benjamin Shears, a minor, all currently residing at 6135 Run Cross Lane, Enola, County of Cumberland, Pennsylvania 17025. 2. Benjamin Shears was born on March 29, 1994, and will reach maturity on March 29, 2012. 3. On October 22, 2010, Benjamin Shears was injured in an automobile accident in Silver Spring Township, County of Cumberland, Commonwealth of Pennsylvania. 4. The Volkswagen Jetta automobile in which Benjamin Shears was a passenger was driven by Christopher McCleery, 5845 Aspen Lane, Enola, PA 17025 and the automobile was owned by Jamie A. McCleery, of the same address. Benjamin Shears was a backseat passenger and when the automobile driven by Christopher McCleery collided with an on-coming vehicle. Benjamin was rendered unconscious and without pain response. A copy of the police accident report is attached as Exhibit "A." 1 9 Qom} %l03.?s C?-+t Icy 9 -.5-0 p Wc)7IgS 7SPPd n 6. Benjamin Shears had to be extracted from the Volkswagen Jetta and was transported via Life Lion to the Hershey Medical Center. A photo of the accident scene, after the passengers were extracted, is attached as Exhibit "B". 7. As a direct and proximate result of the accident, Benjamin sustained serious and life-threatening injuries. (See Hershey Medical Center and Penn State Rehab Hospital discharge summaries attached hereto as Exhibit "C".) Benjamin underwent medical treatment for his injuries which cost in excess of $300,000, and which treatment was covered under a health plan that is self-funded by the employer of Nicholas Shears, Benjamin's father and Petitioner herein. 9. Christopher McCleery was insured by Encompass as of the date of the automobile accident. 10. On or about December 15, 2010, Petitioners engaged the law finn of Mette, Evans & Woodside, pursuant to a fee agreement that states the law firm's fee would be calculated at a rate of 20% of gross settlement. (See Fee Agreement attached as Exhibit "D".) 11. Mette Evans & Woodside, among other things, engaged in considerable effort in the prosecution of this claim, gathering Benjamin's medical records; analyzing those records and his injuries; negotiating with Encompass and Gibson & Sharps, who represented Highmark Blue Shield, the plan administrator, which asserted a lien in this matter; engaged in research and negotiation with Encompass; and negotiated the lien asserted by Gibson & Sharps on behalf of Highmark Blue Shield. 12. Mette, Evans & Woodside incurred costs relevant to the obtaining copies of medical records and costs associated with the investigation of this matter in the total amount of $1,265.50. 2 13. As stated, Gibson & Sharps has submitted a treatment lien pursuant to health insurance plan administered by Highmark Blue Shield through Nicholas Shears, employer for reimbursement of treatment costs rendered to Benjamin. The amount of the asserted lien is $138,635.16. (See e-mail of 2/23/12 and plan subrogation language attached hereto as Exhibits "E" and "I"' respectively.) 14. Gibson & Sharps, on behalf of its client, Highmark Blue Shield, has agreed to accept a compromised figure on the lien in the amount of $40,000. (See Exhibit "E".) 15. Encompass, on behalf of the policyholder, Jamie A. McCleery, has agreed to settle this matter for the sum of $90,000 in exchange for a general release of all claims. (A true and correct copy of the proposed release is attached hereto as Exhibit "G".) 16. The Petitioners request that the Court approve settlement and distribution of the Mette, Evans & Woodside Gibson & Sharps Petitioners in trust for Benjamin TOTAL: $19,265.50 ($18,000 + $1,265.50 in costs) $40,000.00 $30,734.50 $90,000.00 17. The Petitioners request that the payment to Petitioners of $30,734.50 in trust for payment of $90,000 to Benjamin as follows: Benjamin be paid without formal appointment of a guardian of the estate of the minor, or entry of security, by the Petitioners, and approve holding the funds in trust for the short period of time until Benjamin reaches the age of majority. 18. Based upon the foregoing, Petitioners consent to this Petition and request this Honorable Court to issue and Order in the form attached hereto as Exhibit "H". 3 WHEREFORE, the Petitioners request this Honorable Court to enter an Order approving the foregoing compromised settlement and directing the distribution of proceeds as set forth herein. Respectfully submitted, METTE, EVANS & WOODSIDE; By:``-' L IMPSON, ES' U 28960 . Sup. 11' 3401 North Front Street P. O. Box 5950 Harrisburg, PA 17110-0950 (717) 232-5000 - Phone (717) 236-1816 - Fax Attorneys for Benjamin Shears, a Minor, by Nicholas and Andrea Shears, as Parents and Natural Guardians Date: February 24, 2012 550962vl 4 e 0tc.20. 2010, 9:19AM SILVER SPRING POLICE rMlU1CJ WuIzs13d0 CDMMOt116'MLFH OF PEFIUSYLVMIA POUCI CASH RP PORTNG FORM Caro Cased Report Me txash AA .50 1 © Yes Ott ¦ Yes O No 1 No. 0848 P. 1/11 rage 1 or 11 iRN9Idi1N ?..? ? kwidm Number palmA en Parr za" SIL2010-10-00639 21212 070 Rama Predrrct kpAwU YYW aftn UM 0W*0D - g Silver Spring Township 10 - 22 • 2010 A rims IA X .Aff*4 nrtw fad PRvW or souk **"row 0735 0737 TODD LINDSAY 2402 Rwlwrsr t Number Oats wOp•YYYY} LEROY L HIPPENSTEEL II 11 • 19 • 2010 Caun Cetm up** Rpu PkWft .*mid I'd Now _ Day Of wiw4 Z 1 bt nand 212 Pilver Spring Township O Sun O Thu _ Crash Dalti {hthip).YYYY} G'asla 71ae me of ttnhs pimple Jn1urW & 41f! all Mon 10 fd O Tue (;)Sal 10 - 22 - 2010 0733 3 7 6 0 roan ? 0 Wed 0 Unk IA?o*wW i m Q Yes f t? ti Q Yes a No w70r* O Yes No lamoTQ Yes tb n ec 4 Way Wvuc i.n O •Y• Irdersaction a O all R&,,p O R W.A Crossing t° ° 00 O -T• kMtmcdon O ? 0 oasan,a O CM.O.'er c 000 T North ? 0 0944 02 45 Q Scutt, street motq street rmd4y O Eau ra ww-t4? 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EtcJ ,3 03.0 rlar +r t>dac *k*AAa t? 9d?ttu m a,g,ry b Hng Unlr 144 A.Minor [ntury 14.Ririne On V41r¢le fxFezior 8+trrjur, tk,fc tS-Sus Vau nger 09aMOt0?ope Eye oya 86.?Bicydis Wsarirtg BbonNCtredF ads 10-Ai lag Not Depkyetk Swft On Sow' 9st odd 9-Lk*rtewo W 9R-U, 1 t sag Nor Deployed Swatch Off 1-ft Fatricated 11-41so w Gep;R, MAric0ed 8r mecluniud wl?arr 3 d By won MKhw scot taea is 1)** Bag brwmeo INW to Crash! 8a 19.1>rA3v*«, H Air lag DYploy'4d Bxdh>fwwn 94-tk+lawrNn EMS Ageruy SILVER SPRING,HAMPDE Madkal Faciity. HERSHEY MEDICAL CENTER, HOLY SPI Writ ft FWUM No Oft of Birth QAOD-YYM A 8 c 3 E F G #i I Walk == O 1 O t 10 - 10 - 1993 1I M7 27 01 03 O 1 D l i L 1 ? ? ..-. ,.^ Nam 1 Address t Mime W.5 TraHS -pa r7 0 ?+ or MCCLEEREY, CHRISTOPHER M 5845 ASPEN LN ENOLA PA 17025 71 Yes ON. Unh No Person Mo Dei.>~e? iof m `? ooaJEE] oE] O1 02 (] 04 23 - 1994 2 M 4 03 0 0 0 Name t Address I PAoae EMTappa San* r [] Opcr w VINCENT SCOTT TERMIN 5835 SPRING TREE CT ENOLA PA 17025 ! Ylaa O No Unit No Parson No D611iaT Date O 1 03 O 03 29 YYYYI A H -1 1 27 Im 19941, ! 06 I: 00 E1Q l J __ ._. Nwnt 1 Address I Phone FMS Tri m"rt ©anr BENJAMIN SHEARS 6135 RUN CROSS LN ENOLA PA 17025 7176915 Yes O &F Birth %"DD-YYM unit Na Person h4 O ? Oe 10 1993 2 F 2? 050 OOE OOF 0 0 Z Nam 0 ? Oae EMS Transport ? Sairle ELIZABETH MCCLEEREY 5845 ASPEN LN ENOLA PA 17025 7177569 +? Yes ONO UnK No Parser No 0010347 Data Rush @AA-DO-yrm A B C D F F G H F Ol OS F ?• 14 - 1994 a F 2 04 03 00 F J1= J . , I'mp i Addrou !!bane 1:MM5 Transport Q operou ANTHONY PESAVENTO 2325 LONGWOOD LN ENOLA PA 17025 717732 IN Yes O Unit O No Oran #a O f D E DI U/ sa at lsktlr lAwM-DC?-vri"r) 56 F11 l_3l? O 1 03 O 1 F E][F?L=J %am / Address J Phone ERAS Transport Same as SPONSLER, DARLENE S 2480 LAMBS GAP RD ENOLA PA 17025 717 operm arcs Nv POOP 1 AAapp(ty" PE NKMO'T 00" http://Www. dot6.state.pa.us/crsappIPrintImageslXmIFiles/2010102644201012200915331... 12/20/2010 Dec.20. 