HomeMy WebLinkAbout06-06-06
JUN 0 7 20D~
IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA
IN RE:
ORPHANS' COURT DIVISION
PATRICIA J. SHAY
AN ALLEGED
INCAPACITATED PERSON.
No. ~\ -Olo - ()L\:c~d-
PETITION FOR THE APPOINTMENT
OF A PERMANENT PLENARY GUARDIAN
OF THE PERSON AND ESTATE
A
Filed on Behalf of Petitioner:
TRACY D. SHAY-SNYDER
Our Matter No.
Counsel of Record for this Party:
CAPOZZI AND ASSOCIATES, P.C.
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Doreena Oiig Sroan, Esquire
Attorney ID No. 44880
2933 North Front Street
Hanisburg, PA 17110
(717) 233- 4101
(717) 233- 4103
Attorneys for Petitioner
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IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA
IN RE:
) ORPHANS' COURT DIVISION
)
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No.
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PATRICIA J. SHAY,
AN ALLEGED
INCAPACITATED PERSON.
PETITION FOR THE APPOINTMENT
OF A PERMANENT GUARDIAN
OF THE PERSON AND EST ATE
IMPORTANT NOTICE / CITATION WITH NOTICE
A PETITION HAS BEEN FILED WITH THIS COURT TO HAVE YOU DECLARED AN
INCAP ACIT A TED PERSON. IF THE COURT FINDS YOU TO BE AN INCAP ACIT A TED
PERSON, YOUR RIGHTS WILL BE AFFECTED, INCLUDING YOUR RIGHT TO
MANAGE MONEY AND PROPERTY AND TO MAKE DECISIONS. A COPY OF THE
PETITION, WHICH HAS BEEN FILED BY ATTORNEY DOREENA CRAIG SLOAN,
ESQUIRE, IS ATTACHED.
YOU ARE HEREBY ORDERED TO APPEAR AT A HEARING TO BE HELD IN
COURTROOM NO. CUMBERLAND COUNTY COURTHOUSE, ONE
COURTHOUSE SQUARE, CARLISLE, PENNSYLVANIA 17013-3387, ON
AT O'CLOCK, .M. TO TELL THE COURT
WHY IT SHOULD NOT FIND YOU TO BE AN INCAPACITATED PERSON AND
APPOINT A GUARDIAN TO ACT ON YOUR BEHALF.
TO BE AN INCAPACITATED PERSON MEANS THAT YOU ARE NOT ABLE TO
RECEIVE AND EFFECTIVELY EVALUATE INFORMATION AND COMMUNICATE
DECISIONS AND THAT YOU ARE UNABLE TO MANAGE YOUR MONEY AND/OR
PROPERTY, OR TO MAKE NECESSARY DECISIONS ABOUT WHERE YOU WILL LIVE,
WHAT MEDICAL CARE YOU WILL GET, OR HOW YOUR MONEY WILL BE SPENT.
AT THE HEARING, YOU HAVE THE RIGHT TO APPEAR, TO BE REPRESENTED BY
AN ATTORNEY, AND TO REQUEST A JURY TRIAL. IF YOU DO NOT HAVE AN
ATTORNEY, YOU HAVE THE RIGHT TO REQUEST THE COURT TO APPOINT AN
ATTORNEY TO REPRESENT YOU AND TO HAVE THE ATTORNEY'S FEES PAID FOR
YOU IF YOU CANNOT AFFORD TO PAY THEM YOURSELF. YOU ALSO HAVE THE
RIGHT TO REQUEST THAT THE COURT ORDER THAT AN INDEPENDENT
EVALUATION BE CONDUCTED AS TO YOUR ALLEGED INCAPACITY.
IF THE COURT DECIDES THAT YOU ARE AN INCAPACITATED PERSON, THE
COURT Iv1A Y APPOINT A GUARDIAN FOR YOU, BASED ON THE NATURE OF ANY
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CONDITION OR DISABILITY AND YOUR CAPACITY TO MAKE AND COMMUNICATE
DECISIONS. THE GUARDIAN WILL BE OF YOUR PERSON AND/OR YOUR MONEY
AND OTHER PROPERTY AND WILL HAVE EITHER LIMITED OR FULL POWER TO
ACT FOR YOU.
IF THE COURT FINDS YOU ARE TOTALLY INCAPACITATED, YOUR LEGAL
RIGHTS WILL BE AFFECTED AND YOU WILL NOT BE ABLE TO MAKE A CONTRACT
OR GIFT OF YOUR MONEY OR OTHER PROPERTY. IF THE COURT FINDS THAT YOU
ARE PARTIALLY INCAPACITATED, YOUR LEGAL RIGHTS WILL ALSO BE LIMITED
AS DIRECTED BY THE COURT. IF YOU DO NOT APPEAR AT THE HEARING (EITHER
IN PERSON OR BY AN ATTORNEY REPRESENTING YOU) THE COURT WILL STILL
HOLD THE HEARING IN YOUR ABSENCE AND MAY APPOINT THE GUARDIAN
REQUESTED.
By:
Clerk, Orphans' Court
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IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA
INRE:
) ORPHANS' COURT DIVISION
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PATRICIA J. SHAY,
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AN ALLEGED,
INCAPACITATED PERSON.
PETITION FOR THE APPOINTMENT
OF A PERMANENT GUARDIAN OF
THE PERSON AND ESTATE
Petition For The Appointment Of A Permanent Guardian
Of The Person And The Estate Of An Alle2ed Incapacitated Person."
