Nursing Home Deposition 1 - Plaintiff's Deposition of Physician - Part 2

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Would you agree with me that the nurses -- strike that.
Would you agree with me it's possible that the nurses at Manor Care Nursing Home who were caring for Betty Kunz on June 13 of 2000, it was possible for them to have contacted Dr. Beezhold's office regarding this patient?
A. It was possible for them to? Yes, it was possible.
Q. That the nurses at the nursing home both on June 13th and June 14th of 2000 had information in the chart which identified Dr. Beezhold's name and the number at which they could contact Dr. Beezhold?
A. For a follow-up appointment was what the order said, yes.
Q. Okay. But my question specifically?
A. They knew who he was, yes.
Q. So my specific question is the nurses who were caring for Betty Kunz at Manor Care on June 13th and June 14th of 2000 had information available to them which identified Dr. Beezhold as the infectious disease consultant and also identified his phone number?
A. Yes.
Q. Earlier you mentioned that Gentamicin is nephrotoxic?
A. Yes.
Q. Can you describe for us what you mean by that.
A. Well, nephro means kidney, and toxic, so it's very hard on the kidneys.
Q. Are registered nurses as part of their training, do they learn about the nephrotoxic aspects of Gentamicin?
A. I would believe so, yes.
Q. Are there any special precautions that you as a nurse take when you are caring for a patient that is on IV Gentamicin?
A. Specific precautions?
Q. Correct, as opposed to a patient that is not on any IV Gentamicin therapy?
A. You know, generally if they're on Gentamicin, you're going to be -- they also have an infection and probably a very difficult infection. So you're going to be looking at that portion of it. You're going to be making sure that they get fluid intake and monitoring that they continue to urinate.
Q. As a registered nurse, would you monitor the laboratory results for patients under your care that are undergoing Gentamicin therapy?
A. Yes.
Q. And why would you as a nurse be monitoring the laboratory results for a patient under your care that's undergoing Gentamicin therapy?
A. You're going to want to see if there's any abnormalities and you're going to see the reports usually before the physicians so that you can get the information to them.
Q. Is there any particular laboratory result that you're looking at when you're caring for a patient that is receiving Gentamicin therapy?
A. You're going to be looking at your kidney function tests.
Q. And creatinine is one of those lab results that indicate kidney function?
A. Yes.
Q. What other lab results indicate kidney function?
A. BUN.
Q. Anything else other than creatinine and BUN?
A. Not that I can think of right away.
Q. What does BUN stand for?
A. Blood urea nitrogen.
Q. Is that another way to say urea nitrogen serum?
A. Yes.
Q. If serum creatinine is elevated, I know I'm giving a little practical exam here with all of these terms, so let me ask you a different question.
If serum creatinine in a patient is elevated, is the BUN generally elevated as well?
MR. FURA: Objection as to incomplete hypothetical.
A. I don't think I know.
BY MR. McKENNA:
Q. Did Dr. Tang come to the nursing home and see this patient Betty Kunz on June 14th of 2000?
A. On June 14th?
Q. Yes.
A. I don't think so.
Q. Did any of the nurses based on the information you've reviewed in this case request Dr. Tang to come into thenursing home to see this patient on June 14th of 2000?
A. I don't believe that the nurses requested him to come to the nursing home to see the patient on the 14th.
Q. Is there a particular record in a nursing home setting that is kept which monitors the actual administration of medications?
A. Yes.
Q. And what is that record called?
A. Usually a medication administration record.
Q. And in a nursing home setting, who is responsible for filling out the medication administration record?
A. The nurse that gave the medication.
Q. And as we established earlier, a nurse cannot stop application of a medication without a direct physician order, correct?
A. Generally not.
Q. Let me ask it a different way, so it's clear for the record. In a nursing home setting, a nurse generally cannot stop the application or administration of an IV drug without a physician order, correct?
A. Correct.
Q. In a nursing home setting, is it the policy at the nursing homes that you've worked at that all orders from a physician must be in writing and entered into the chart?
A. Yes. Normally physician orders are in writing, entered in the chart and cosigned by the physician if he didn't write them.
Q. Who was the director of nursing in June of 2000 at Manor Care when Miss Kunz was a patient?
A. I believe it's Noreen Buchthal.
Q. Buchtal?
A. Buchtal.
Q. I think we established earlier that on June 13th when Miss Kunz was reporting difficulty in urinating and the outputs that were measured measured low urine output, that those were signs of possible renal compromise in this patient?
