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HomeMy WebLinkAbout04-06-15 ANNUAL REPORT OF GUARDIAN OF THE PERSON COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,PENNSYLVANIA ORPHANS' COURT DIVISION Estate of Carmen Arce ,an Incapacitated Person No. 881 of 2014 I. INTRODUCTION Keystone Guardianship Services was appointed ® Plenary ❑ Limited Guardian of the Person by Decree of Albert H. Masland, J., dated 11/6/14 © A. This is the Annual Report for the period from November 6 2014 to December 31 , 2014 (the "Report Period"); or ❑ B. This is the Final Report for the period from , to , (the "Report Period"), and is filed for the for the following reason: {> ' "d ZT- L''fhe death of the Incapacitated Person. Date of death: C-- <-)2,:.-;The Guardianship was terminated by the Court by Decree of LU LU co Uj ;- �" J., dated cs ►- mac, tz cn C= c v r co w W a,. o - � W c5 UP For a Final Report, omit Sections II through IV.. Form G-03 rev. 10.13.06 Page 1 of 4 Estate of Carman Arce ,an Incapacitated Person II. PERSONAL DATA Age of the Incapacitated Person: 48 Date of Birth: January 5, 1966 III. LIVING ARRANGEMENTS A. Current address of the Incapacitated Person: Golden Living West Shore Room 806 770 Poplar Church Road Camp Hill, Pa moil B. The Incapacitated Person's residence is: ❑ own home/apartment ® nursing home ❑ boarding home/personal care home ❑ Guardian's home/apartment ❑ hospital or medical facility ❑ relative's home(name,relationship and address) other: C. The Incapacitated Person has been in the present residence since 12/24/13 If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: Farm G-03 rev. 10.13.06 Page 2 0£4 Estate of CarmanArce, .an Incapacitated Person D. Name and address of the Incapacitated Person's primary caregiver: Skilled Care Staff at Golden Living West Shore Room 806 770 Poplar Church Road Camp Hill, Pa 17011 IV.MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person areas follows: See detailed list of Allergies, Diet, Diagnosis and Medicines Attachment"A" B. Specify what, if any, social, medical,psychological and support services the Incapacitated Person is receiving: See list following as Attachment"B" V. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: ® continue ❑ be modified ❑ be terminated Form G-03 rev.10.13.06 Page 3 of 4 L Estate of Carman Arce ,an Incapacitated Person The reasons for the foregoing opinion are: Carmen is unable to care for herself due to the progression of Cerebral Palsy. She is receiving socialization and has made friendships within the staff of Golden Living and the other services available as listed on the Attachment`B"of this report. B.During the past year,the Guardian of the Person has visited the Incapacitated Person 5-8 times with the average visit lasting 15 to 45 minutes The report of a social service organization employed by the Guardian to oversee and coordinate the care of the Incapacitated Person for the period covered by this Report may be attached to supplement this Report. I verify that the foregoing information is correct to the best of my knowledge, information and belief,and that this Verification is subject to the penalties of 18 Pa. C.S.A. § 4904 relative to unsworn falsification to authorities. Date Si lure of Guardian of the Person Constance E.Stoneroad Name of Guardian of the Person(Ope or print) PO Box 804 Address Elizabethville,Pa 17023 City,State,Zip 717-265-4056 Telephone Form G-03 rev. 10.13.06 Page 4 of 4 ATTACHMENT "A"- . Facility GL-West Shore[00285] Pharmacy AlbfaRX Physician KUNKLE,THOMAS Allergies penicillins ivp dye shellfish seafood Diet Regular diet Dysphagia texture,Thickened Liquid Honey consistency Unscheduled wOthW Ofders METHICILLIN RESISTANT PNEUMONIA DUE TO STAPHYLOCOCCUS AUREUS(482.42),IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY,UNS(337.00),ESOPHAGEAL REFLUX(530.81),UNSPECIFIED INFANTILE CEREBRAL PALSY (343.9).METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS SEPTICEMIA(038.12).CHRONIC DEPRESSIVE PERSONALITY DISORDER(301.12),OTHER SPECIFIED MENTAL RETARDATION(318),OTHER