2010 9:30AM SILVER SPRING POLICE runt wvia1JDo CO MMO9t1MALTH OF PENr1I5'1fLVAMA Poua CRASK RVOP.T" FORM Pew AA 5W 3 rotceawro+er -? 1 111 lp W0181360 No, 0848 P. 6/11 rage u of i i Omit mm w I A to liter D E ot+elUnd `dE Apptcabk G 2aPassengat 01.0dwr • Au v J.Pedestrtan 02aFrant Sei, lA+ddle Position OIUQmidar Bd, Used ,=Net E Cad , &h shed 2mT ? Sao#* 03.itont Sea, i<Ight Side n3L-j 03?L;'a And Sltovlder m m ow - Leh SR,e or 9dlnknoswr 04+Second R So m U? 9¦(MkAbWri R? " Umd P O ad Row Side 07-lhltd Atfw bt C tlr S ty ohA Aa Lest Side k e v.ro 1, V. &I* Seat Used hpoperly ? Owp* Sade Not Aqk2ble 0 1Z4wf"t Umd . Z.Mwm* Side Window = T?ifd Maw Or Ck htr . 0$. edZ 3¦ Mratdstsield 09vTN?d mw Or Gleaw • ! t k s li b 1 o di 5=? Berk Door T Aate oAetdnq brrltraayh RnnE Opening (S -000 t A i d I N b* F U an a nx ecper as ca • fax severlw C OsNCt kyursi I t.dn Odw E!Klow t3 n Open.Amts o Ades g m o se CtutMrdZ Top DowN 01.Fr4ttt Air Bey Deplored (Fou Tfks Seau 7_ ft taegh I?4t {)peNryS FCOr?v@rtibla 03;03 Qtiw 7M Ai m Seaq g ( f ? ?" 3eModerate aMd Of Pickup. Etc} fli,dyt ate Ar epsored y,E ry 13.7mli g Unit A r Atlury 14456mg On VW%t* Uhni r J 9;ury. l7nlc 154' asssnger flS?At> trcte Eyes oon 06.W*Iisk we*- ublh"neepa& iO.Ai Bey Abt , 540, on I ?0 ? SetKtrty 9B=0tftet 4=tki4nown if 9g+1:nEnawn 1 h-V Bag AM Deployed Switch Off 1.Not Eat/italad 12-Air Bay Not Deployed; 2+Ea,titated 67f tRethanKal Meaxr, p lit Ualc Sruiach Setting. 1444 Bag bm&*0 to CroA &reed BY Non Madmwal Maass vsk:t 19eUA%rKr# <t n Air Rag Deployed ?tt awn 99=UNkr%7" EPaS Agency. SILVER SPRING,HAMPDE rdedal Fina HERSHEY MEDICAL CENTER, HOLY SPI tMwt No Pwum Na ? rite of Birth (MM-0D•YYY17 A B C 13 E F G H r 63 O 1 O ? F O5--J- 29 M 1972 1 F 4 Ol 03 01 1. , d 1.,?1 Name I Addmu / Pheae SiiiRS Frenepasl 0 ?ewr HARRIS-FRANKS, GINA L 71 PINE TREE LN SHERMANS DALE PA 1 Yes Oko o 0 ? 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The #4ronq 1ti+ay on 9MmQdW P ??g 4ciirae Nc4own ?+=Toot W= 14.g?y OOad. tiowL Eft +tdm 09- IS.Trai(er its 01=6rakt S 1.Wir Strati y L3+5teerutiq System OQ?I i? Ol + 14 x No 3 t ? ?r?nT 11?iillrgrt lE3=TraiiKOytrlrraGed 3 No Ol + 00 t T? T? 02 + 00 x W* 3 4 LL. hKkt ihr 02 0o T F r--a nt , x I ! l k `! n9 6 N N 'O k CI fl pr9 {x 4 pr oon 1vc x g 4e M c 00 -AWQK f vet?eav arar?aaearPriere fictar iirNC tic faaat code rb mt ,.,r? Ol 14 aa ?, na. Run»n?. ??? o7?srandtny 99 we f/8 V t# P s L i 0 0 Q * Q trER it the Mn nFurw o fir t 2 u? d0 Ol ? ry e, hvtrt una No bwd tunertA4,MI' Otlj PMWIDT COPY http://www. dot6.state.pa.uslcrsappIPrintlmageslXmIFiles/20101026442010122009153 31... 12/20/2010 Dec.20. 2010 9:33AM SILVER SPRING POLICE rml Ckc , Gvuiaiso0 ft3MM0MMa? UK OF PEWS1L'tlANIA POUCi LUSH SSG FORM ? AA 544 4 .§-SW ATO _ t P44B51r w ?il1rS 7=F « i,01110AW ~ s4Akle Tmffio ay 7m00M (Ramp kft(300iooj 9dn PAT" LAM 9¦lhaMttomm rot p i4 a 0-Al wC lOm 2-mw on 1 Ralstsw oo Pooa?Yty im0n Tavel Lows y-Msam t-Stw*w 4~irde NOON n 1~ 3mmSU 3=SwIl fw Wry Y?L 1liW: ? i¦Hht r?wee¦r hash mo t 12 ? ? 03 3 0 1 Ahm Pin nier' O itam Ereet 1/R khosO LkIlly We Number y tlaR p!o 1 El =2 [] 0 twin Order 4 ?._.... ? © Unk No ttamr Event Mat Unit No Kota. E4mR O 02 I MFI-t Oi 02 Dope wea yap ryM.ur.? an wNrw yaps ErtyhonearrSat/doadMas. i 00 2 3 FotarrWf Factors fi>'Iq 00¦Nax 11¦? Road Craadtirnts(kerSox} 01sWdxry Cgnditi0rs tts het oa f" CZ*Sud4feniVaaf?e Condhiats 13.tsaifbks t13.Otlttr Weather Corrdliom t4.itroken Or Cradcad Poomnt 0444 in 304may 15¦1tD otstKow 054wade On loado" 16¦5oft 3-44441 or Romer Drop ON amotho NATW h Road" ZB.Oatm RDadr?y Fear PUG)" 29-co. Errdoommtii ficPx z 09-Vkrk Zone ReWed 49¦tiinknwm Aaxstiy 4hidle Failures iM 12s?Voo QD-km 13-•0rirv 91 S1e?1? 14 5=rravDObg y E t 1 ttit tr Oa3+ 4yn 0= 16="Wh!!ts G5¦POrRr irirnl?W 'Q RQCS Ma tlSF -1 F w?a 03 i 00 2 ? 21 12D?e,?T w?hhrda ? ? 1 ? _ ? ?-UrllrY:hND arditaaai A+om flow kksM Nc Potato Cock o°4?m..,m ti w O1 14 ti/d V 8 P O O # Q If Sk h the Mft FWW TM kan 46Wj No biana 5.Fag 7-aa & Foy 1-Wu am &Aoln A Fop s odw omrr+r.?nemue.•?nses 4.91ue11 6 7 01=1 un1 1 M:A olos a dl 3 D" 4 05"u t5 t1 p*m ottw 1tat6c Lind 07:4* Dm 06-M Odd AnhvW o cdwm w Offer Ncn rood Moo 11+5ktd by {kit 1 12-SmA By Unit 2 13¦Srrt,dt Sr tJr,it ? 14;5bsrck 8y Unrt 4 TS¦Sbudr By drat 5 16. wo* $y OSser Toik, 4frtit 21 die Tree or 5kubb" a-00 &dbarkna?N 1 i Mt 14451 Tuf 5qn 2A Coded RBU End 27-oft Curb 28-A Cqw to or 291 fit Y No.0848 P. 8/11 rage u of i 1 1IM1111 Craahidumber W0181360 Kdd Pt rm Ff" AWA Stop 30" Fen[e or wa6 31.1 Buidvg 3t.xir Cuwert 33-A Ibidge Per Or Abutm m 3440 Parapet FM e obsude on Roadway 37d1q WVM AWWOtor 38-A Fire kytaM 39¦9d RadW Egrapmtirt 1301kA rraf9G died 42.Frr1 Shaw Bank 41 ,:,IM", Coroenrtlbn i.r 4WA 06W 49,M Vnbom 50 moeum" ow SuSfru& Sy lhfo" Or Famno 52.PCt Or other Pavemem kreg"ifies S3-ado?le 54=Fire h Vehide so-oft RW.Cda= $9•lftmVA NNT*ftd EVfo.. I 14dacieh ft*q Or tans 15¦P in No Pastrvq Zone 1o.EYrretg Wratp way on 03 t 00 2 3 =.4= rfss?ss 93.trlp oaftfuh, 03 Wed n At fOnWhide Leaving yetick 02 oWAr f AunzimQ 3o9girq (M Mft 9 Unit Na 03 ggAk&fmm FMI rAaoor2M PONWiQGT CO" http://www. dot6. state.pa.uslersappIPrintImageslXmIFiles/2010102644201012200915331... 12/20/2010 8ec.20. 2010. 9:35AM SILVER SPRING POLICE rrmiCKS Wuiaiso0 b 7 COMMONWEALTH Of PENNMVANIA POEyEE CRASH REP09nRG MAN! page AA 500 5 FQW # AA-WV=1A No, 0848 P. 9/11 rage Y oI ii RlNEll CrI_NURA.1 W0181360 S I .. i 3 I ..... 1 l I i I I r I ; J ; f :_ ? I` I T? ? t ? ..._.?....•..,. ....? ,,. i., _{",._ _.. _.....? ...??.,.... .....%•._.._.?..,..._I?...?.......?..._.? E ? f ?W E i I i ? I ?# 1 ?_ t .•?1YiVP: ?? 1 i ' I 1 s i ? _ l .,_ •-w-.......?...-. ....»i... x «kw...,E, ?....??..nl?.«w.4......isw..:ww-.»..tw.-i».....g.«i».?:».,nw....w:M,....t.._..«i..« ?....»,.#.,»...:.i...K... Fr. i x ; ?--' 's 3 E f ' > i ? 's f I i > E ? i r i i i i ' i ff .-,..1 ?..:. k ?...."1 ? R ? ^ ..?w. I w ...-?.I.. v. ? . .?„w.....I.......? _. A ...i.u...5....... ........+ I' f tt VO%m Nome Add Ph= ress MICHAEL SEAVERS 6 K EYSTONE DR MECHANICSBURG PA 17050 7176975717 z J!ia ida and addltWid wkrms m Acddent enrastlgtt3otE "mifkadoa 1W *a • Ps Ity Damage 0 Silver Spring Township Police were dispatched to an auto accident in the area of 6853 Wertzville Rd for an auto accident with unknown Injuries. Upon my arrival I saw there were 3 cars involved. There were several people standing around a blue Volkswagen Jetta that was severely damaged. It was sitting facing southwest in the middle of the roadway. I approached the wreckage and saw there were 5 people in the Jetta. There was a silver BMW that had heavy front end damage that was sitting in front of the Jetta in the eastbound lane (mostly) of travel. There was a female in the drivers seat On the opposite side of the road was a cream colored SW. The rear drivers side door of the SUV had a large dent and blue paint on it There was an older female standing outside of it. I advised county of the situation and requested more EMS units as well as aero-medical. There were a total of 5 people in the car. The front seat passenger was awake and looking around. He looked really dazed and did not say too much. There were three people in the back seat The rear passenger side passenger was leaning over the center passenger which was a female. The female was bent over at the waist with her head stuck between the front bucket seats. I cut the side curtain airbag with my knife in an attempt to get better access to the occupants. I tapped the male that was slumped over the female to try and get a MMIDOT COPY http://www. dot6.state.pa.uslcrsappIPrintImagcslXmIFilcs/2010102644201012200915331... 12/20/2010 Cec.20. 