A. They could have been.
Q. Is it fair to say that there were no signs of poor renal function or renal compromise prior to June 13th, 2000 while this lady was at the nursing home; is that correct?
A. There were no signs at the nursing -- from -- in the nursing home, is that what you're asking?
Q. Yeah.
A. No, I don't believe there were.
Q. And I guess what I'm trying to establish is that when Miss Kunz got to Manor Care Nursing Home on the evening of June 10th, the nurses did not chart any signs of renal compromise or poor renal function, correct?
A. Correct.
Q. In general in a nursing home setting when a patient under your care as a nurse needs consultation or examination by a specialist physician, is it the job of the nurse or the attending physician to get that consultation?
A. Generally, the physician will say -- either they will contact for consult or they will say call and make an payment for. Generally, the consultants don't come into the nursing home.
Q. And if there is a need for some reason for the consultants to come into the nursing home, it sounds like it's usually the job of the physician to make sure they'd get into the nursing home to see this patient?
A. I would say rarely does the consultant come into the nursing home. So most often, it's making arrangements for the patient to see the consultant.
Q. Either through transfer to the hospital or some type of Medicar or something like that to the consultant's office?
A. Yes, or a car. Family can take them sometimes.
Q. But in any event, whether or not the consultation is to take place at the nursing home or outside of the nursinghome, it sounds like it's the job of the attending physician to make sure that consultation takes place?
A. To make sure that it takes place?
MR. LITTMAN: Objection to foundation.
A. I guess I don't quite know how to answer it. The physician says, I want Mrs. Jones to see this consultant. You know, you call the office, make the appointment and make the arrangements for the person to go and see them.
BY MR. McKENNA:
Q. Well, you reviewed Dr. Tang's deposition, you mentioned?
A. Yes.
Q. That was -- I think that's one of the more recent depositions you've reviewed?
A. Yes.
Q. You recall there's one part in Dr. Tang's deposition where he mentions that he -- and you can correct my words if they're incorrect, but he wanted one of the nurses at the nursing home to contact Dr. Beezhold's office. Do you recall that testimony?
A. I recall that he had also attempted to reach Dr. Beezhold and that he had asked them to go ahead and call also.
Q. Okay. So did the nurses at the nursing home ever get in touch with Dr. Beezhold?
A. At that exact time?
Q. Yes.
A. I don't know if it related. Well, sometimes, at some point, they took orders from him, but I don't know if it was at that specific time.
Q. Is it the responsibility of the nurses to contact a consultant when requested to do so by the attending physician?
A. Is it a nurse's responsibility; is that what you said --
Q. Yeah, let me ask it --
A. To --
Q. I'll ask it again so we're clear. Is it the responsibility of a nurse in a nursing home to contact a consultant when the attending physician requests the nursing home nurse to do so?
A. It's the nurse's responsibility to make every effort to reach that consultant at the request of the physician, yes.
Q. And do you know what efforts, if any, the nurses at Manor Care made to contact Dr. Beezhold's office when requested to do so by Dr. Tang?
A. No, I don't.
Q. You mentioned you've done some work before as an expert?
A. Yes, I have.
Q. Approximately how many cases have you worked on as an expert?
A. Five.
Q. And have any of those cases previously been for Mr. DeLora or his firm?
A. Yes.
Q. How many?
A. One.
Q. And do you remember the name of that case? If you don't --
A. I don't recall.
Q. That's fine.
Have you ever done any work on behalf of a plaintiff as an expert in a case?
A. No, I haven't.
Q. So all the five cases you've worked on as an expert, those have been on behalf of defendant nursing homes?
A. No.
Q. Have those been on behalf of either a defendant nursing home or a defendant hospital?
A. Yes.
Q. Have you ever done expert work for Little Company of Mary Hospital?
A. No, I haven't.
Q. What about for Manor Care?
A. No, I haven't.
Q. Have you ever worked at Manor Care?
A. No, I haven't.
Q. Do you know any of the physicians that have been mentioned in this case?
A. No.
Q. Do you know any of the nurses?
A. No.
Q. How much do you charge for your time?
A. $200 an hour.
Q. How much time have you spent up to now on this case?
A. 23 hours.
Q. Have you ever testified before at a trial here in Cook County?
A. No, I haven't.
Q. Have you testified at a trial anywhere else in the State of Illinois?
A. Not in Illinois.
Q. Did the care plan that was created when -- strike that.
When was the care plan completed at the nursing home regarding Miss Kunz?