FORMS OF EPILEPSY AND Medical Conditlons RECURRENT SEIZURES(345.8),NEUROGENIC BLADDER,NOS(596.54),URIC ACID NEPHROLITHIASIS(274.11),ILEOSTOMY STATUS(V442),POSTTRAUMATIC STRESS DISORDER(309.81),PHLEBITISBTHROMBOPHLEB DEEP VEINS LOWER EXTREM(451.1),CONTRACTURE OF JOINT OF MULTIPLE SITES(718.49),OSTEOPOROSIS(733.0),DECUBITUS ULCER(707.0),UNSPECIFIED PLEURAL EFFUSION(511.9),OTHER OPEN FRACTURE OF LOWER END OF FEMUR (821.39),DEPRESSIVE DISORDER NOT ELSEWHERE CLASSIFIED(311),UNSPECIFIED PSYCHOSIS(298.9),MULTIPLE SCLEROSIS(340),UNSPECIFIED HYPOTHYROIDISM(244.9),UNSPECIFIED QUADRIPLEGIA(344.00) A&IIII ed Directive Full Code Schedule for Thu Fri Sat Sun Man T1s Wed Thu Fd Set Sun Mon TUG Wed Thu Frl Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon T. Wed Thu Fri Set Jan 2015 Hours 1 2 3 4 5 6 7 B 9 10 11 12 13 14 16 18 17 18 19 20 21 22 23 24 25 28 27 28 29 30 31 Ability Tablet 6MG(ARIPipramle) 0800 J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J Give 1 tablet by mouth one time a JA00 id JA00 JA00 JA00 JA00 ANA6 JA00 JA00 sm sm ANA6 JA00 JA00 JEW4 JA00 JA00 JA00 AAD1 LW1 LW1 JA00 JAOD dt AAD1 ANA6 JA00 JA00 JA00 JEW4 JA00 ay related to DEPRESSWE DISORDER NOT ELSEWHERE CLASSIFIED(311) -Order Date- 1029I2014 2220 Aspirin Tablet 81 MG aeoD J X J X J x J X J X J X J X J X J X J X J X J X J X J X J X J Give 1 tablet by mouth one time a JA00 JA00 JA00 ANAs JA00 sm JA00 JEW4 JA00 IAA'11 LW1 JA00 AAD1 JA00 JA00 JA00 ay every other day for CAD -Order Date- 121O120141417 Cek XA Tablet 10 MG(Ci alopram WOO JAJ00 J J J JJJ J J AJ A00 J JJ 7 d J sm sm NA6 JA00 JA00EW4JA00A0A1 1WJJ AJ BOJ Hydrobmmide) J JJJ A00ADWJA00 EW4 JA00 Give 1.5 tablet by mouth one time a day related to DEPRESSIVE DISORDER NOT ELSEWHERE CLASSIFIED(311) -Order Dete- 122420141533 Chart Codes/Follow Up Codes InIt Name Signature h* Name Signattn Nam Signature —Follow Up Codes— 5=LOA J=Administered 6=NauseatedNomiting Chocked By 1st 1=Ineffective 7=Other I See Nurse Notes E=Effective8=pulse below 60/min Chedod BY 2nd U=Unknown 9=Sleeping y B H=On Hold By Physician 10=Toilafing Did not Occur Chedoed"7 11=Resident Discharged -ChartCodes- 12=Resident Deceased MEDICATION ADMINISTRATION 0110M016-01/31/2015 1=Away from home with meds RECORD ARCS,CARMEN(46161) 2=Drug Refused 3=HcldlSes Nurse Notes 4=Hospitalized Admit Date 1 12/24/2013 1 DOB 1 01/05/1966 Unit Wing'D' Room 00806 Bed F 1 Printed on:Feb 2,2015 at 14:09:53 EST ARCE,CARMEN(46161)-Page:1 of 11 Fadlity GL-West Shore[00285) Pharmacy AlbtaRX Physician KUNIaE,THOMAS Allergies penicillins ivp dye shellfish seafood Unscheduled 'Otheri'Orders Advanced Directive Full Code Shcedlde for Thu Fd Sat Sun Mon Tue wed Thu Fri Sat Sun Mon Tus Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Jan 2015 Hours 1 2 3 4 5 6 7 B 8 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 tDd 31 Magnesium Hydrobde Suspension J J J J J 400 MG/1oML J J J J J J J J J J J J J J J J J J J J J J J J 2000 CMR CMR CMR CMR CMR ALMi 3 ALM1 ALM1 3 ALM1 ALM1 ALM1 ALM1 SDC6 SDC6 3 ALM1 ALM1 3 SDC6 sm sm SDC6 3 SDC6 DWZ DW2 ALM t AADt ALM1 ALMt ALM1 DW2 Give 30 ml by mouth at bedtime for Constipation -Order Date- 10/29/2014 2305 Melatonin Tablet 1 MG J J J J J J J JJJJJJJJ JJJJGive 1 tablet by mouth atb&Mme 2000 ALM1 CMR ALM1ALM1 CMR ALM1 ALM1 jAL`M1 JALM1 SDC6 SDC6 CMR JALMIIALMI CMR SDC6 sm sm ISDC6 CMR SDC6 DW2 DW2 ALM1 AAD1 ALM1 ALM1 ALM1 DW2 udh DW2 for Supplement 3 3 3 3 3 -Order Date- 10/292014 2307 Multivitamins Tablet Chewable J J J J J J J J J J J JAJ00AJDLJ 1 LWJ t A0AOD dJ AAJD1 ANJA6 JAJ00 JAJ00 JAJ00 JEJW4 JAJ0 00800 A00 NA6JA00 A00EA00 JA00 WJJtleVlmfn6Mieras) 0JJ6J W(Multip40JJ J 0 A Give 1 tablet by mouth one time a day for Supplement -Order Date- 10292014 2237 Protonbt Tablet Delayed Release 080 J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J 0 MG(Pantoprazole Sodium) JA00 jd JA00 JA00 JAOD JA00 ANA6 JA00 JA00 sm sm ANA6 JA00 JA00 JEW4 JA00 JA00 JA00 AAD1 LWt LW1 JA00 JA00 dt AAD7 ANA6 JA00 JA00 JA00 JEW4 JAOo Give 1 tablet by mouth one time a ay related ID ESOPHAGEAL REFLUX(530.81) -Order