2010 9:36AM SILVER SPRING POLICE No, 0848 P. 10/11 rMl Cr'S ? v U l a 13 b 0 rage l u of 11 ?f?E Q ilrw ? CrasA t?unb?? WNIM147M *0= W0181360 181360 AA SW N z Nw atlw and addWWW VA6=5W response and there was none. I then tried to pull him up to assess his life status butwas unable to. I went to the drivers side rear and saw the rear passenger looking out the window. His eyes were open; he was bleeding from the mouth, moaning and unresponsive. The driver appeared to be trapped by the legs by the dash. His left arm was sticking out the window and he, too, was unresponsive. The passengers side of the car looked like it had been t-boned. I attempted to hold c-spine stabilization on the rear drivers side passenger. At I was doing this a fireman from Hampden arrived. He took over stabilization. I continued to attempt to get a response from the other occupants with no luck (except for the front seat passenger.) As I was doing this EMS personnel started to arrive. I made contact with the driver of the BMW and asked if she was ok. She said that she thought so. I asked if she remembered what had happened. She said she wasnt sure. I told her to remain in her vehicle, locate her drivers license, registration and insurance and that I would be back with her. I then approached the female that was standing by the SUV. I asked her if she was ok and she said that she was. I asked if she knew what happened. She said that she was stopped to make a left onto Beard Rd. (from Wertzville Rd, Westbound). She looked back and saw the car flying up on her. She said that she knew he wasnt going to get stopped but she does not recall what she did after seeing him coming. While I was gathering Information, the front seat passenger, Vincent Termin, was placed in the rear of my Ti police car while EMS was extricating the rest of the occupants from the car, so that he could stay warm. Officer Walters had requested he provide names of the others in the car with him. While I was in the car with him he was very talkative and believed he had a concussion. The nature of his talking was about his injuries. I did ask a few questions about the accident but he was not sure what happened. The county crash team was called to assist with the crash scene. On 1084/101 spoke to Vincent Termin (front seat passenger) at his residence after he was released from a the hospital. He stated that he had some minor injuries, scratches & bruises, but nothing serious. I asked him to tell what happened on Friday morning, the best he could remember. He stated that he walked to Chriss house (driver) so they could ride to school together. This is not a normal occurrence and is, maybe, only the 2nd or 3rd time hes gone to school with Chris. The female, Chriss sister, Elizabeth, (middle, rear passenger) got in the car at the house as did Pez. (Anthony Pesavento, drivers side p me rw?om+9=M I iDOT COPY http://www. dot6.state. pa.us/orsapp/Printhnages/XmIFiles/2010102644201012200915331... 12/20/2010 'Cec.20. 2010. 9:37AM SILVER SPRING POLICE No. 0848 P. 11/11 rani CRC W U 1251300 rage 11 or 11 C0t649 CRAM = OF MUMYLVARA Q W" 111111911 Crah *AMbW ?o 1 0 ffJKM7MG Pam 11 W0181360 AA 50D N ? 2 Mumd . and a"dowl VAbMse : rear passenger). They then went to the other end of the development and picked up Ben Shears (passenger side rear passenger). It was a pretty quiet ride and Vincent said that he was tired and just looking out the passengers side window for most of the ride. He believes that Elizabeth was listening to her Pod & that Pez had an Pod that was plugged into the stereo with a long cord and he was controlling the music they were listening to through the car stereo. He remembers someone saying Chris! Look out! and he turned his head to see the SUV in front of them. He doesnt recall seeing the lights of the SUV being on. He said after the crash happened he remembered looking around the car. He called to several of the others and got no response. He does not recall Chris being on the phone. While talking to him he said that he Doesnt know what distracted him. He stated that Chris was distracted but since he was looking out the window, doesnt know by what County Crash Team to complete diagram & other investigative items. r ffi h it a Poarr ! R11 mail Raul PE+t OT COPY http://www. dot6. state.pa.uslcrsappIPrintlmageslXmIFiles/2010102644201012200915331... 12/20/2010 ?? ??? \?? ??V %. `.?? PENNSTATE HERSHEY 1XT- Milton S. Hershey Medical Center Patient Name: SHEARS, BENJAMIN N MRN: 7508542 Date of Birth: 3/29/1994 Patient Gender: Male Penn State Hershey Tel: (717) 531-8055 Milton S. Hershey Medical Center Health Information Services, HU24 500 University Drive R O. Box 850 Hershey, PA 17033-0850 Visit Number:. 10508542 Visit Type: Inpatient Patient Location: 7ME1; 7214; 1 ......................................................................?............w......................._ ....w....,..?.... .............................u.........?...........................w..............v. Discharge Summary RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: Final .D/C Summary Simmons,Lynn G (11/9/2010 06:37 EST); Engbrecht,Brett W (11/3/2010 08:22 EDT) DISCHARGE SUMMARY Name: SMEARS, BENJAMIN N HMC Number: 7508542 DOB: 03/29/1994 Date of Admission: 10/22/2010 Date of Discharge: 11/02/2010 Reason for Discharge: Transfer to PSHMC Rehabilitation Physician: Engbrecht, Brett W Service: Peds Surgery Discharge Diagnosis: Right Pneumothorax, Bilateral pulmonary contusions, pneumomediastinum, L pubic rami fx, Fracture of L occipital condyle, epidural hematoma with mass effects of the medulla, DAI, L2 articular facet fx, grade 111 liver lac, L hepatic vein injury, grade I splenic lac, hemoperitoneum Other Diagnoses: Acute respiratory failure Aspiration Pneumonia Surgical Procedures: Right tube thoracostomy (32-French right fifth intercostal space, mid axillary line). Inserted and subsequently removed Insertion and subsequent removal of Codman 10-22-2010; 10-27-2010 Diagnostic Imaging: Non Contrast Brain MRI 10127/10 1. Multiple bifrontal intraparenchymal hemorrhages, similar in size to 10/24/2010. Additional foci of hemorrhage identified within the body and splenium of the corpus callosum, as described above. 2. Foci of increased T2 signal in the left cerebral peduncle, and right pons, may represent additional areas of contusion. 3. Small right occipital subdural hematoma. 4. Intraventricular hemorrhage layering in the bilateral occipital horns, unchanged. Date/Time Printed: 2/22/2011 05:55 EST Printed By: Tice,Cindy L Page 1 of 220 PENNSTATE HERSHEY 1T7. Milton S. Hershey iW Medical Center Patient Name: SHEARS, BENJAMIN N MRN 7508542 ,...,..,....,.,.?.....,....,.»,,.,.,,.,,,,,,,,.,,,,.........,.....,,,......,.....r,...,,........,..,..,,, ....,? ...........................,`. ............................ 5. Epidural hemorrhage adjacent to the clivus, similar to 10/24/2010 with mild mass effect on the left brain stem and mild narrowing of the ventral spinal canal at the level of the skull base/C1 junction. 6. Skull base/left occipital condylar fractures, similar to 10/24/2010. CT Head 10/24/10 1. Evolutionary changes of multiple bifrontal intraparenchymal hemorrhages without significant interval growth. Large superior right frontal hematoma appears slightly smaller. No new areas of hemorrhage identified. 2. No significant interval increase in the degree of cerebral edema. 3. Area of epidural hemorrhage adjacent to the clivus appears slightly smaller with decreased mass effect on the adjacent brainstem. MRI C-Spine 10/27/10 1. MultipI0 bifrontai intraparenchymal hemorrhages, similar in size to 10/24/2010. Additional foci of hemorrhage identified within the body and splenium of the corpus callosum, as described above. 2. Foci of increased T2 signal in the left cerebral peduncle, and right pons, may represent additional areas of contusion. 