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AND NOW comes Petitioner, TRACY D. SHAY-SNYDER, through her attorneys, D<8ena
Craig Sloan, Esquire, of Capozzi and Associates, P .C., and presenting this Petition to this
Honorable Court for the Appointment of a Permanent Guardian of the Person and the Estate of
PATRICIA J. SHAY, an Alleged Incapacitated Person, representing as follows:
1. Petitioner, TRACY D. SHAY-SNYDER is the natural daughter of PATRICIA J. SHAY
and currently resides at 2713 Columbia Avenue, Camp Hill, P A 17011.
2. PATRICIA J . SHAY is currently a resident of Claremont Nursing and Rehabilitation
Center, a long-term care facility that is licensed to participate in the Medicaid and
Medicare programs.
3. The Alleged Incapacitated Person is PATRICIA J. SHAY, a 72-year-old female residing
permanently at Claremont Nursing Home. Her date of birth is October 23, 1933 and her
Social Security number is 210-26-9049.
4. Petitioner is an interested party because the Petitioner is the natural daughter of
PATRICIA J. SHAY who, by information and belief, holds one of two existing Powers
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5. PATRICIA J. SHAY, by information and belief, gave a second Power of Attorney to her
husband Charles E. Shay, who as a fiduciary has a statutory and moral obligation to act in
the best interests of the Alleged Incapacitated Person.
6. The Alleged Incapacitated Person was admitted to Claremont Nursing and Rehabilitation
Center, 1000 Claremont Road, Carlisle, PAl 70 13-8805, on February 4, 2005. Her prior
residence was 27 I 3 Columbia A venue, Harrisburg, PAl 701 I.
7. The Alleged Incapacitated Person is diagnosed with, among other things, Senile
Demensia Alzheimer's Type and delusions.
8. The Alleged Incapacitated Person has never served in the Armed Forces of the United
States of America.
9. The Alleged Incapacitated Person does not generally comprehend her surroundings to
such an extent that she requires consistent supervision in her activities of daily living. As
a result of her condition, the Alleged Incapacitated Person requires specific one-on-one
assistance with grooming, transferring, ambulation, toileting and bathing.
10. The Alleged Incapacitated Person is incapable of handling her personal affairs, however
minor, and if called upon to grant informed consent to any medical procedure she would
be unable to grant it because of her inability to comprehend the nature of the procedure.
Additional information is set forth in the competency affidavit, prepared by her treating
physician Dr. Ernest Josef, 1830 Good Hope Road, Enola, PA 17025, and incorporated by
reference attached hereto, and marked Exhibit "A."
11. The Alleged Incapacitated Person is not expected to recover from her current condition to
become sufficiently independent to return to the cOlnmunity.
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12. The Alleged Incapacitated Person has the following living next of kin:
Charles E. Shay Jr. (Spouse/POA) Tracy D. Shay- Snyder (Daughter/POA)
1926 Longboat Drive 2713 Columbia Avenue
Lakeland, FL 33810 Camp Hill, P A 17011
Cory L. Shay (Son)
328 Ridge Road
Grantville, P A 17028
13. Petitioner believes that she is the most appropriate person to serve as Guardian because
she cared for PATRICIA J. SHAY solely during the two years preceding her admission
to the nursing home; she actively participates in her mother's medical care; visits on a
regular basis, and is willing to make informed medical, personal, and financial decisions
in the best interest of Mrs. Shay.
14. Petitioner avers that Charles E. Shay Jr. has continuously refused to pay for the costs of
providing the needed care to his wife, Patricia J. Shay, and has also continuously refused
to provide information to the Department of Public Welfare to aid them in properly
determining Patricia J. Shay's eligibility for Medical Assistance.
15. The current bill for the provision of nursing home services exceeds $23,265.25 and Mr.
Shay continues to refuse to pay any portion of the bill for the care of his wife.
16. The alleged incapacitated person has an interest in property currently listed in the sole
name of her husband, Charles E. Shay Jr., which is located at 1926 Longboat Drive,
Lakeland, Polk County, FL., with the most recent assessed value being $116,170.00.
17. Various checking accounts, CD's and other financial instruments are or were held in the
names of Charles E. Shay Jr. and/or Patricia J. Shay and Tracy D. Shay-Snyder, some of
which Petitioner has learned were converted by Charles Shay either to his own personal
use, to new account(s), or to remodel his girlfriend's Florida home and to prevent access
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by Tracy D. Shay-Snyder, as Power of Attorney, to pay for ongoing nursing home
services for Patricia J. Shay.
18. Charles E. Shay Jr. holds a power of attorney for the alleged incapacitated person which,
on information and belief: was executed simultaneously with the power of attorney held
by Tracy D. Shay-Snyder.
19. Petitioner applied for Medical Assistance benefits on behalf of The Alleged Incapacitated
Person and was originally denied due to excess resources and the failure or refusal of
Charles E. Shay Jr. to provide verification of income, assets and expenses.
20. During the application for benefits process, the Cumberland County Assistance Office
conducted a Resource Assessment for Patricia J. Shay and deemed that the couple's
accounts totaled $37,464.85 of which Mr. Shay's share was calculated to be $19,020.00
and Patricia Shay's share was $18,444.85 which was to be used to pay for her nursing
home care.
21. Charles E. Shay Jr., as husband and Power of Attorney, was properly notified of the
County Assistance Office's Resource Assessment and has failed or refused to release
Patricia Shay's resource share and has advised Petitioner that he will not pay for
an ything.