Date- 10292014 2318 Chart Codes/Folow Up Codes Inst Name Signature Ink Name Signature Name Signattms - —Follow Up Codes— 5=LOA Checked By 1st J=Administered 6=11auseatedAromiting ]=Ineffective, 7=Other!See Nurse Notes E=Effective 8=Pulse below 60/min Checlmd BY 2nd U=Unknown 9=Sleeping CheckedHen Hold By Physician 10=Toileting Did not Occur W 3M 11=Resident Discharged —Chart Codes— 12=Resident Deceased MEDICATION ADMINISTRATION 01/01/2015-01/31/2015 1=Away from home with meds Resident ARCE,CARMEN(46161) rRECORD=Drug Refused 3=Ho1d/See Nurse Notes =Hospitalized Admit Date 12/24!2013 1 DOB 1 01/05/1966 1 UnitWing'D' Room 00806 Bed 1 Printed on:Feb 2,2015 at 14:09:53 EST ARCE,CARMEN(46161)-Page:2 of 11 Facility GL-West Shore{00285] Pharmacy AlixaRX Physidan KUNta E,THOMAS Allergles penicillins ivp dye shellfish seafood UnscInduled "Other"Orders Adyanoed DireCtiye Full Code SCtladull@ Hours Thu Fd Sal Sun Man Tue Wad Thu Fri Set Sun Mon TUB Wad Thu Fd Sat Sun Mon Tue Wad Thu Fd Sat Sun Mon Tus Wbd Thu Fd Sat Jan 2015 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Synthroid Tablet 25 MCG J J J J J J J J J J J J J J J J J J J J J J J J J J J J J ANM ANM ANM ANM ANM (Lswthyroodne Sod0600 ium) AIMS AIMS SML4 SML4 9 AIMSJ SML4 g AIMS AIMS AIMS dt 9 AIMS AIMS AIMS SML4 SML4 AIMS AIMS AIMS g AIMS AIMS AIMS 9 AIMS AIMS AIMS AIMS nd Give 1 tablet by mouth one time a ay related to UNSPECIFIED HYPOTHYROIDISM(244.9) -Order Date- 11042912014 ate- 1042912014 n4 0 Doxycycline Hydate Capsule 100 0800 J J J ANA6 JA00 J J J AJ JJ 0JA00JEJW4JAJ00JJ 0AJ 0AJ J J JJ JD1 ANJA6 JAJ00 JAJ0JAJ00JJ JFJW4 JAJ0 0MG JA00 id JA00JA00JAJ00J J Give 1 capsule by mouth two times J MCM J J J J J JJ J J J JJ Jday for Chronic Infection 1600 CMR CMR CMR CMRALM7 3 ALM1 ALM1ALM1 LM LM SDC6 SDC6 3 ALM1 ALM 3 SDC6 sm sm ISDC6 3 SDC6 DW2 DW2 ALM1 AAD1 ALIM ALM1 ALM1 JA00 udh DW2 -Order Date- 12/0120141309 Ferrous Sulfate Tablet 325(65 Fe) 0800 J J J J J J 0J AJDtAJAJJ 0JAJ00JJ 0JJ 4 JAJ0 01J0MG A0A0A0JA00AA00 m smAJJOJJ0JEN4 A00 A00A00A1LWLWt JAO0 JA0dt NA0A0EVJJ0J AOA0 Give 1 tablet by mouth two times a J JJ J J ay for Supplement 1600 J CMR J J CMR J J J J CMR J J CMR J J J J CMR J J J J J J J J J J J ALM', 3 JAIL.M1 ALM1 3 ALM1 ALM1 ALM1 JALM,ISDIC61SDqC61 3 ALM1 ALM1 3 SDC6 sm sm SDC6 3 SDC6 DW2 DW2 ALM1 AAD1 ALM1 ALM1 ALM1 JA00 udh DW -Order Date 10292014 2248 LaFACtal Tablet 200 MG J J JJ JJ JJ JJ JJ JJ JJ JJ 4J JJ JJ J id 080 JA00 JAO0 JAO0 JAO0 JAO0 ANA6 00 Sm sm ANA6 JAO0 JAO0 JEW4 JAJJ00 JAJJ00AJJ AAJJD1 LWJJ 1 LWJJ 1 JAJJ00 JAJJ00 dt AAJJD1 ANJJA6 JAJJ00 JAO0 JAJJ00 JEW4 JAJJ0 0 Give 1 tablet by mouth to times a ay related to OTHER FORMS OF 160 CMR ALM1 ALM1 CMR CMR ACMR CMR A 3 ALM1 ALM1 ALM1 ALM1 SDCDC6 LAJSDC6 sm sm SDC6 SDC61 DWDW2 ALM1 AAD1 ALM1 ALM1 ALM1 JAO0 udh DW2 EPILEPSY AND RECURRENT 3 33 SEIZURES(345.8) -Order Data- 10292014 2244 Chart Codes/Follow Up Codes Init Name Sowltae InIt Name Signature Name Signature —Follow Up Codes— 5=LOA Chedwd By 181 J=Administered 6=Nauseated/Vomiting 1=Ineffective 7=Other/See Nurse Notes heclied E=Effective 6=Pulse below 60/min C' By 2nd U=Unknown 9=Sleeping H=On Hold By Physician 10=Toileting Did not Occur Chedwd"�p., 11=Resident Discharged -Chart Codes- 12=Resident Deceased MEDICATION ADMINISTRATION 01/01/2015-01/31/2015 1=Away from home with medsRECORDResident ARCE,CARMEN(46161) 2=Drug Refused 3=Hok1/See Nurse Notes 4=Hospitalized Admit Date 1 12/24/2013 1 DOB 1 01/05/1966 1 Unit wing'D' Room 00806 lied 1 Printed on:Feb 2,2015 at 14:09:53 EST ARCE,CARMEN(46161)-Page:3 of 11 Facility GL-West Shore[00285] Phamracy I AlixaRX Physician I KUNKLE,THOMAS Allergy penicillins ivp dye shelif h seafood Unscheduled "Offal Orders Advanced Directive Full Code Schedule for Ttw Fri Sat S. Mon T. Wed I Thu Fd Sat Suri Mon T. Wed Thu Fri I Set I Sun Mon T. VV d Thu Fri Sat Sun I Mon Tua Wed I Thu Frf Sat Jen 2015 Hours 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 16 19 20 21 22 23 24 25 26 27 28 29 30 31 Semen Tablet 8.6 MG 0800 J 44 J J J J J J J J J J J J J J J J J J J J J J J J J