3. Small right occipital subdural hematoma. 4. Intraventricular hemorrhage layering in the bilateral occipital horns, unchanged. 5. Epidural hemorrhage adjacent to the clivus, similar to 10/24/2010 with mild mass effect on the left brain stem and mild narrowing of the ventral spinal canal at the level of the skull base/C1 junction. 6. Skull base/left occipital condylar fractures, similar to 10/24/2010. Vaccinations Received This Hospital Stay: No vaccinations were given this hospital stay. Discharge Medications: 1. Albuterol (albuterol CFC free 90 mcg/inh MDI) 4 puff Inhalation every 2 hours, as needed for Wheezing. 2. Albuterol (albuterol CFC free 90 mcg/inh MDI) 4 puff Inhalation every 6 hours. 3. Docusate (Colace) 50 mg by NJ-tube 2 times daily. 4. Enoxaparin (Lovenox) 30 mg subcutaneously every 12 hours. 5. Lactobacillus acidophilus and bulgaricus (lactobacillus acidophilus and bulgaricus oral granule) 1 packet by NJ-tube every 8 hours. 6. Methadone 5 mg by mouth every 12 hours. 7. Multivitamin with minerals (AquADEKs) 2 mL by NJ-tube every 24 hours. 8. Senna 5 mL by NJ-tube once daily. 9. Acetaminophen-codeine (acetaminophen-codeine 120 mg-12 mg/5 mL oral liquid) 15 mL by NJ-tube every 4 hours, as needed for Pain. (not to exceed 4000 mg acetaminophen per day) 10. Cefuroxime (cefuroxime 125 mg/5 mL oral liquid) See Instructions . 500 mg NJ tube g12h Brief History of Present Illness: 16 year old male who presented with major trauma due to a MVA. R PTX, BL pulm cont, pneumomediastinum, L pubic rami fx, Fracture of L occipital condyle, epidural hematoma with mass effects of the medulla, DAI, L2 articular facet fx, grade III liver lac, L hepatic vein injury, grade I splenic lac, hemoperitoneum. Hospital Course: Date/Time Printed: 2/22/2011 05:55 EST Page 2 of 220 Printed By: Tice,Cindy L PENNSTATE HERSHEY OPM Milton S. Hershey qP Medical Center Patient Name: SHEARS, BENJAMIN N MRN 7508542 ?....? ..................................... ...............?.? .....;Discharge Summary. ,........,................................................................................?...,.. Once in the PICU, an ICP monitor was placed at bedside by neurosurgery. His pressures remained stable throughout the duration of monitoring. He initially required a nifedipine drip in order to keep blood pressures low enough from a neurosurgery standpoint. He did have significant ventilatory requirements the first few days but was gradually weaned down. He did have some dark output from his OG tube and he was subsequently started on protonix and carafate to treat his presumed gastritis. A keofeed was eventually placed and tube feeds initated, only being held for imaging and extubation. Patient was found to have gram negative rods on sputum culture and was subsequently started on antibiotics. ICP was removed and patient had an MRI of the head and neck. MRI showed no worsening mass effect and improved hemorrhage. His keppra was stopped. He was then extubated without complication. After extubation, the patient was cut back on pain medication and became more communicative. He was able to follow commands and verbally communicate with his family. His C/T/Ls were cleared by neurosurgery and he was able to sit up in bed. By PID#7 he still had elevated bilirubin levels and fevers. He was recultured for the fevers, but all returned negative for growth. Sensitivities returned for his pneumonia which was HIB and klebsiella, and therefore continued on cefepime. PID # 10. Fevers could be due to Thorazine. Anthony is really looking around today - talkative at times, but not for staff rounds this AM. He is following commands. On a methadone wean - decreasing to dosing every 12 hours today. Continues with tyelnol with codiene PRN for pain. Self-extubated NJ tube during the night - replaced. Tolerating NJ feeds well, on bowel program. Abdomen soft. bilirubin levels decreasing daily. HIDA Scan did not reveal any bile leak. WC 9.5, HCT 34, NA 150. Continues on Cefuroxime, one more day. T max 38.8. CVL is out - 2 PiVs, sites intact without redness. R chest s/p tube site - non red, open. Xeroform and dry gauze dressing, to change daily. He has a strong moist cough - encouraging coughing/deep breathing with CPT every 4 hours. Lovenox therapy started, venous duplex negative. The patient was allowed to ambulate after neurosurgery approval. Therapist is allowed to get him out of bed. He continues in MJ cervical collar - Ocean back while lying supine. Dr. Bramley, Rehab team continue to evaluate. He is medically stable for transition to inpatient rehab as soon as tomorrow - need insurance verification. Insurance was improved and he was transferred to rehab on 11 /2/2010. Exam on Discharge: GCS 11 Left sided hemiparesis, Left arm>Left leg FC on right side on face NJ in place, feeds infusing Coarse breath sounds, positive cough RRR Abdomen soft and non distended Afebrile with stable vital signs Care Instructions: 1. see the head injury instructions. Supervision at all times to maintain safety. 2. see the spleen injury care instructions. 3. MJ cervical collar - on all all times. Routine care and pad changes, daily and when wet/dirty. No pillow under head when lying supine, may use small pillow under head when lying on your side to keep the head/neck aligned. To remain on a total of 12-16 weeks Only the hard back of the Miami J should be used according to Dr. Dias. Do not use the softer back as its support is limited. 4. R chest tube dressing site - small amount of xeroform covered with 4x4 until healed 5. encourage cough/deep breathing. Oral suctioning PRN. 6. NJ with routine care/flushes. Benjamin can be fed NG, it does not need to be in the small intestine 7. Elimination - dipaered, dependent . Last stool - 10-31 8. Wash all abrasion slncisions with soap/water. Dry and apply a thin layer of bacitracin twice/day until healed. 9. NO NSAIDS - ibuprophen, aspirin, aleve, celebrex, etc, this will delay bone healing Date/Time Printed: 2/22/2011 05:55 EST Page 3 of 220 Printed By: Tice,Cindy L PENNSTATE HERSHEY FX7 Milton S. Hershey W Medical Center Patient Name: SHEARS, BENJAMIN N MRN 7508542 ».»`»...»........»......,.....» ...............»,.»....,.».,......,.. »..»..................Discharge`Summary».»..»,»,».,»,,,.», .......».».».....»...,.....»........... ».. »» »..»........ You will have follow-up appointments scheduled with: orthopedics (Dr. Reid) In @ weeks, will need to be transported back to Hope Drive if still @ Select/PSHMC rehab; pediatric surgery, and neurosurgery (Dr. Dias) teams. If they are not listed below, please call to confirm , or call the pediatric surgery office at 717-531-8342. Neurosurgery and pediatric surgery appointments may be scheduled for after discharge from inpatient rehab. Please call us sooner it issues arrise. Diet Guidelines: NJ - Nutren 1.0 with 4 scoops of Adult Benepro daily (6 g Protein per scoop) Rate 75 mis per hour for 24 hours ORAL: Sips of thin water/ice chips via teaspoon, sitting upright only . Oral feeding advances to be determined by ongoing speech therapy. Activity Guidelines: pelvic fractures - may be weight bearing as tolerated. Liver/spleen injury - may be OOB with therapy team as tolerated. No contact/impact activites (IE jumping). Must wear the cervical collar at all times. - work on Range of motion of all lower extremity joints to include achilles stretching return to school - to be determined by the rehab team/ongoing progression Call your doctor if: Call your doctor with questions regarding your Orthopaedic Surgery - Call with any questions concerning increased pelvic pain, numbness or tingling or any questions you feel necessary - Monday - Friday 8am-4:30pm Call (717) 531-5638 - Ask to speak to Carol Forsyth CRNP - Evenings or Weekends call the hospital operator (717) 531-8521 and ask for the Orthopaedic resident on call to be paged for pediastric surgery questions, please call the pediatric surgery office at 717-531-8342. Can make Pediatric Surgery appointment same day as another provider post rehab. for Neurosurgery questons and follow up 717-531-4191 Follow up Dr. Dias in 6 weeks. Other Instructions: Penn State Children's Hospital Injury Prevention Tips - Teen Driver Safety 1. ALWAYS travel with your lap and shoulder seat belt, snugly fastened. 