22. Medical Assistance benefits for Patricia J. Shay have been approved pending the
appointment of a Guardian.
23. The Incapacitated Person, Patricia Shay receIves Social Security in the aInount of
$822.00 per month that is directly deposited into her joint account with Tracy D. Shay-
Snyder who then uses it to pay on the ever-increasing bill for nursing hOIne services for
Patricia J. Shay.
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24. Petitioner requests the Guardian be assigned the following powers below described:
a. Making Medical decisions, which would include but not be limited to:
1. medication, antibiotics, hydration, tube feeding, respirator use;
11. situations related to the active dying process;
Ill. hospice selections;
IV. selecting or replacing the attending physician;
v. skilled care and acute care placement;
b. Maintaining order in the financial affairs of the Alleged
Incapacitated Person, which would include but not be limited to:
1. establishing the guardianship bank account;
11. marshalling the alleged incapacitated person's assets;
111. paying bills for the alleged incapacitated person, including
bills for nursing care and services;
IV. making bank deposits;
v. writing checks for expenses;
VI. performing all other acts necessary to avoid waste with
respect to the assets of the alleged incapacitated person.
25. Petitioner knows of no available less restrictive alternative to the establishment of a
Permanent Guardian of the Person and Estate of the Alleged Incapacitated Person.
26. The Proposed Guardian is Petitioner, Tracy D. Shay-Snyder, of 2713 Columbia Avenue,
Camp Hill, P A 17011.
27. Tracy D. Shay-Snyder, having no interest adverse to the Alleged Incapacitated Person,
has agreed to act as Guardian of her Person and Estate if this Honorable Court shall so
appoint. The executed Consent of the Proposed Guardian is attached to this Petition and
marked Exhibit "B."
28. If appointed by this flonorable Court, the Guardian wiIJ act in compliance with
regulations promulgated under Court Order in Pennsylvania Bulletin 931, et seq., April
19, 1975.
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29. An Application for Medical Assistance was initially denied by the Department of Public
Welfare because the application for benefits was incomplete due to the inability of
PATRICIA J. SHAY, the alleged incapacitated person, and Tracey D. Shay-Snyder, as
Power of Attorney to provide the required information and the consistent failure or
refusal of Charles E. Shay Jr. husband and other Power of Attorney, to provide the
required information.
30. The current bill for nursing home services exceeds $23,265.25.
31. As a Medicaid recipient, the Alleged Incapacitated Person is required to maintain total
assets of not more than $2,500.00.
32. As a Medicaid recipient, the Alleged Incapacitated Person will receIve a personal
allowance of $40.00 a month.
33. 20 Pa.C.S.A. 95515 states "... prOVISIons relating to a guardian of an incapacitated
person and her surety shall be the same as are set forth in the following provisions of this
title relating to a personal representative or a guardian of a minor and their sureties:..."
Section 5122 (relating to when bond not required).
34. 20 Pa.C.S.A. 95122 (d) states "in all other cases, the court may dispense with the
requirement of a bond when, for cause shown, it finds that no bond is necessary."
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WHEREFORE, Petitioner respectfully requests this Honorable Court to:
1. Award a Citation directed to PATRICIA J. SHAY and others as the Court sees fit to
show cause why PATRICIA J. SHAY should not be declared an incapacitated person and
why a Permanent Guardian of her person and Estate should not be appointed;
2. Appoint Tracy D. Shay-Snyder as Permanent Guardian of the Person of PATRICIA 1.
SHAY.
3. Dispense with the requirement that the Proposed Guardian obtain a bond.
4. Decree as null and void the current Power of Attorney held by Charles E. Shay, Jr.
Respectfully submitted,
Date: ---~;\^'C (; 2c.,i(){;
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CAPOZZI AND ASSOCIATES, P.C.
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Doreena Crai oan, Esquire
Attorney 1D No.: 44880
2933 North Front Street
Harrisburg, PAl 711 0
(717) 233- 4101
Attorneys for Petitioner
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IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA
IN RE:
) ORPHANS' COURT DIVISION
)
) No.
)
) PETITION FOR THE APPOINTMENT
) OF A PERMANENT GUARDIAN OF
) THE PERSON AND EST ATE
)
PATRICIA J. SHAY,
AN ALLEGED
INCAPACITATED PERSON.
VERIFICA TION
I, TRACY D. SHAY-SNYDER, Petitioner in this matter, do hereby depose and state that
the facts contained in the foregoing Petition are true and correct to the best of lny knowledge,
infonnation and belief. I understand that false statements made herein are subject to the
penalties of 18 Pa.C.S.A. Section 4094, relating to unsworn falsification to authorities.
Date: "c-) / 1-5 Ie ~,
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Tracy D.~hay-Snyder '
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHAN'S COURT DIVISION
IN THE MATTER OF PATRICIA J. SHAY,
an Alleged Incapacitated Person No.