J J J (Sennosides) JAOO jd JA00 JAQO JAOO JAOO ANA6 JAOO JA00 sm sm ANA6 JA00 JA00 JEW4 JA00 JA00 JAOD AAD1 LWi LW1 JA00 JA00 dt AAD1 ANA6 JAOO JAOO JAOO JEW4 JA00 Give 1 tablet by mouth two times a JJ J J J ay for Constipation 1600 J CMR J J CMR J J J J J J CMR J J CMR J J J J CMR J J J J J J J J J J J -Order DeteLMi 3 ALMi ALM1 3 ALM1 ALM1 ALM1 ALM1 SDC6 SDC6 3 ALM1 ALM1 3 SOC6 sm sm DC a SDC6 DW2 OW2 ALM1 AAD1 ALM1 ALMi ALMI JA00 udh DW2 10/292014 2308 antafardrte HCI Tablas 75 MG 0800 J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J Give 1 tablet by mouth two times a JA00 jd JAOO JA00 JA00 JA00 ANA6 JA00 JA00 sen sen ANA6 JA00 JAOO JEW4 JAOO JAOO JA00 AA01 LW1 LW1 JAOO JAOO dt AAD1 ANA6 JA00 JA00 JA00 JEW4 JAOO ay related to DEPRESSIVE J J J J J J J J J J J J J J J J J J J J J DISORDER NOT ELSEWHERE 1600 CMR CMR CMR CMR CLASSIFIED(311) ALM1 3 JALMIJALM,ICMRI 3 ALM1 ALM1 ALM1 ALM1 SDC6 SDC6 3 JAL'MIIAL'Mi 3 SDC6 sen sm SDC6 3 SDC6 DW2 DW2 A 4 1 AAD1 ALM LM LM1 JA00 udh OWL -Order Date- 10292014 2311 buterol Sulfate Nebulization min 15 10 TDJA001JAO0 15 is 10 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 10 is 15 15 12 15 lutlon(2.5MG13ML)0.083% -- _ -- -- 1 -- -- — -- — -- -- 1 -- _— — -- _ __ 1 via[Inhale orally via nebulizer J J J J J J J J J J J J J J J J J J J J J J J J J ree times a day for SOB 0800 JAOO jd JA00 JA00 ANA6 JA00 JA00 sm sm ANA6 JA00 JAOO JEW4 JA00 JAOO JAOO AAD1 LW1 LW1 JAOO JA00 dt AAD1 ANA6 JAOO JA00 JA00 JEW4 JAOo Hier Date- 102912014 2233 mitt 15 10 15 15 10 15 15 15 15 15 15 15 20 15 15 15 15 15 15 15 15 15 15 10 15 15 15 12 15 1200 J J J J J J— J J J J J J J J J J J J J J J J J J J J J J J JA00 jd JAOO ANAS JAOO JAOO sm sen NA6 JA00 JA00 JEW4 JA00 JA00 LW1 AAD1 LM JA00 JAO0 JAOO dt AAD1 ANA6 JAOO JAOO JAOo JEW4 JAOO min 15 10 15 15 15 15 15 15 15 15 15 15 15 [151 20 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 1600 CMR CMR CMR CMR J GMRALM1 3 ALM1 ALM1 3 ALMt ALMI ALM1 ALM1 SDC6 SDC6 3 ALM1LM3 SDC6 sm Sm SDC6 3 SDC6 DW2 DW2 ALMI AADi ALM1 ALMt ALM1 JA00 udh DW2 Chart Codes/Follow Up Codes [nit Name Signature Init Name Signature Name Stgromm Follow Up Codes— 5-LOA - J-Administered 6=1,lauseatedNomiting Cheftd By 1st 1=lnefrective 7=0ther I See Nurse Notes E=EHecfivo 8=Pulse below 60/min Chedind By 2nd J=Unknown 9=Sleeping H=On Hold 8y Physician 10=Toileting Did not Occur ChedoOd By 3rd I I-Resident Discharged •• —Chart Codes— 12=Resident Deceased MEDICATION ADMINISTRATION0110V2015-01!31!2015 =Awa gy from home with meds �� Residerd ARCE,CARMEN(46161) 3-Hold/See Nurse Notes 4--Hospitalized Admit Date 1224!2013 DOB FO1/05/1966 1 Unit Wing'D' Room 1 00806 Bed I 1 Printed on:Feb 2,2015 at 14:09:53 EST ARCE,CARMEN(46161)-Page:4 of 11 Faali!)r GL-West Shore(00285) Pharmacy Al(xaRX Physician I KUNnE,THOMAS Anergies peniciAins lyp dye sheafish seafood Unsdteduled "Other"Orders Advanced Directive Full Code ScItiedtile fOf Thu Fri Sat Sun Mon Tue Wsd Thu Fri Sat Sun Man Tue VWd Thu Fd Set Stn Man I T. I Wbd Thu Fri I Set Sun Mon T. VWd Thu Fd Sat Jan 2015 Hours 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Baclofen Tablet 10 MG 0800 J JJ J J J J J J J J J J J J J J J J J J J J J J J J J J J J Give 0.6 tablet by mouth three JA00 jd JA00 JAOO JAOO JAOO ANA6 JA00 JAOO sm sm ANA6 JAOO JAOD JEW4 JAOO JAOO JAOO AAD1 LW1 LW1 JAOO JAOO dt AAD1 ANA6 JAOO JAOO JAOO JEW4 JAOO mea a day related to J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J CONTRACTURE OF JOINT OF 1200 JAOO jd JAOO JAOO JAOO JAOD ANA6 JAOO JA00 sm sm ANA6 JAOD JAOO JEW4 JAOO JAOO LW1 AAD1 LM JAOO JAOD JA00 dt AAD1 ANA6 JAOO JAOD JA00 JEW4 JA00 MULTIPLE SITES(718.49) J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J -Order Date- 1W0 CMR CMR CMR CMR CMR 1029120142228 ALMi 3 ALM1 ALM1 3 ALM1 ALM1 ALMi ALM1 SDC6 SDC6 3 ALM1 LM1 3 SDC6 sm sm SDC6 3 SOC6 DW2 OW2 ALM1 AAD1 ALM1 ALM1 ALM1 JA00 udh DVV2 Enteral Feed order Day 7 J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J every shift Continuous Jevtty1.6at JAOO jd JAOO JAOO JAOO JAOO ANA6 JAOO JAOO sm sm ANA6 JAOO JAOO JEW4 