Fill and Sign the Louisiana Protective Elderly Form

STATE OF LOUISIANA NUMBER: DIV.: ____ JUDICIAL DISTRICT COURT IN THE INTEREST OF PARISH OF __________________ __________________ STATE OF LOUISIANA PETITION FOR EMERGENCY PROTECTIVE SERVICES NOW INTO COURT , comes ______________ , Attorney for _________________ , on behalf of Elderly Protective Services (EPS), who respectfully represents the following: 1. A complaint of caregiver neglect of the elderly adult, ______________ has been filed with the Office of Elderly Affairs, Elderly Protective Services for the State of Louisiana, Parish of ______________ . 2. The complaint of caregiver neglect of the elderly adult has been investigated by the Office of Elderly Affairs, Elderly Protective Services for the State of Louisiana, Parish of ______________ and said Office of Elderly Affairs alleges neglect of said elderly adult occurred as per the following facts, circumstances and dates set forth below: 1. ______________ is ________ ( ___ ) years old and lives at ______________ , ________ , LA, with his daughter, ______________ , who is also his caregiver. ______________ has been diagnosed with terminal liver and lung cancer. Furthermore, ______________ is incontinent and malnourished. 2. On __________ ___ , 20 ___ , ______________ ’s nurse, ______________ , noticed that ______________ ’s liquid pain medication, ______________ , looked different. ______________ noticed that the medication smelled different and there was more in the bottle that what was prescribed. ______________ along with ______________ , took the medication to ______________ and had it examined by ______________ , Pharmacist. ______________ found that the medication had been replaced with water. Furthermore, the prescription for the pain medicine was called into the pharmacy on __________ ___ , 20 ___ , but was not picked up by ______________ until __________ ___ , 20 ___ . 3. ______________ , daughter and caregiver, denies that the medication has been replaced. However, ______________ did admit that she was reluctant to administer the medication to ______________ and only did so when he complained of pain. 4. ______________ is also not being fed his meals on a timely basis. ______________ has noted that during his visits ______________ would be eating breakfast at 11:00 a.m. Further, that ______________ ’s medication was being administered orally when it should have administered through his peg tube, due to his risk for aspiration. 5. Furthermore, ______________ will not open the door for the nurse, nurse aid or the social worker. When ______________ does allow the home health care workers into the home, the home is filthy and ______________ has been found in diapers soaked with urine and feces. 6. ______________ was taken to ________________________ because he was suffering with pain from his liver and lung cancer. This was due to his medication not being administered properly and also the medication being replaced with water. 7. ______________ has currently been placed at ________________________ , ______________ , ________ , Louisiana. 3. ______________ is a total needs patient. ______________ suffers from liver and lung cancer, is incontinent and malnourished. ______________ has been neglected by his caregiver, ______________ . 4. Pursuant to LSA R.S. 14:403.2 N(1) through N(4)(E), for a period not to exceed fifteen (15) days, petitioner requests an ex parte order compelling ______________ to comply with the following protective services: (a) nursing home placement at ________________________ , ______________ ., ________ , Louisiana. 5. Petitioner avers that the elderly adult is at immediate and present risk of substantial harm or deterioration from caregiver neglect; that the elderly adult lacks the capacity to consent as defined in LA R.S. 14:403.2B(4); and that is it necessary that this Court issue said ex parte order, without the necessity of posting bond, to provide emergency protective services in order to prevent further harm to the elderly adult. 6. Petitioner further desires that a rule issue herein, within fifteen (15) days of the issuance of the ex parte order, commanding defendant ______________ , to show cause why defendant should not be compelled to comply with the Court’s order for services, which orders shall not exceed a period of fifteen (15) days. 7. Petitioner requests that the defendant be represented by an attorney of defendant’s choice or that an attorney be appointed to represent defendant. WHEREFORE , petitioner prays that: 1. That certified copies of this petition, with ex parte order for emergency protective services and rule to show cause, together with citation, be issued and served according to law on the defendant, ______________ . 2. That the ex parte order requested in paragraph four of this petition be granted; 3. That a rule issue for defendant to show cause why the orders for emergency protective services as requested in paragraph five of this petition should not be granted and why defendant should not be ordered to pay all costs of these proceedings; 4. That defendant be represented by an attorney at law as requested in paragraph seven; and 5. For all necessary orders and decrees as may be required or proper in the premises and for full, general and equitable relief. RESPECFULLY SUBMITTED BY: __________________ , # _______ ________________________ __________________ ___________ , LA _______ ( ____ ) _______ ( ____ ) _______