: Petition for the Appointment of a Permanent
: Guardian of the Person and Estate
Affidavit of Dr. Ernest Josef in Support of Petition to
Adiudicate PATRICIA J. SHA YI an AlleQed Incapacitated Person
1. My name is Dr. Ernest Josef
2. My occupation is as a physician.
3. My business address is 1830 Good Hope Road, Enola, PA 17025.
4. My educational background is as follows:
a. State Medical! Graduate School
M~IUlt. Cc~ of 1/111.6/~14
b. State Undergraduate
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5. I am licensed by the State of Pennsylvania as MB; fc#- P~C~A
6. I specialize in A"..,,/t,r ~tnlt:./+'e.
7. I am affiliated with Claremont Nursing and Rehabilitation Center
8. I have been affiliated with Claremont Nursing and Rehabilitation Center since J/1/t-( Ir~)
9. I first met PATRICIA J. SHAY in C-t. 41ft!'" ,-r'rJr N~n.FIH?- ~ RtH4-4IL I r~Tl()""/ c~
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I last met with PATRICIA J. SHAY on
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11. I last reviewed PATRICIA J. SHAY'S chart on 4/.. ;?~~
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12. PATRICIA J. SHAY'S pertinent diagnoses are: ~ A/7~ - E~fllJir.4,)j
13.
PA TRICIA J SHAY currently takes the medications on the list attached to this Affidavit. E ~r/1IJ} rH 2-;/
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EXHIBIT
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15.
PATRICIA J. SHAY'S prognosis is: @ fair
good
16. The extent of PA TRIQ./AJ.. SHA YIS ability to communicate is as follows:
a. Verb~l!y ~.P9.g.L-') fa~r good Ox ~ 0 f IH <; rn- 11r-)
b. In Wntlng C.PQQI/ fair good
c. Other Means (poor,) fair good
17. The extent of PATRICIA J. SHA YI S ability to receive information is as follows:
a. Reading: (pqo() fair;;,.. good
b. Hearing: poor fair) good
18. PATRICIA J. SHAY is capable of independently performing ONLY the following activities of
daily living. (Circle all that apply)
\ a~/)Eating ~) L~-~~:>
b.' Grooming
c. T oileting
d . Transferring
e. Bathing
19.
PATRICIA J. SHAY has emotional/imitations in the form of:
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20. PATRICIA J. SHAY is ABLE~UNABL~,_Jo interact socially on any meaningfulleve!.
If ABLE, then please describe: Although limited by her dementia.
21. PATRICIA 1. SHAY does not generally comprehend her surroundings to such an
extent that she requires consistent supervision in her activities of daily living. As a
result of her condition, she requires specific one- on- one assistance with groolning,
transferring, ambulation, toileting and bathing. She absolutely could not manage any
of her own activities of daily living without supervision or assistance. 6)F
22. PATRICIA J. SHAY IS I @apable of handling her financial and personal affairs,
however minor. She requires total assistance in these areas. CV/F
23. P,A,TRICIA J. SHAY, if called upon to grant informed consent to any medical procedure,
however minor or straightforward, would be unable to grant it because of her inability to
comprehend the nature of the procedure. (]IF
24. PATRICIA J. SHAY absolutely cannot actively and effectively participate in monitoring and
managing her own medical care and medication. She requires supervision in this area. (i)F
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Exhibit "A"
25. PATRICIA J. SHAY's limitations relevant to this guardianship proceeding are not likely to
improve neither in the immediate future nor over time . To the extent relevant change is likely J
it will be, in my opinion, expressed with reasonable medical certainty, for the worse. c]JF
26. I have been made aware of the statutory definition of "incapacitated person" under
Pennsylvania law. <1JF
27. My opinion, based on my examinations of PATRICIA J. SHAY and my review of her medical
records, expressed with reasonable medical certainty, is that PATRICIA J. SHAY is totally
incapacitated as to matters affecting her person, lDF
28. My opinion, based on examinations of PATRICIA J. SHAY and my review of medical records,
expressed with reasonable medical certainty, is that she is totally incapacitated as to matters
affecting her financial affairs. dfF
29. Based on the opinions that I have expressed, my opinion, expressed with reasonable medical
certainty, is that PATRICIA J. SHAY requires the appointment of a guardian of her person and
estate, CVF
30. My opinion is that PATRICIA J. SHAY could possibly be harmed if she were required to attend
her guardianship hearing, however, I feel this point is moot because PATRICIA J. SHAY would
not be able to contribute in any way to the hearing, <fJF
31, My opinion is that PATRICIA J. SHAY would not understand nor benefit from participation in a
court hearing regarding a determination of her capacity to handle her own personal and
financial affairs. (J}F
I, Dr. Ernest Josef, being duly sworn according to law deposes and says that I make this Affidavit
on behalf of PATRICIA J . SHAY and that the facts set forth in the foregoing Affidavit are true and correct to
the best of my knowledge, information, and belief.
I verify that the statements in this Affidavit are true and COITect. I understand that false
statelnents herein are Inade subject to the penalties of 18 Pa.C.S.A. 9 4904 relating to unsworn
falsification to authorities.
Date: ~- 5...()lJ
Sworn to and subscribed before me this :::\'fJ'\
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Dr.E~~ ~
day of J lLn{,,\/ ,2006
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My Commission Expires:
COMMONWEALTH Of" "'~NNSiLVANIA
i Notarial Seal ~
l,. Amy A. Reavey, Notary Public I
I City Of Harrisburg, Dauphin County r
My Commission Expires .June 23, 2008 I
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Memb€'r. PE;,rvsylvcmi-t . :..,'~ .