JAOo JAOO JAOD AAD1 I LWt LWt JAOO JAOO dt AAD1 ANA6 JAOO JAOD JA00 JEW4 JAOO tlmubourfor 1440coto provide J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J 160 calories. Eve ALM1 CMR ALM1 ALM1 CMR ALM1 ALM1 JALM1 ALM1 SDC6 SOG6 CMR ALM1 ALM1 CMR SDC6 sm sm SDC6 CMR SDC6 DW2 DW2 ALM1 AAD1 ALM1 ALM1 ALM1 JAOO udh DW2 -Order Data. 3 3 3 3 3 11106120141600 J J J J J J J J J J J J J J J J J J J J J J J J JNght SMSMANM ANM ANM ML4 SL4MAIMSANM AIMSAIMS ANMAIMS 9 AIMS SML4 9 AIMS AIMS AIMS dt 9 AIMS AIMS AIMS S9 AIMS 9AIMS AIMS AIMS AIMS not MW S pengn Tablet 600 MG J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J Give 1 tablet by mouth three times JAOO jd JAOO JAOO JA00 JAOD ANA6 JAOO JAOO sm I sm ANA6 JAOO JAOO JEW4 JA00 JA00 JAOD AADi LW1 LW1 JAOO JAOO dt AAD1 ANA6 JAOO JAOO JAOO JEW4 JAOO day related to IDIOPATHIC J J J J J J J J J J J J 102913 J J J J J J JJ JJ J J J J JJ JJ J JJ0 JAWJJO 2oPERIPHERAL AUTONOMIC 1200 JAO0 jd JAOOJA00 JAOO JAOO ANA6 JAOO JAOO sm sm ANA6 AO AO JAOD JAOO LW1 AA01 LW1 JAOO JAOO JAOO dt AAD1 ANA6 JAOO EUROPATHY,UNS(337.00) Order Date 1600 R J MJ J J J CMR 20142230 LMALM ALM11 ALM1 ALM1 ALMi SDC6CJ M1 SDCsm sm SDC6 SDC6:DW2 LAL4MIAADALM1 ALM1 DJ J J MJJ 3ARJ JJ ALM1 ALJ 3 Chart Codea_!F0110W Up Codes ht Name Signe me Inst New Signahme Name Signattae Follow Up Codes— S=LAA =Administered 6=NauseatedNomiting ChedWd By let 1=1nefrective 7-Other/See Nurse Notes E=Effective B=Pulse below 601min Ched(ed By 2nd U=Unlafavm 9=Sleeping H=On Hold By Physician 10-Talfeting Did not Occur Chedued By 3rd 11=Ras1dent Discharged Chart Codes— 12=Resident Deceased MEDICATION ADMINISTRATION 01!0112015-01/312015 1=p==Away from me with meds used RECORD Resident ARCS,CARMEN(46161) 3-HokVSee Nurse Notes =Hospitalized Admit Date 12124/2013 1 DOB 0110571966 Unit Wing'D' Room 00806 Bed t Printed on:Feb 2,2015 at 14:09:53 EST ARCE,CARMEN(46161)-Page:5 of 11 Facility GL-West Shore[00285] Phamiacy I A6xaRX Physician KUNKI.E,THOMAS Allergies penicillins ivp dye shellfish seafood Unscheduled "Otherl Orders Admoed Directive Full Code Schedule for Thu Fri Bet Sun Man T. Wed Thu Fri Bet Sun Mon Tue W d Thu Frl Sat Sur Man T. Wed Thu Fn Set Sun Mon TI, Wed Thu Fri Sat Jan 2015 Hqurs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 18 20 21 22 23 24 25 26 27 28 28 30 31 Monitor 02 sat q shift 02 Seta 92 97 92 95 94—I 92 95 92 94 97 95 97 93 93 95 90 93 93 96 91 94 �90 93 95 96 95 93 94 90 �92 90 very shift Date- 1012912014 1551 OayT J OO id JA00 JA00 JACO JA00 ANA6 JA00 JA00 sm, m ANA6 JAOO JAOO JEW4 JA00 JAOO JA00 01 L91ILW�1 J 00 JACO dt AAD1 ANA6 JACO JACOJ J J JAOO JEW4 JAOO 02 Sets 92 96 94 92 92 93 93 93 96 93 94 97 92 93 96 94 96 96 93 93 92 93 94 96 96 94 95 92 91 9J3 92 CMR CMR CMR CMR CMR A ]ALM1 ALM1 ALM1 ALM1ALM1 SDC6SD6 ALM1 ALMSDC6 sm DC6 D2 DW2 ALMAAD1 ALM1ALM1 ALM1 OW2 udh DW2 J Eve3 ALM1 LM3 W 3 3 3 3 J 02 Sets 95 96 96 92 94 94 93 95 97 95 96 95 95 96 97 95 97 96 95 97 94 95 96 97 93 96 96 95 94 96 91 ►�9llt ANM ANM ANM ANM ANM AIMS SML4 SML4 $ AIMS SML4 AIMS AIMS AIMS dt 9 AIMS AIMS AIMS SML4 SML4 AIMSAIMS AIMS 9 AIMS AIMS AIMS 9 AIMS AIMS AIMS AIMS nd MWS. Chart Codes/Follow Up Codes knit Name s4non Inst Name Signature Name ftnatm Follow Up Codes-- 5=LOA .� _ J=Administered 6=NauseatedlNomiting Checked B 1st 1=1neRective 7-Other I See Nurse Notes E=Effective 8-Pulse below 60/min Checited By 2rW U=Unknown 9-SNMping H--On Hold By Physician WTo3eting Did not Occur CiheCkW By 3rd 11=Resident Discharged ---Chart Codes--- 12-Resident Deceased MEDICATION ADMINISTRATION 01/01/2015-01/31/2015 1=Away from home with reds RaWard ARCE,CARMEN(46161) =Drug Refused 3=Hoid/Sea Nurse Nous 4=Hospitalized Admit Date 12/24/2013 DOB 01/05/1966 Unit Wing'D' Room 00806 Bed 1 Printed on:Feb 2,2015 at 14:09:53 EST ARCE,CARMEN(46161)-Page:6 Of 11 Facility GL-West Shore(00285] Pharmacy AlbtaRX I Physician KUNKLE,THOMAS Allergies penMilins ivp dye shellfish seafood Unscheduled "Other"Orders Advanced Directive Fun code Schedule for Thu Fd set sun men T. wed Thu Fd Sat Sun Mon T. VV d Thu Fit Set Sun