2. Never ride or drive under the influence of alcohol or drugs. 3. Obey posted speed limits. 4. Avoid distracted driving - using cell phone or texting, eating, adjusting the climate or music controls. When children are seriously ill or injured, they and their families may feel upset/worried. These feelings are common, normal and can continue after returning home. Visit aftertheinjury.com for interactive tools and quick tips to help recovery. Follow-Up Appointments: Scheduled Penn State - Hershey Appointments Within the Next 90 Days. Date/Time Printed: 2/22/2011 05:55 EST Page 4 of 220 Printed By: Tice,Cindy L PENNSTATE HERSHEY 1 Milton S. Hershey Medical Center Patient Name: SHEARS, BENJAMIN N MRN 7508542 .......... ................................?...... ......Discharge Summary. w ...,.. ., a.........,....., ....., ...... 1. Follow-Up with Radiology EC at Orthopaedics East Campus on 11/17/2010 at 08:00 am 2. Follow-Up with Reid, Spence at Orthopaedics East Campus on 11/17/2010 at 08:30 am Follow-U12 Imaging Studies Orthopaedic Surgery Follow up Please call (717)531-5638 to confirm your follow up appointment f/u with Dr. Reid in 2 weeks with x-rays of the Pelvis. AP only 30 Hope Drive; Building B, second floor Suite 2400 Hershey, Pa 17033 362230 Electronic Signature on File CC: James E Mosher, MD 2025 Technology Parkway Suite 108 Mechanicsburg PA 17050 Electronically Reviewed/Signed by. Lynn G Simmons, MSN, CRNP Author Signature Dt/Tm:09.11.2010 06:37 AM Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Brett Engbrecht, Kerry Fagelman, Dorothy Rocourt, Mary Santos Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP, PNP-BC Lynn Simmons MSN CRNP Electronically Reviewed/Signed by. Brett W Engbrecht, MDCosigner Signature Dt/Tm: 03.11.2010 08.22 AM Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Brett Engbrecht, Kerry Fagelman, Dorothy Rocourt, Mary Santos Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP, PNP-BC Lynn Simmons MSN CRNP LGS/CR DD: 11102110 DT: 11/0211016:23 Date/Time Printed: 2/22/2011 05:55 EST Page 5 of 220 Printed By: Tice,Cindy L NDSRPTPRT HOSPITP'• Penn St Hershey Rehab DATE12/06/2010 PHYSICI. DISCHARGE SUMMARY REPORT TIME: 11:52:22 DISCa ARGE DATE: 11/30/10 PAGE: 1 Physician: BRAMLEY HARRY Patient: 7700018 MR#: 1617 SHEARS BENJAMIN N Admit Date: 11/02/10 Room/Bed: 1047/A Admitting Diagnosis: TBI ----------------- --------------------------------------------------------------- PHYSICIAN DISCHARGE SUMMARY: REASON FOR ADMISSION: Multiple trauma with closed head injury with diffuse axonal injury, multiple bifrontal intraparenchymal and intraventricular hemorrhages, left occipital condyle fracture, epidural hematoma, left hemiplegia, solid organ injuries involving grade 3 liver laceration and grade 1 splenic laceration, and resolving pulmonary contusion with right pneumothorax. HOSPITAL COURSE: The patient is a 16-year-old Caucasian male who was admitted from Penn State Hershey Children's Hospital following a motor vehicle crash which occurred on October 22, 2010. He was admitted at a Rancho level 3, early 4, with a cervical collar in place for a period of 3 months for the left occipital condylar fracture stabilization. On admission, the patient was significantly fatigued with no movement of his left arm or leg. He was intermittently alert and responsive and made steady cognitive gains within the first week consistent with Rancho level S. At that time, he appeared robotic with a bland affect, was making unusual and confabulatory statements and demonstrated significant processing deficits. He was slow to initiate movements and had delayed responses to commands. His verbalization was limited to single word responses to questions. By November 10, 2010, the patient was beginning to talk with brief responses and more complete sentences, but continued with significant fatigue which limited his participation in therapies. He exhibited minimal movement of his left hand, actively moving only his thumbs and extending his fingers. Because of moderate truncal weakness with deviation to the left weaker side, he required moderate to maximum assistance to sit at the side of the bed. On November 17, 2010, he was seen by Dr. Reed at the Orthopaedic Clinic and had a pelvic x-ray which was negative and required no further follow up. Baclofen was utilized for about two weeks due to clonus of his left ankle inhibiting ambulation. This clonus resolved as his left leg strength improved and the baclofen was subsequently removed. He complained of increased left knee pain greater than baseline and exhibited hyperextension of the left leg with some buckling. Initially, a previously used left knee sleeve was utilized from an injury he incurred about two years ago. On discharge, this was changed to a Neoprene left knee sleeve orthotic with patellar stabilization. The knee pain had greatly diminished as the muscle strength of the left leg improved and his knee sleeve was utilized for support. within a two weeks period, Ben had increased left sided functional level with increased left arm movement and began to participate during activities of daily living with minimal to moderate assistance. Upon discharge, his balance had greatly improved and he was stable, although cautious, with his gait. Cognitively, Ben had very poor eye contact initially and was easily distracted. His attention and mood improved as his discharge became more eminent, although distraction and impaired attention of new learning are ongoing issues. His speech became more fluent and engaging with a brighter affect. By discharge, he was conversing more easily in complete sentences, initiating conversation and had some self-recognition of his memory and problem solving deficits. His parents were actively involved in his rehabilitation and very supportive of the goals set forth by the team. They had requested that his weight not be rechecked because of previous weight loss post injury. They expressed concern that further weight loss would depress him as this was something he had been NDSRPTPRT Physician: Patient: Admit Date: Room/Bed: HOSPITAT-: Penn St Hershey Rehab DATE12/06/2010 PHYSICI: DISCHARGE SUMMARY REPORT DIME: 11:52:22 DISC,..,& B DATE: 11/30/10 PAGE: 2 BRAMLEY HARRY 7700018 MR#: 1617 11/02/10 1047/A SHEARS BENJAMIN N Admitting Diagnosis: TBI -----------------------------------------------------------------------•--------- working on prior to the injury. Ben was able to go for a therapeutic home visit last weekend and spent an overnight stay in his home. No barriers were identified by the family at that time for his discharge. His parents were feeling ready to take him home and felt that he would be able to maneuver the steps at least once a day to return to bed and that they could ensure his safety. On October 30, 2010, prior to admission at the Penn State Hershey Rehabilitation Hospital, a Duplex scan had been completed because of an ongoing fever and some "hot spots" noted on his lower extremities. His right thigh was also larger than the left at that time which family contributed to previous muscle building of right leg after left leg injury. No DVTs were identified with that Duplex and DVT prophylaxis with Lovenox was