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CUMULATIVE DIAGNOSES SHEET
DATE ACTIVE PROBLEMS
,
'2/04/05 SOAT - Se17, fL a,'WI7f/{L IfIz/;r'II"<T,-!fX-
2/04/05 HTN 1tt)Pl/ kf)SK~
2/04/05 Hyperlipidemia 4 e
2/04/05 PVD Per/~hera_/ t~'(S{{.i(tiI1 t~c~<-zL
2/04/05 Seizure disorder? (no seizures> 20 yrs per daughter)
2/04/05 Pacer/murmur 12/27/04
2/04/05 DepressIon (cnronic since early adulthood)
2/04/05 MJ
/"Iy. I) cc)rCl J /" a 0'/""' /' I
I' (, 1t-4-3 -<~ . J t {Jr." .;< /; /7
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2/04/05 Ambulatory dysfunction
2/04/05 AnemIa
2/04/05 Failure to thrive
2/04/05 Pneumonia
10/04 G I bleed
VOS Barrett's esophagus; hiatal hernia
9/30/05 Dysphagia
10/7/05 ORJ F left wrist
-I'f;~ DC c LU\/(J~
Allergies:
Pneumovax ~
Positive Mantoux:
Positive Serology:
Date: 2/7/05
Date of Tx.:
Date of Tx.:
"hyaician Signature:
~
Date:
5;-. 1-0 (p
Shay, Patricia
#4538
rCO-9 CODe Dr. Initia' i DATI RESOLVED PROBLEMS
331.0/294.10
401.9
272<4
4439
V4501/785.2
311
410.92
7812
285.9
783<7
486
578.9
530<85/553.3
, 787. 2
V54.19N45.4
10/3/05 Pneumonia resolved
10/3/05 GI bleed resolved
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Add ress-a-graph
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CNRC: 2/06
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Physician must sIgn and date the bottom of th.s form at adrnlss'on. AU d.agnoses added after the
admitting diagnoses must be initia'ed by the physician in the appropriate COIUnl".
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EXHIBIT
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REVIEW Of ENTIRE DRUG REGIMEN AND _
ANY IRREGULARITIES ARE DOCUMENTED IN THE PHAAMACIS :al'l~J J1?;)
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DATE
(DATE '\ Name. vlln I I
I" J 3/17/06. ./ APR06
I n I n... I.ILM U
10/22/03 DIC Rx'
-CRUSHADLE "EDS nAY DE CRUSHED
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7A-7P 03/05/05 ole Drder' 00011
UEEKLY DLOOD PRESSURE UEDHESDAY ORTHOSTATIC DIP
1ST NEDHESDAY Of EACH nOHTH ~
02/07/05 D/C Rxl 177488.03
ZOCOR 10 n, TADLET (SInUASTATIH)
1 TABLET OY MOUTH EVERY EVENING ~
9:00A 02/04/05 D/C Rxl 177485.03
ARICEPT 10 nG TABLET (DOHEPEZIL HCL)
1 TABLET BY HOUTH OHCE DAILY (SDAT) ~
,/
9:00A 11/07/05 D/C Rxl 174866.00
/ ASPIRIN 81 nG TADLET CHEU (ASPIRIN)
1 TABLET BY MOUTH ONCE DAILY (PVD)
~
9:00A 03/03/06 DIC Rx' 182796.00 RTH
CITALOPRAn HDR 40 nG TADLET (FOR CELEXA 40 nG TADLET)
1 TABLET BY "nUTH ONCE DAILY (DEPRESSION) ~TAKE UI
lOnG TAB TD= SOMG DOSE* ~
9:00A 03/03/06 DIC Rx' 182797.00 RTH
CITALDPRAn HDR 10 nG TADLET (FOR CELEXA 10 n, TADLET)
1 TABLET BY MOUTH ONCE DAILY (DEPRESSION) MTAKE U/
40"' TAB TD= SONG DDSE~ ~
9:00A 06/07/05 DIC Rxl 166637.00 RTN
LDRATADINE 10 nG TABLET (FOR CLARITIN 10 nG TADLET)
1 TABLET ~Y MOUTH DNCE DAILY (RUNNY NOSE)
~
9:00A 02/04/05 DIC Rx' 1774SQ.03
nETOPROLOL 25 nG TABLET (nETOPROLOL TARTRATE)
5:00P 1 TABLET BY nOUTH TUICE DAILY MSUB fOR LOPRESSOR*
(HHO
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9:00A 02/04/0~ DIC Rx' 177486.03 RTH
HAnENDA 10 ne TABLET (nEnAMTINE HCL) /
5: OOP 1 TABLET OY MOUTH TUICE DAILY (SDAT)
DATE
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DOCTOR
JOSEf I ERNEST M 717-732-8877
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EXHIBIT
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PHARMERIO\
ORIGINAL
COpy
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CODE STATUS:
DNR PER MEDICAL DIRECTIVE ~
RESIDENT IS INCAPABLE DF UNDERSTANDING DIAGNDSIS
, PLAN Dr CARE & RESIDENTS RIGHTS. DUE
TO: DEnEHTIA
~
RTH
DISCONTINUE ALL PREVIOUS DRDERS. ~
FOLLDU AUTOMATIC STOP ORDER POLICY ~
DIET ORDERS: ~
RTN REGULAR 1500~ ~~D I ~ LU:t ~
ACTIVITIES: ~
ACTIVITY LEVEL:
RTN
nISCELLANEOUS ORDERS: ~
YEARLY INfLUENZA VACCINE
flU OFfICE VISIT EHDDSCOPY CENTER IN 1 YEAR~
rlu PACEMAKER CHECKS AT MOfrITT HEART VASCULAR
GROUP AS SCHEDULED ~
YEARLY PPD DUE 2/06 ~
RESIDENT MAY GO LOA UITH MEDICATIONS ~
P. T. [VAL & TX AS IHDICATEDJj{~
RESTORATIVE NURSING:
RHP UHTIl GOALS nEV.1>~ltrlob
RTN
LAB ORDERS: ~
fLP lAST ,AlT EVERY YEAR ~ 1/07
BMP EVERY 6 MONTHS t\~D 31'/ /Db ~
FASTING DLDDD SUGAR AND LIPID PANEL EVERY THREE
MONTHS TInES ONE OHE UITH DOSAGE CHANCES, THEN ~
EVERY SIX nDNTHS TD "ONITOR FOR ADVERSE SIDE \/'
--.EffECTS RELATED 10 SER9UE~ Jhu, 7/0 {;
DATE 0 -JA ~f;
UHEEZIHG/PNEUnONIAt SDATtDEPRESSIDN~HYPERLIPIDEMIA,
~tMI/A"B. DVSF/AHEM AI fA LURE Tn TH~IUE,GI
f N
:tUb ALLERGIES
~~~~el11 SHtlY, PATRICIA J
Cilia)
III'
Pl-IARMERI Q
PHYSICIAN'S ORDER
( DA TE '\
\. 03/17/06" /
APR06
ORIGINAL
COpy
. .. ., .