Mon TUB Wed Thu Fd Sat Sun Man Tue Wed Thu Fd Sat Jan 2015 Hiwrs 1 1 2 3 4 5 8 7 8 9 10 11 12 13 14 15 16 17 18 18 1 20 21 22 23 24 25 26 27 28 29 30 31 S q shift BP 132/ 108/ 122/ 119/ 122/ 106/ 114/ 129/ 124/ 119/ 126/ 122/ 127/ 126/ 104/ 118/ 121/ 120/ 128/ 102/ 117/ 127/ 112/ 118/ 114/ 114/ 133/ 119/ 117/ 91/ 110/ ryshtfl __ 58 69 64 62 62 59 _66_ 62 _73 67 72 64 73 76 69 62 63 68 81 69 70 77 62 68 79 62 69 63 79 55 61 rtler Oate- - -- 10/19/20141549 Temp 97.2 99.8 98 97.9 97.5 98.7 97.4 98.1 98 97.9 98 98 97.8 98.1 99.9 97.7 96.4 97.3 97.9 97.5 97.2 97.7 97.6 97.9 97.2 97.6 97.4 98.2 98.2 97.7 98.2 Pulse-I 91 92 82 85 84 93 88 85_I 87 89 81 80 88 87 98 83 79 88 83 82 89 82 78 100 70 79 89 97 81 82 Resp _18 20 20 18 16 20 18 18 18 18 18 20 18 L20 20 18 18 18 18 18 18-�18 18 18--18 18 18 18 20 20 18 Day J J d J J J J J -T* J J J J J J J J J J J J J J J J J J J J J J JA00 jd JA00 JAOD JA00 JA00 ANA6 JAOD JAOO sm sm ANA6 JAOD JA00 JEW4 JA00 JA00 JA00 AAD1 LW1 LW1 JA00 JA00 cit AAD1 ANA6 ACID JAOO JA00 JEW4 JA00 121/ 107/ 121/ 122/ 120/ 121/ 120/ 126/ 118/ 127/ 106/ 116/ 122/ 118/ 120/ 107/ 127/ 123/ 103/ 106/ 159/ 120/ 116/ 121/ 11/ 122/ 127/ 120/ 120/ 110/ 116/ SP 60 64 60 _60 68 60 60 70 70 69 64 65 67 68 64 65 67 65 65 68 88 171 70 70 67 67 68 60 78 ( 76 68 Temp 98 97.3 97.9 97.7 98.1 L98.4 97.5 98.3�II 97.9 98.9 99.2 98.1 98.1 l�98.2 98.8 98.7 97.8 97.9 98.5 981 98.7 L97.8 97.8 98.1 98.6 97.9 97.6 98.6 98.4 L97.8 98.4 Pulse 93 99 87 82 88 96 89 89J 88 80 95 78 91-1-89 86 84 80 86 81 75 91-�89 85 77 74 66 70 91 91_76 80 Resp-I 20 18 18 21 17 �18 20 20 20 20 18 18 19-111119 20 16 18 18 18 17 18- 18 18 19 -17 20 19 19 19 18 20 Eve J CMR J J CMR J J J J J J CMR J J CMR J J J J CMR J J J J J J J J J J J LM1 3 ALMt LM1 3 ALM1 ALM1 ALM1 ALM1 SDC6 SDC6 3 ALM1 ALM1 3 SDC6 sm sm SDC6 3 SDC6 DW2 DW2 ALM1 AAD1 LM1 ALM1 ALM1 DW2 udh DW2 116/ 114/ 126/ 135/ 117/ 128/ 115/ 118/ 112/ 119/ 114/ 97/ 1321 115/ 121/ 113/ 129/ 118/ 116/ 110/ 94/ 1181 110/ 119/ 121/ 127/ 121/ 118/ 117/ 113/ 131/ _BP 66 73 65 _66 73 71 _66 76 67 66 64 _65_ 66 67 _66_ 65 69 72 78 76 62 78 76 76 _67 72 76 68 76 66 _77 TemptI 97.7 97.5 97.6 99.5 98.3 1x98.2 97.8 97.9 97.8 97.9 97.5 96.1 97.4 98.4 98.6 98.6 97.5 97.3 98.3 986 97.3 197.4 97.3 97.6 96.6 98.3 97.5 97.7 98.6 98.5 95.9 Pulse) 94 88 89 96 88 1] 96 72 80 88 86 72 81 90-II-88 88 81 176 88 80 76 16 as 88 78 76 68 72 90 90 89 90 Resp_I 2018 18 16 18-I�-18 72 20� 20 20 18 16 18-L20 20 18J 18 18 18 18 16-L18 18 18 -16 20 18 20 18-I-18 18 Chart Codes/Follow Up Codes Ir t Name Signature Ink Name Signature Name Signature -Follow Up Codes- 5=LOA J=Administered 6=Nauseated/vomiting Chedmd By 1st 1-Ineffective 7=Other/See Nurse Notes Chedmd By2nd E=Effective 6=Pu1se below 60/min U=Unknown 9=Sleeping H--On Hold By Physician 10=Toileting Did not Occur Checked By 3rd 11=Resident Discharged -Chart Codes- 12=Resident Deceased MEDICATION ADMINISTRATION 01/0112015-01/31/2015 1-Away from home with meds RECORDResident ARCS,CARMEN(46161) 2-Drug Refused 3-Hold/See Nurse Notes Ho4pitag� Admit Date 12/24/2013 DOB 01/05/1966 Unit Wing'D' Room 00806 Bed 1- 1 Printed on:Feb 2,2015 at 14:09:53 EST ARCE,CARMEN(46161)-Page:7 of 11 Facility GL-West Shore[00285) Pharmacy I AlbcaRX Physician I I(UNIaE,THOMAS Allergies penicillins ivp dye she6flsh seafood Unscheduled 'Other"Orders Advanced Directive Fug Code Schedule for Thu Fri Set Sun Mon Tue Wed Thu Fri Ser Sun Mon Tug Wed Thu Fri Set Sun Mon Tue Wed Thu Fri Sat Sun Mott Tue Wed Thu Fri Set Jan 2015 Hours t 1 2 1 3 1 4 1 5 1 S 7 8 9 10 11 12 13 14 15 1 16 17 18 19 20 21 22 23 24 26 28 27 28 29 30 31 S a shift ...continued from previous page... very shift -Order Date- J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J Nght AIMS SML4 SML4 JANM AIM5 SML4 ANM AIM5 AIM5 AIM5 dt ANM AIMS AIMS AIMS SML4 SML4 AIMS AIMS AIMS �M AIMS AIMS AIMS ANM JAI45MAIM5 AIMS AIM5 nd MW5 10/29/20141549 9 9 9 9 9 Acetarninophen Tablet 325 MG J Give 2 tablet by mouth every 4 AN M hours as needed for Mild pain PRN 9 DO NOT exceed 49m/24hours 0 E 9 AP" -Order Dats- 102920141621 