initiated. On November 8, 2010, the patient's right thigh was notably larger than the left, as well as left pedal edema was noted. Therefore, a repeat venous Duplex scan was done of the bilateral lower extremities. The results indicated that there were four areas within the right lower extremity common femoral vein that were occluded. No DVTs were identified in the left lower extremity or the popliteal veins. Therefore, therapeutic anticoagulation was initiated with Lovenox and subsequently transitioned to Coumadin. The most recent INR on November 26, 2010 was reported at 2.99 with the current dose of Coumadin 7.5 mg p.o. daily. Mild pedal edema persists and varies with the patient's activity level and dependent position. In regards to nutrition, the patient was admitted receiving nasogastric feeds and was transitioned to mechanical soft with thick liquids within the first week as dysphagia improved. He quickly progressed to a regular diet and thin liquids with resolution of dysphagia and exhibited a good appetite. Constipation was controlled with the current bowel program medications. As noted previously, his parents did not wish to have him re-weighted, but his admission weight here was 131 pounds or 59.6 kg and was noted to be 150 pounds prior to admission. MEDICATIONS ON DISCHARGE: Coumadin 7.5 mg p.o. daily. Senna 17.2 mg p.o. daily. Colace 100 mg p.o. every 12 hours. Acetaminophen 650 mg p.o. every 4 hours p.r.n. pain. DISCHARGE DIAGNOSIS: Closed head injury with improving frontal lobe dysfunction with ongoing deficits (impulsivity, attention, focus, retention of higher level learning/skills, and short term memory). Left occipital condylar fracture, stabilized with cervical collar for three months. Right lower extremity deep vein thrombosis in common femoral vein. Resolving left hemiplegia with premorbid left knee pain, increased with left-sided weakness. Constipation. CONDITION ON DISCHARGE: 1. Cognitively: The patient was discharged in good condition at a Rancho level 7. He required ongoing supervision due to mild deficits in selective attention, immediate memory, problem solving, executive functions, visual spatial skills. He is independent with ADLs after set up. 2. Mobility: He was able to ambulate up to 150 feet to a quarter mile with supervision only. He is permitted to use a wheelchair as needed for longer distance. He is able to go up and down stairs with a contact guard and a hand rail. He was able to walk on treadmill for ten minutes at 1.5 mph. 3. Safety: He has an ongoing need for 24 hour supervision due to remaining impulsivity and impaired safety awareness. NDSRPTPRT HOSPITPT: Penn St Hershey Rehab DATE12/06/2010 PHYSICI. DISCHARGE SUMMARY REPORT TIME: 11:52:22 DISC.r,ARGE DATE: 11/30/10 PAGE: 3 Physician: Patient: Admit Date: Room/Bed: BRAMLEY HARRY 7700018 MR#: 1617 11/02/10 1047/A SHEARS BENJAMIN N Admitting Diagnosis: TBI --------------------------------------------------------------------------------- RECOMMENDED FOLLOW-UP: No contact or impact activities as outlined by previous medical team. Adult supervision at all times to maintain safety. Educational support with home bound education and reintegration into the school as tolerated. Home bound instruction will be provided until January 6, 2011 and then a partial class schedule is recommended. The length of class time will be recommended by Dr. Ramer. He must wear the cervical collar at all times. When he is riding in a car he must have a high head rest elevated and secured with a shoulder lap restraint. He will continue anticoagulant therapy for DVT treatment and follow up with Dr. Unger for ongoing management. A neurocognitive evaluation is scheduled with Dr. Christopher Royer in one month. Dr. Royer's office will call the family with the date and time. Appointments scheduled: Brain Injury Clinic with Dr. Ramer on December 20, 2010 at 2 p.m. Neurosurgery Clinic with Dr. Dias on December 6, 2010 at 10:45. Pediatric Surgery Clinic with Dr. Brett Engbrecht on December 9, 2010 at 12 noon. Outpatient therapies to include occupational therapy, speech therapy, and physical therapy three times per week at Health South Life Program. Electronically signed by Myra Popernack, CRNP at 12/02/2010 11:44:17 DIET: *** N/A *** CASE MANAGEMENT DISCHARGE SUMMARY: Recommended Follow-Up Services: OP Therapy Other Primary Caregiver Post Discharge: Parents Discharge Destination: Own home Electronically Signed By: Martha Esoldo, RN at 11/30/10 15:08:00 PHYSICAL THERAPY DISCHARGE GOAL AND SUMMARY: Functional Status at Discharge: Transfers: supervision Ambulation: .25 miles with close supervision for safety related to cognitive deficits and navigating around environmental obstacles. Stairs: up and down four stairs x 3-4 trials with one handrail and supervision Treadmill x 10 minutes at 1.5 miles per hour Anticipated or Recommended Equipment: Assistive device and a platform rolling walker Electronically Signed By: Amy Flinchbaugh, PT at 11/30/10 07:40:00 OCCUPATIONAL THERAPY DISCHARGE GOAL AND SUMMARY: Functional Status at Discharge: ,NDSRPTPRT Physician: Patient: Admit Date: Room/Bed: HOSPITPT- Penn St Hershey Rehab DATE12/06/2010 PHYSICI. DISCHARGE SUMMARY REPORT TIME: 11:52:22 DISC= RGE DATE: 11/30/10 PAGE: 4 BRAMLEY HARRY 7700018 MR#: 1617 11/02/10 1047/A Admitting Diagnosis: TBI SHEARS BENJAMIN N -------------------------------------------------------------------------------- Patient requires set up/ supervision for dressing and grooming. Tub and car transfers required contact guard or close supervision. Patient requires supervision for toileting and bathing. Patient requires superision of eating. Patient is demonstrating some visual perceptual deficits especilly in figure ground. Anticipated or Recommended Equipment: tub seat grab bars wheel chair Electronically Signed By: Donna T Skelton, OT at 11/30/10 07:45:00 SPEECH THERAPY DISCHARGE GOAL AND SUMARY: Functional Status at Discharge: A significant degreee of progress was achieved during his admission to rehab. Tasks have been completed to maximize level of cognitive linguistic functioning. He has been completing high difficulty level abstract tasks. Reviewed internal retention strategies and he chose visualization as a technique he initially wanted to try. He was able to recall five pieces of related information without prompt for 8/10 stimulus sets. He was able to generate meaning to idiomatic phrases with greater insight this day, being able to verbalize the abstract component on 8/10 trials. The remainder of the session was spent in reviewing his home exercise program, which included tasks for alternating and divided attention, inductive / deductive reasoning and internal/external retention strategies. He was able to complete three to five examples for each item and complete independently. His dysphagia has resolved. A home exercise program, which included tasks for alternating and divided attention, inductive / deductive reasoning and internal/external retention strategies, visual comprehension, visuospatial skills, numerical reasoning and problem solving, and flexibility of thinking was provided and reviewed. He will be receiving a home tutor prior to return to school. Additionally, he will benefit from ongoing short term intensive speech therapy on an outpatient basis. He will be participating in a program at Health South in Mechanicsburg. Anticipated or Recommended Equipment: paper and pencil tasks Electronically Signed By: Heather Noll, SLP at 11/30/10 16:29:00 PHYSICIAN SIGNATURE: DATE: .Z /U ?G?' ?