9:00A 02/04/05 ole Rxt 177487.03
HORUASC 5 ns TABLET (AnLODIPIHE BESYLATE)
1 TABLET or MDUTH DNCE DAILY (HTN)
RTH
/
REHABILITATIVE POTENTIAL:
HMREHAOILITATIU[ PDT[HTIALM~
GDDD___fAIR___PODR___MAIHTENANCE_X_
/
9:00A 06/06/05 DIC Rxt 175352.05 RTH
onEPRAZOLE 10 ns CAPSULE DR crOR PRILOSEC 10 ns CAPSULE
1 CAPSULE BY MOUTH EVERY nDRHING (HID GI BLEED) . ~
MMDO NOT CRUSHMM ~ .:MRESIDENT REQUIRES NURSING fACILITY SERbtCES
9:00A 02/04i05 DIC Rxl 158SQ9.00 RTN CDNTINUE INDIVIDUALIZED RESIDENT DRDERS ~
/ DNE-TABLET-DAILY <fOR nULTIUITAnIH TABLET)
1 TABLET oy MOUTH DNCE DAILY (VITAnIN SUPPLEMENT)
V
I HAVE REUIE~ED AND APPRDVE THE ABDUE OVERALL PLAN
Df CARE ~
9:00A OS/25iOS DIC Rxl 175654.0Q
SEROAUEL 100 nG TABLET CAUETIAPIHE funARATE
1 TABLET BY MOUTH EUERY MDRNING MTAKE ~ X 25MG
TABS TD= 150MC ~DSE* (SDAT UI DElU S)
RTN
nAY USE GENERIC SUBSTITUTIDN UNLESS DTHERMISE
INDICATED ~
/
9:00A 05/25/05 DIC Rxl 5655.04
SEROQUEL 25 nG TADLET TIAPINE funARATE)
2 TABLETS BY nOUTH ~ MC) EVERY MORNING MTAKE UI
lOOMS TAB TD= 1~ G DOSE~ (SDAT UI DELUSIDNS)
NURSING ORDERS:
FDLLDU SKIN & UDUND PRDTDCDL fDR ALL SKIN
CONDITIDNS
RTM
/
06/08/05 Rxl 177489.03 RTN
SEROQ 300 nG TADLET (AUETIAPINE funARATE)
4:00P 1 ILET BY MnUTH DNCE DAILY AT 4pn (SDAT UI
LUSrnHS)
02/22/05 DiC Rxl 179071.02 RTM
LISINDPRIL snG TAD (FOR PRIHIUIL 5 nG TABLET)
5:00P 1 TABLET BY MDUTH EVERY EVENING MM HDLD "f SYST
B/P BLDOD PRESSURE (100 MM FOR HTN \I'
P 01/16/06 ole Rxl 179363.00 PRH
)R ACETAnINOPHEN 325 nG TABLET (fOR TYLENOL 325nG TABLET)
v' H 2 TABLETS (650MG) BY MOUTH EVERY 4 HDURS AS HEEDED
fOR C/D PAIN OR DISCOMfDRT ~
02/05iOS Die Rxl 158862.00 PRH
ANTI-DIARRHEAL 2 nc CAPLET <rOR InODIun A-D 2nG CAPLET)
2 CAPLETS BY MOUTH INITIALLY THEN 1 CAPLET BY J
MOUTH AS NEEDED AFTER EACH UNfDRMED STOOL *NAX
16MG/24HR*
02/21/06 D/C ________ Rx' 181791.00 PRH
PHEHADOZ 25 nG SUPPDSITORY (rOR PHENERGAH 25 ne SUPPOSI
INSERT 1 SUPPDSITORY RECTALLY EVERY 6 HDURS AS
NEEDED rDR NAUSEA I VOMITING ~
--------~-------------------------------------
~RESCRIBER SIGNATURE
EVIEU[f) [iV~ ~ 1-:tIa~.IItrrJJ.DPJL _ '-I /~I J(J(; NDII1LllL\...