Aceterninophen Tablet 326 MG Temp Give 2 tablet by mouth every 4 ---- — -- ---- -- — -- ---- -- ---- — _ _ — -- — -- -- — -- — -- -- — — — -- — -- --- -- hours as needed for Temp>1012 PRN O NOT exceed 49m24 hours AP" -Order Date- 10/2920141621 Albuteral SuUate Nebulization min Solution(2.6 MG/3ML)0.08396 1 vial inhale ondyvia nebulizer —— — —— — — — -- — -- -- — -- — very 4 hours as needed for SOB PRN -Order Data- 10292014 2233 Chart Codes/FoAow Up Codes Inst Name Signature Init Name Signature Name Signature Follow Up Codes— 5=LOA Checked By 1St ^T' =Administered 6=NauseatDdNomiting 1=1neffective =Other/See Nurse Notes c.. E=Effective 6=Pulse below 60/min Checked B U=Unknown 9=Steeping u H=On Hold By Physician 10=Toileting Did nBy riot Occur - Checked 1 1=ResidentDischarged ChartCodes- 12=Resident Deceased MEDICATION ADMINISTRATION 01/01P2015-01/31112015 1=Away from home with medsRECORDResident ARCE,CARMEN(46161) 2=Drug Refused 3=Hold/See Nurse Notes _ 4=14osateraed AdmltDate 1=4/2013 DOB 01/05/1966 Unit Wing'D' Room 00806 Bed 1 Printed on:Feb 2,2015 at 14:09:53 EST ARCS,CARMEN(46161)-Page:8 Of 11 Facility GL-West Share[00265] Pharmacy AIb(aRX Physician I KUNKLE,THOMAS Allergies penicillins ivp dye shelfth seafood Unscheduled "Other"Orders Advanced Directive Full Code Schedule fof Tru Fri Sat Sun Mon T. Wed Thu Fri Sat sun Mon T. wed Thu Fri Set Sum Mon T- Wed TI. Fd We Sat Sun Mon T. d Thu Fri Bat Jan 2015 Hours 1 2 3 4 5 6 7 6 9 10 11 12 13 14 15 16 17 16 18 20 21 22 23 24 25 26 27 26 29 30 31 Dulcolro(Suppository 10 MG PRN (Bisacodyl) Insert 1 suppository rectally as needed for Constipation Diva at 0600 PRN If MOM ineHecOve for BM -Order Date- IQQ 2014 1624 Fleet Enema Enema 7-19 PRN GWI18ML(Sodium Phosphates) Insert 1 dose rectally as needed r Consdpatlon Give on 3-11 PRN If MOM and Suppository ineffective r BM.if enema Ineffective,notify MD. -Order Date- 10119120141625 Maalox Regular Strength PRN Suspension 225-200-25 MG15ML (Alum&Mag Hydroidde-Shrietlt) Give 30 ml by mouth every 6 hours as heeded for Indigestion -Order Data- 10,129420114 1 623 Chan Codes!Follow Up Codes inft Name swab" Inst Name swab" Name Sigraftre Follow Up Codes— 5=LOA By =Administered 6-Nauseated (ed tVomrdng Ched1tt 1-Ineffective 7=Other/See Nurse Notes E=Effective 6=Pulse below 601min Checked By2nd U=Unknown 9-Sleeping H=On Hold By Physician 10=Toileting Did not Occur Cl*dwd By 3rd 11=Resident Discharged —Chan Codes---- 12=Resident Deceased MEDICATION ADMINISTRATION 01/01/2015-01/3112016 1=Away from no"vAth mads RECORDResident ARCE,CARMEN(46161) =Drug Refused 3=HoldlSee Nurse Nates =Hospitalized Admit Date 1 12/24/2013 1 DOB I 01/05/1966 Unit Wing'D' Room 00806 Bed 1 Printed on:Feb 2,2015 at 14:09:53 EST ARCE,CARMEN(46161)-Page:9 of 11 Facility GL-West Shore[00285] Pharmacy I AlixaRX Physician KUNKLE,THOMAS Allergies penicillins ivp dye shoNsh seafood Unscheduled "Other"Orders Advanced Directive Full Code Schedule for Shu Fri Set Sun Mon T. Wed Thu Fri Set Sun Mon T. Wed Thu Fit Set Sun Mon T. Wed Ttw RA Set Stat Man Tue Wad Ttw Fd set Hours Jen 2015 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 26 26 27 28 29 30 31 Milk of Magnesia Concentrate PRN Suspension 2400 MC910ML (Magnesium Hydroxide) Giwe 30 mt by mouth as needed for Constipation 30 mL PO q 3rd day PRN for no SM -Order Date- 101Z9/20'141623 Custom PM*Legend 1.Anticonvulsant Drug level (ACDL) 5.Digoxin Level(Dig) 9.Potassium(K) 13.TSH(TSH) Z BUN(BUN) 6.Glucose(Glu) 10.PT/INR(PTINR) 14.Urine pH(UcpH) 3.CBC(CBC) 7.Hematocrit(Hct) 11.PTT(PTT) 4.Creatinine(Creat) 8.Hemoglobin(Hgb) 12.Theophylline Level(Theo) SWAdm[nisbution Legend:Jan 2016 Initial Long Usemanne, Username DestgnaWn AAD1 ANITA DANQUAH LPN AAD0059 AiM5 Amy Mastreila LPN AIM0037 ALM1 Ashley Musser LPN ALM1103 ANA6 Angela Alvarado LPN ANA0049 ANM9 Autumn Minnie LPN ANM0077 CMR3 Christine Rzepela LPN CMR0147 Chart Codes/Follow Up Codes [nit Name Slgrlahae [nit Name Signature Name Slgr"Itt" —Follow Up Codes— 5-LOA L`het I{��) =Administered 6=NauseatedNonu6ng st 1=ineffective 7=Other!See