/? ?? ??? DEC-15-2010 WED 11:37 AM V- ISLE SYNTEC FAX NO. 717'''50361 P. 02 POWER OF ATTORNEY AND FEE ARRANGEMENT THIS AGREEMENT, is made this t Snday of Rem 2010, by and between Nicholas and Andrea Shears ("Clients") of Enola, PA and Mette, Evans & Woodside, Harrisburg, PA ("Attorneys'), Clients, as parents and natural guardians of Benjamin Nicholas Shears, hereby retain Attorneys to represent, appear and act for Clients acting as Attorneys for the purpose of providing such services and/or bringing such proceedings as may be necessary to prosecute the causes of action arising from a motor vehicle accident that occurred on October 22, 2010 which injured Benjamin Nicholas Shears, at or near Wertzville Road, Cumberland County, Pennsylvania. Clients empower Attorneys to file such legal action as may be advisable in their judgment. Clients shall pay Attorneys, as Attorneys' fees for such representation, a sum equal to 20 percent of whatever may be recovered before the case goes to trial and 33-1/3 percent after the case is listed and certified for trial. Clients further agree that, in addition to the Attorneys' fees, ail costs and expenses, including expert witness' fees, incurred in investigating, preparing, or litigating these claims shall be guaranteed by Clients, with payment and reimbursement to be made from the net proceeds of recovery, if any. That is, costs and expenses Oil be paid by the Clients from the sums remaining after Attorneys' fees are paid. Attorneys shalt not receive any fee for their services in the event there is no recovery of any sums by settlement or verdict except that Clients shall pay the above-mentioned costs and expenses. Clients empower Attorneys with full power to make any inquiries, to negotiate, bring, conduct, prosecute, sue or compromise and settle, with Clients' approval, any claim, action 533182vi DEC-15-2010 WED 11:37 AM C ISLE SYNTEC FAX NO, 71" 50361 P. 03 or suit, and to exercise and endorse any papers or orders on Clients' behalf in connection therewith. Attorneys shall be entitled payment for time expended on the case in the event Clients discharge them or obtain a substitute attorney before such settlement is made or judgment is had. Clients agree that they shall not settle or compromise the claim without the written consent of Attorneys. Please be advised that it is Matte, Evans & Woodside's policy to retain Client files for a period of five (S) years following termination of a matter, at which time the file will be destroyed. Prior to the destruction, you may forward a written request for the return of the file, which we will provide you at no additional cost except for postage or shipping charges, provided that all sums due and owing the firm are paid in full. Upon closing of the file, the firm will attempt to return to you, at your last address with our firm, any original documents contained in the file. No other notice will be provided prior to the destruction of the file. 2 DEC-15-2010 WED 11:38 AM C ISLE SYNTEC FAX NO, 71' 50361 P, 04 IN WITNESS WHEREOF, Attorneys and Client have set theirs hands and seals the day and year aforesaid, WITNESSES: (SEAL) METTE, EVANS & WOODSIDE l BY: (SEAL) BY: J I SEAL 3 ALL STATE LEGAL SUPPLY CO. ONE COMMERCE DRIVE, CRANFORD, NEW JERSEY 030 w EDIi£ Message Simpson, Kathryn From: Robert Keisler [rlk@GibsonSharps.com] Sent: Thursday, February 23, 2012 2:05 PM To: Simpson, Kathryn Cc: Derek P. Shawley; Robert Keisler Subject: RE: Ben Shears; Event Number 7337438-7340510 RE: Your Client: BEN SHEARS Health Plan: HIGHMARK BLUE SHIELD Event Number: 7337438 - 7340510 Date of Injury: 10/22/2010 Ms. Simpson, Page 1 of 2 Please allow this email to serve as confirmation that the above referenced plan and Healthcare Recoveries have agreed to accept your offer below ($40,000.00) as satisfaction of the plan's right to be reimbursed from your client's recovery as indicated earlier. I would ask that you send $40,000.00 me at the above address as soon as possible. The check should be made payable to the order of Healthcare Recoveries (Tax ID# 61-1141758), subrogation agent for the health plan. Please also put the above event number on the face of the check. Please have someone from your office call my paralegal, Derek at 800-230-1049, and he can give them further instructions in that regard when you are ready. Upon receipt of the funds, the plan's lien and claim will be fully resolved for all past and future accident-related medical claims (the current claim/lien total is $138,635.16). I have appreciated your professionalism in the resolution of this matter. Should you have any questions, please do not hesitate to contact me or my paralegal. Thank you. Bob Robert L. Keisler, Esq. IBSO SR S Alter at Law 9420 Bunsen Parkway - Suite 250 1 Louisville, KY 40220 800.893.9539 502.214.4970 1 Fax 502.214.6126 Derek Shawley, Legal Assistant 1800230.1049 1 dshawleyra,,eibson-sharoslaw.com Gibson i Sharps, P.S.C. intends that this electronic message be used exclusively by the individual or entity to which it is addressed. This message may contain information that is privileged, confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering the message to the intended recipient, be aware that any disclosure, dissemination, distribution or copying of this coirununication or the use of its contents, is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and delete the original message from your e-mail system. Thank you. Zixsecure 2/23/2012 ?/ ??? L THE PREFERRED PROVIDER ORGANIZATION HEALTH BENEFITS PROGRAM QCC Insurance Company (Hereafter called "the Claims Administrator") Genesis HealthCare PPO-NAI-BC Revision date: 1.10 When the Claims Administrator needs to obtain consent for the release of personal health information, authorization of care and treatment, or to have access to information from a Covered Person who is unable to provide it, the Claims Administrator will obtain consent from the parent, legal guardian, next of kin, or other individual with appropriate legal authority to make decisions on behalf of the Covered Person. Consumer Rights Each Covered Person has the right to access, review and copy their own health and membership records and request amendments to their records. This includes information pertaining to claim payments, payment methodology, reduction or denial, medical information secured from other agents, plans or providers. For more information about accessing, reviewing or copying records, call Member Services at the toll-free number on your ID card. Limitation Of Actions No legal action may be taken to recover benefits prior to 60 days after notice of claim has been given as specified above, and no such action may be taken later than two years after the date Covered Services are rendered. Claim Forms The Claims Administrator will furnish to you or to the Group Contractholder, for delivery to you, such claim forms as are required for filing proof of loss for Covered Services provided by Non-Preferred Providers. Timely Filing The Claims Administrator will not be liable under the coverage unless proper notice is furnished to the Claims Administrator that Covered Services have been rendered to a Covered Person. Written notice must be given within 20 days after completion of the Covered Services. The notice must include the date and information required by the Claims Administrator to determine benefits. An expense will be considered Incurred on the date the service or supply was rendered. Failure to give notice to the Claims Administrator within the time specified will not reduce any benefit if it is shown that the notice was given as soon as reasonably possible, but in no event will the Claims Administrator be required to accept notice more than two years after the end of the Benefit Period in which the Covered Services are rendered. The above is not applicable to claims administered by Preferred Providers. Employee/Provider Relationship a. The choice of a Provider or choice of treatment by a Provider is solely yours. b. The Claims Administrator does not furnish Covered Services but only makes payment for Covered Services received by persons covered under the Claims Administrator. The Claims Administrator is not liable for any act or omission of any Provider. The Claims Administrator has no responsibility for a Provider's failure or refusal to render Covered Services to a Covered Person. Subrogation In the event any service is provided or any payment is made to you or your covered Dependent under this Plan, the Claims Administrator shall be subrogated and succeed to your rights of recovery against any person, firm, corporation, or organization except against insurers on policies of insurance issued to and in your name. You or your covered Dependent shall execute and deliver such instruments and take such other reasonable action as the Claims Administrator may require to secure such rights. You or your covered Dependent may do nothing to prejudice the rights given the Claims Administrator without the Claims Administrator's consent. 