~~I~~6:i'1~I~~E~~~~ ~~~~N~ED IN THE PHAA A rs MONTHL Y REPORTS 0 NO IRAEGUl AlliES N ED
~~~;) 0 INSIGNifiCANT IRHEGUIARITIES NOTED
X ' r1tf'11J7.- 0 SIGNIFICANT IRREGULARITIES NOTED
PHARMACY DATE
)2
R
H
,P
R
H
DOCTOR
lDSEr, ERNEST M 717-732-8877
tlH PLAH- pes SEX- F DDB- 10/23/1931
NH RESt-04538 RES CDDE- 03251
DIAGNOSIS DNR SOB DR UHEEZIHC, PNEunDHIAf SDATtDEPRESSIDN"HYPERLIPIDEnIA,
PACER nunURtnIJAno. DYSFJAHEn A} FA LURE TD THKIUEJGI
BLEED,PVD,H H
ALLERGIES ND Jl:HDI.IH DRUG ALLERGIES
(DATE-----~.-- '\
l__ 03/17/06
l'(OIIIC, _.~... I
rn '''''-'14'- ~ Uft."'';R.
, .
~iili~
PHARMERI G\
APR06
ORIGINAL
COpy
02/23/05 D/C Rxl "
NURSING CARE PROfILE & RESIDENT CARE PLAN fOLlD~ED
THRDUGHDUT THIS SHIfT - INCLUDING DUT HDT LInITED
TO PERSDNAL PRDTECTIVE Ep.UIPnEHT IN PLACE} SAFETY
ALA M . ~
INTERVENTIDNS} GRDDMING, ORAL' NAIL CARE
\,-'
7A-7P 10/24/03 D/C Drder' 00013
nDN SKIN ASSEssnEHT - TOTAL OODY SKIN ASSEssnEHT ONCE
UEE~lY + If O~ - If SOMETHING fOUND ~
~h ~,.. I,.J J() 300~ P,O
~~~~~ \l PRESCRIDER SIGNATURE
0J l.D l5 b~JL ck.O..u-,l.LC~)
Y/3, (J"
Qf , " 0 HDTED .,BY
().Yi L l CXA T R I (\.J ...::> f:.- (j
(COmb pc' 810LOu~
REUIEUED BY
q DATE tf ?4filt
~D &~Ltu:li..US DATE L;l;)../~,
~dkt)AJ DATE ~
c;itahl""'l....l4:ddfl-;> ~/z<(/,."
[At. R~-~ TOTAL .DUTIES: 15
TDTAL III TRIll: 8
TDTAL PlI:
TITAl. PRI TilT:
:I REVIEW Of ENTIRE DRUG REGIMEN AND COMPREHf:NSIVE RESIDENT CARE PLAN IS COMPLETED
;J ANY IRREGULARITIES ARE DOCUMENTED IN THE PHARMACIST'S MONTHl Y REPORTS
.
DOCTOR
JDSEf, ERNEST" 717-732-8877
~N PLAH- pes SEX- r Dn~--1llL23/1933
NH RESI-04Sj8 RES CDDE- 03251
X
PHARMACY
o NO IRREGULARITIES NO"!TC
o INSIGNIFICANT IRREGULARITIES NOTED
o SIGNIFICANT IRHFGULARITIES NOTED
DATE
DIAGNOSIS DHR SIlB DR t.lHEEZIHG I PHEUtlDHIAt SDATtDEPRESSIDH J. HYPERLIPIDEtlIA I
PACER "UnURt"I/A"B. DYSt)AHEn AI FA LURE TD TH~IVE}bI
BLEED,POD," H
ALLERGIES ND I(HDUH DRUG ALLERGIES
<.'U^I,I D^T[lT('T^ I
"'01
..
IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA
IN RE:
) ORPHANS' COURT DIVISION
)
) No.
)
) PETITION FOR THE APPOINTMENT
) OF A PERMANENT GUARDIAN OF
) THE PERSON AND THE ESTATE
)
PATRICIA J. SHAY,
AN ALLEGED
n~CAPACITATED PERSON.
CONSENT OF THE PROPOSED GUARDIAN
I, Tracy D. Shay-Snyder, do hereby certify that I am willing to act as the Permanent
Guardian of the Person and Estate of PATRICIA J. SHAY, if the Court shall so appoint Ine.
Further, I do hereby certify that I mn not a fiduciary of any estate in which the alleged
incapacitated person has an interest, nor have I any interest adverse to the alleged incapacitated
person.
I mn an adult and read and write the English language.
The facts and opinions contained herein are true and correct to the best of lTIY knowledge,
infonnation and belief.
J J,
~-5 ( rs (cJ lc'
Date
/ .' .
. ;/? IlL
\..;:/'~J~:;?-' J' . \. _J 1/ d. T
Tracy .Jj. Shay-Snyd~r
,;7 ,
~jJzn/" (Q...,;''__
,
/
l~._/
S worn to and subscribed before Ine this
I C..'")- -J}\
, ,
I
day of
, 2006.
My COlTIlTIission Expires:
COMMONWEALTH Of PENNSYLVANIA
Notarial Seal
Amy A. Reavey, Notary Public
City Of Harrisburg, Dauphin County
My Commission Expires June 23. 2008
Member, Pennsylvl'lni?' A~sociation Of Notari~.
EXHIBIT
I~
)
D
:9
/7
'/ j'
~;\
J/!
~
..
IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA
INRE:
) ORPHANS' COURT DIVISION
)
) No.
)
) PETITION FOR THE APPOINTMENT
) OF A PERMANENT GUARDIAN OF
) THE PERSON AND THE EST ATE
)
PATRICIA J. SHAY,
AN ALLEGED
INCAPACITATED PERSON.