Nurse Notes E=Effective 6=Pulse below 601min Checked By 2nd U=Unknown 9-Sleeping H=On Hold By Physician 10=Toileting Did not Occur Checked 13y 3rd 11-Resident Discharged —Chart Codes--- 12=Resident Deceased MEDICATION ADMINISTRATION 01/01/2015-01131/2015 1=Away from horns with reeds RECORD Resident ARCE,CARMEN(46161) 2=Drug Refused 3-Hold/See Nurse Notes =Hospitalized Adn*Date 1 12/24/2013 1 DOB 1 01/05/1966 Unit Wing'D' Room 00806 tied 1 Printed on:Feb 2,2015 at 14:09:53 EST ARCE,CARMEN(46161)-Page:10 of 11 Facility GL-West Shore[00285] Phamtacy I AlbcaRX Physician I KUNKLE,THOMAS Allergles penicillins ivp dye shellfish seafood Unscheduled "Other Orders Advanced Direclllve Full Code Schedule for Thu Fri Sat Sun Mon Tue Wed Thu Fri Set Sun Man Tue Wed Thu Fri Set Sun Mon T. Wad Thu Fri Set Sun Mon T. Wled Thu Fri Sat Jan 2016 Hours 1 1 2 1 3 4 5 6 7 1 B 8 10 1 11 1 12 1 13 1 14 1 15 16 17 18 18 20 21 22 23 24 25 Ze 27 28 29 30 31 StaffAdministrallon Legend:Jan 2015 (continued from previous page) initial Long Username Username Designation dt Dorothy Tee LPN DNT0008 DW2 Danielle Wissler LPN DBWO018 JA00 Janelle Ondrusek LPN JA00056 jd Janyce Hobart LPN JED0041 JEW4 JENNIFER WEESE RN JEW0100 LW1 LAURI WERT RN LBWO027 MW5 Marcia Williams LPN MYW0007 nd Nguyen Doan LPN NTD0002 SDC6 SHELLON CHASE LPN SDC0110 sm Stella Mwangi LPN SMM0207 SMI-4 SHANE LAUGHMAN LPN SML0109 udh Ursula Herr udh0003 Chart Codes/Follow Up Codes InIt Name Signatures Init Name Signature Name Slgnalin —Follow Up Codes— 5--LOA wd-/=Administered S=NaussatedlVomiting C ' B`�y 18t 1=Ineffective 7-Other I See Nurse Notes E=Effective 8=Pulse below 80/min ChediedBy 2nd U=Unknown 9=Sleeping H=On Hold By Physician 10=Toileting Did not Occur C+ By I I=Resident Discharged -Chart Codes- 12--Resident Deceased MEDICATION ADMINISTRATION 01101r2016-0113112015 1=Away from home with meds RECORD ARCE,CARMEN(46161) 2=Drug Refused 3=Hold/Ses Nurse Notes =Hospitalized Admit Date 12/24/2013 1 DOB I 01/05/1966 Unit Wing'DRoom 00806 Bed 1 Printed on:Feb 2,2015 at 14:09:53 EST ARCE,CARMEN(46161)-Page:11 of 11 C, c�MENT «B A TA List of Supports in place for Carmen Arce Primary Care Doctor: Established due to living at Facility Thomas Kunkle 550 Brandt Avenue New Cumberland, PA 17070 CMU SC Supervisor: Karen Wolf (717) 441-7345 kwolf(a,cmu.cc UCP of Central PA (Jamie Fleck),Program Manager 925 Linda Lane Camp Hill PA 17011 Tel 737-3477 X 360 Fax 737-5136 Providing Companion Service at Facility signed up 12/9/12 SS Rep Payee: ARC of Dauphin County 2569 Walnut Street Harrisburg, PA 17103 Phone: (717) 920-2727 Pat Stefan Deb Johnson—djohnson(cr�,arcofdc.org PO Box 804 Keystone Elizabethville, PA 17023 Guardianshipconnie@keystoneguardianship.com melanie@keystoneguardianship.com Servicesheather@keystoneguardianship.com gina@keystoneguardianship.com egu missy@keystonardianshi p.com March 30, 2015 - --- --_ - Register of Wills Cumberland.County Courthouse Suite 102 :, Courthouse SquareVo Carlisle, PA 17013 r- I . In Re: Carmen Arce fh3 t" a) 881 0f2014 r M- CD '-ri � :M- Dear Dear Madame: ►-r r " Enclosed you will find the following 1. Annual Report of the Guardian of the Person of Carmen Arce for period of November 6, 2014 to December 31, 2014 to be filed. 2. Our check in the amount of$15.00 for payment of the filing fees; 3. ,A copy of the Report to be stamped and returned to us 4. A self-addressed postage paid envelope for the return of the stamped copy. I apologize for the delay in filing this report. An audit of our file found we misread the Order and calendared it for December 31, 2015 for the first report. Also noticed was the heading of the Order. It states Guardian of the Person and the Estate; however,the matters leading up to the hearing and the petition filed refer to Keystone Guardianship Services as Guardian of the Person. If you have any questions or need additional information, please do not hesitate to contact me. Sincerely, KEYSTONE GUARDIANSHIP SERVICES Constance E. Stoneroad Phone: (717) 674-5757 Fax: (717) 362-3381 www.keystoneguardianship.com