3.2-55 You or your covered Dependent shall pay the Claims Administrator all amounts recovered by suit, settlement or otherwise from any third party or his insurer to the extent of the benefits provided or paid under this Claims Administrator and as permitted by law. The Claims Administrator's right of subrogation shall be unenforceable when prohibited by law. Coordination Of Benefits This Plan's Coordination of Benefits provision is designed to conserve funds associated with health care. The following provisions do not apply to prescription drug coverage when provided through endorsement to the Group Program Document. 1. Definitions In addition to the Definitions of this Plan for purposes of is Provision only: "Plan" shall mean any group arrangement providing health care benefits or Covered Services through: a) individual, group, (except hospital indemnity plans of less than $200), blanket (except student accident) or franchise insurance coverage; b) the Plan, health maintenance organization and other prepayment coverage; c) coverage under labor management trusted plans, union welfare plans, Employer organization plans, or Employee benefit organization plans; and d) coverage under any tax supported or government program to the extent permitted by law. 2. Determination of Benefits Coordination of Benefits (COB) applies when an Employee has health care coverage under any other group health care plan (Plan) for services covered under this Plan, or when the Employee has coverage under any tax-supported or governmental program unless such program's benefits are, to the extent permitted by law, excess to those of any private insurance coverage. When COB applies, payments may be coordinated between QCC and the other Plan in order to avoid duplication of benefits. Benefits under this Plan will be provided in full when QCC are primary, that is, when QCC determine benefits first. If another Plan is primary, QCC will provide benefits as described below. When an Employee has group health care coverage under this Plan and another Plan, the following will apply to determine which coverage is primary: a) If the other Plan does not include rules for coordinating benefits, such other Plan will be primary, b) If the other Plan includes rules for coordinating benefits: 1) The Plan covering the patient other than as a Dependent shall be primary. 2) Except for situations where the parents of a child are separated or divorced, the plan of the male parent is primary. 3.2-56 L' Llz:?? Claim Number: Z0168134 HE RELEASE OF ALL CLAIMS - MINOR READ CAREFULLY BEFORE SIGNING FOR AND IN CONSIDERATION OF THE PAYMENT TO ME/US AT THIS TIME OF THE SUM OF NINETY THOUSAND DOLLARS ($90,000.00) the receipt of which is hereby acknowledged, I/we the undersigned, the father and mother and/or guardian of Benjamin Shears, a minor of 17, do hereby release, acquit, and forever discharge, Christopher Mccleerey & Jamie & Earl Mccleerey Jr. & Encompass Indemnity Co, and Encompass Indemnity Company and all other person(s), firms, and corporations who might be liable of and from any and all actions, causes of actions, claims, demands, damages, costs, loss of service, expenses and compensation on account of, or in any way growing out of, any and all known and unknown personal injuries and property damage which we may now or hereafter have as parents and/or guardian of said minor, and also all claims or rights or action for damages which said minor has or may hereafter have, either before or after he/she has reached his/her majority, resulting or to result from the accident, casualty, or event, which occurred on or about the 22nd day of October, 2010, at or near Intersection Of Wertzvilie Rd And Beard Rd in the city of Mechanicsburg, in the state of PA. And in further consideration of the above payment i/we do hereby agree to indemnify and hold harmless the said persons to be released and insurance company, of and from all loss, damage and expense by reason of said accident, casualty, or event should any claim, demand or suit therefore be brought by or on behalf of said minor child either before or after he/she has reached his/her majority. It is further understood and agreed that this settlement is the compromise of a doubtful and disputed claim, and that the payment made is not to be construed as an admission of liability on the part of the party or parties released, by whom liability is expressly denied. I/We further state that I/We have carefully read the foregoing release and know the contents thereof, and that I/We sign it as my/our own free act. CAUTION! READ BEFORE SIGNING IN WITNESS WHEREOF, I/wE have hereunto set my/our hand and seal this day of Witness Address Witness Address Claimant Address Si#ned, sealed and delivered in the presence of {LS} Page 1 of 2 Claim Number: Z0168134 HE ACKNOWLEDGMENT BEFORE NOTARY PUBLIC OR COMMISSION OF DEEDS STATE OF COUNTY OF On the date of the execution of the Release before me personally came said Claimant known to me to be the individual(s) described in and who executed this Release, and acknowledged that fully understand(s) its contents and meaning and duly executed the same as his/her/their free act and deed for the sole consideration expressed. My Commission Expires: (Seal) RETAIN A COPY FOR YOUR RECORDS Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and the payment of a fine of up to $15,000. Page 2 of 2 r- Rv, i EO All?l IN RE: BENJAMIN SHEARS, A IN THE COURT OF COMMON PLEAS MINOR, BY NICHOLAS AND ANDREA CUMBERLAND COUNTY, PENNSYLVANIA SHEARS, AS PARENTS AND NATURAL GUARDIANS : NO.: ?101 d -//?9 ) 3: N i 0 a, C- Z!c ORDER -` LD - AND NOW, this day of ; v r ` c, / , 2012, in consideration of P do 'rs' } Petition for Approval of Minor Compromised Settlement and Distribution of Proceeds, and for good cause shown; It is hereby ORDERED, that Petitioners' Petition for Approval of Minor Compromised Settlement and Distribution of Proceeds is GRANTED and that Petitioners are authorized to execute the release of behalf of the Minor, BENJAMIN SHEARS, and that the proceeds shall be disbursed in the manner consistent with the Petition; and it is further ORDERED that the ?CZ?t.tano--- settlement to be paid by Encompass on behalf of ' ,shall be paid as follows: An immediate cash payment in the amount of $90,000.00 to Mette, Evans & Woodside, in trust, to be distributed in the following manner: $19,265.50 to Mette, Evans & Woodside for fees and costs; $30,734.50 to Nicholas and Andrea Shears to be held in trust for Benjamin Shears; and $40,000.00 to Gibson & Sharps for reimbursement of Petitioners' employer's self-funded health insurance plan BY THE COURT: `?` ry