ORDER OF COURT DETERMINING INCAPACITY AND APPOINTING
PERMANENT GUARDIAN OF THE PERSON AND EST A TE
AND NOW, this
day of
, 2006 a hearing in
this case having been held on
, 2006 and it appearing to the Court that
PATRICIA J. SHAY, would be harmed by her presence at the hearing, and further finds from the
testimony:
1. That PATRICIA J. SHAY suffers from Alzheimer's Dementia which totally impairs
her capacity to receive and evaluate information effectively and to make and
communicate decisions concerning her management of financial affairs or to meet
essential requirements for her physical health and safety.
2. That there are insufficient supports available to assist PATRICIA J. SHAY in
overcoming such limitations and that there exists no less restrictive mechanism for
decision making than the appointment of a Permanent Guardian of her Person and
Estate.
3. That based on the total incapacity of PATRICIA J. SHAY, to receive and evaluate
information effectively and to make or cOlnmunicate decisions, a Permanent
Guardian of the Person and Estate is required on a pennanent basis.
19
~
..
NOW THEREFORE, based on the clear and convIncIng evidence supporting the
foregoing findings, it is ORDERED, ADJUDGED and DECREED that PATRICIA J. SHAY
be and hereby is adjudged a totally incapacitated person. It is further ORDERED, ADJUDGED
and DECREED:
TRACY D. SHAY-SNYDER is appointed Permanent Guardian of the Person and Estate
of PATRICIA J. SHAY.
The Power of Attorney given by PATRICIA J. SHAY to CHARLES E. SHAY, JR., is
hereby rendered NULL AND VOID AND OF NO EFFECT.
The Permanent Guardian of the Person and Estate shall have full authority to consent to
the general care, maintenance and custody of PATRICIA J . SHAY without exception.
The Permanent Guardian of the Person and Estate shall assure that PATRICIA J. SHAY
receives appropriate services and shall assist her in developing self-reliance and independence.
If there is a safe deposit box in the name of the incapacitated person alone or in the names
of the incapacitated person and another or others, said safe deposit box shall not be entered by
the Guardian except in the presence of a representative of the financial institution where the box
is located or in the presence of a representative of the Orphans' Court Division. The
representative present at the tiIne of entry shall make or cause to be made a record of the
incapacitated person's property, and said record shall be filed with the Clerk of the Orphans'
Court Division. None of the incapacitated person's property may be removed until after the
aforesaid inventory is completed.
If the safe deposit box is jointly owned, five (5) days notice of the proposed entry shall be
given to the other owners by the Guardian.
20
p
...
An Inventory must be filed within
Person and Estate shall be filed within
approved by the Orphans' Court Divisions.
No Surety Bond is required.
PATRICIA J. SHAY, an incapacitated person, has the right to appeal this Order of Court
by filing exceptions with the Clerk of the Orphans' Court Division within ten (10) days of the
days. A report by the Guardian of the
days and annually thereafter in a form
date of this Order or to petition this Court for a hearing to review or terminate the adjudication of
incapacity and guardianship herein established.
If PATRICIA J. SHAY was not present at the hearing on the adjudication of her
incapacity and appointment of a guardian then Petitioner shall serve upon and read to PATRICIA
J. SHAY the Statement of Rights attached to this Order of Court and marked as Exhibit "A".
Proof of Service of the Statement of Rights shall be filed by the Guardian with the Clerk of the
Orphans' Court within ten (10) days of the date of this Order.
BY THE COURT:
J.
21
.,
r
.
STATEMENT OF RIGHTS
AN ORDER HAS BEEN ENTERED BY A JUDGE OF THE COURT OF COMMON
PLEAS OF CUMBERLAND COUNTY, ORPHANS' COURT DIVISION, WHEREBY YOU
HA VE BEEN ADJUDICATED AN INCAP ACIT A TED PERSON AND UNABLE TO CARE
FOR YOURSELF AND/OR MANAGE YOUR PERSONAL AFFAIRS. YOU HAVE THE
RIGHT TO FILE EXCEPTIONS WITHIN TWENTY (20) DAYS OF THE DATE OF THE
COURT'S ORDER WITH THE ORPHANS' COURT OR THE RIGHT TO FILE AN APPEAL
WITHING THIRTY (30) DAYS OF THE DATE OF THE COURT'S ORDER WITH THE
SUPERIOR COURT. IN THE EVENT THAT YOU FILE EXCEPTIONS AND THEY ARE
DENIED, YOU HAVE A RIGHT TO FILE AN APPEAL TO THE SUPERIOR COURT
WITHIN THIRTY (30) DAYS OF THE DATE OF THE DENIAL OF THE EXCEPTIONS.
IN ADDITION, YOU MAY PETITION THE COURT AT ANY FUTURE TIME TO
MODIFY OR TO TERMINATE THE GUARDIANSHIP IF THERE IS A CHANGE IN YOUR
CAPACITY OR IF YOUR GUARDIAN FAILS TO PERFORM HIS/HER DUTIES IN
ACCORDANCE WITH THE COURT'S ORDER.
IF YOU WISH TO APPEAL THE ORDER OR TO PETITION THE COURT TO
MODIFY OR TERMINATE THE GUARDIANSHIP, YOU ARE ENTITLED TO BE
REPRESENTED BY AN ATTORNEY. IF YOU DO NOT HAVE AN ATTORNEY, THE
COURT MAY APPOINT ONE TO REPRESENT YOU. IF YOU CANNOT AFFORD AN
A TTORNEY, THE SERVICES OF AN ATTORNEY WHOM THE COURT MAY APPOINT
FOR YOU WILL BE PROVIDED AT NO COST TO YOU.
Exhibit "A"
22