A. The exact date?
Q. Yes.
A. Depends on the date, different dates.
Q. What's the?
A. 6/10.
Q. What, if you can tell us, what portions of the care plan were completed as of the June 10th date?
A. Potential for complications from IV therapy.
Q. What potential complications did they note there?
A. Their redness, warmth edema.
Q. Is there any mention in the care plan of the June 10th date, any mention of the Gentamicin therapy in particular?
A. No. And it would be unusual to care plan a drug.
Q. Is it usual, however, to care plan for IV medications in general?
A. For IV therapy in general, yes.
Q. You talk here in your witness disclosures that the nurses properly assessed and prepared assessment documentation for the resident. Can you tell us what you mean by that.
A. There is a requirement, both Federal and State, that a minimum data set be completed that is the official assessment within 14 days of admission and on change of condition.
Q. And the relevant Illinois and Federal regulations pertaining to this resident, do those deal with the minimum data set?
A. Yes, they do.
Q. Do you know what Miss Kunz's urinary output was before the first output was measured at approximately 12:30 p.m. on June 13th of 2000?
A. Do I know exactly what her output was, no, I don't.
Q. Is there any way to know from the chart what Miss Kunz's urinary output was between the time of admission to thenursing home and approximately 12:30 p.m. on June 13th of 2000?
A. No, there's no way to know the exact amount.
Q. Was there anything that you're aware of that prevented the nurses who were caring for Miss Kunz at Manor Care, anything that you're aware of that would have prevented them from measuring urinary output between the time that Miss Kunz entered Manor Care on June 10th and the time the first output was actually measured on June 13th of 2000?
A. Anything that would have prevented them, stopped them from doing it, no, there's nothing that would have stopped them from doing it. But there also wasn't necessarily a reason that it had to be measured versus monitored.
Q. But sitting here today, based on the chart, we don't know what the output actually was during that time?
A. We don't know the exact output.
Q. You mention here that nurses at Manor Care complied with the standard of care in informing the resident's physician of the resident's condition. Can you tell us what you mean by that.
A. When they notified the physician, she was having difficulty with urination, they notified the physician. As things progressed, they kept the physician up to date on changes they saw and information that they had.
Q. And regarding monitoring the resident's condition, can you tell us what you mean when you state here that nurses at Manor Care complied with the standard of care in monitoring the resident's condition?
A. If you read through the records, you can see how the patient is doing and you have the information you need. Any changes that are noted are notified to the physician, and so there's ongoing monitoring of the patient condition and notification of the physician.
Q. And what did the nurses do here in regarding to following the resident physician's orders? You have that opinion mentioned here, so I want to know why you feel that they acted properly in following the resident physician's orders.
A. Because there was, the physician did have an order for the antibiotics, and they gave the antibiotics as ordered, and they did follow those orders appropriately.
MR. McKENNA: I think I'm almost done. I just want to take a short break here. So, do you want to break?
THE WITNESS: Sure.
MR. McKENNA: A very short one. I think we're almost done.
THE VIDEOGRAPHER: Going off the record at 11:21 a.m.
(Whereupon a short break was taken, after which the following proceedings were had:)
THE VIDEOGRAPHER: Back on the record at 11:28 a.m.
BY MR. McKENNA:
Q. Looking at the opinions that have been disclosed here for you, it notes here that you will opine that Miss Vajdik's opinion that an unnecessary drug was given is wrong. What do you mean by that?
A. She stated that because Gentamicin was given and there were complications from it, that it was an unnecessary drug. But the patient also had a very severe infection in a joint with a foreign body in it and needed to have antibiotics to treat that infection. The drug wasn't an unnecessary drug.
Q. As a nurse, though, do you decide whether or not a drug is appropriate for a patient or do you leave that up to the physician?
A. The physician decides that it's an appropriate drug. She was saying it was an unnecessary drug.
Q. As a nurse, do you prescribe medications?
A. No.
Q. Are you -- do you consider yourself an expert in the use of Gentamicin?
A. I'm not an expert in the use of it.
Q. It states here you will also opine that Miss Vajdik's opinion is wrong, that the transfer sheet has to be signed by a physician to comply with the appropriate regulations. Can you tell us what you mean by that.
A. The regulation is the transfer order needs to be signed by a physician, not the transfer sheet.
Q. And which transfer sheet are you referring to?
A. The transfer sheet that was filled out and sent with the resident to the nursing home.
Q. Well, which regulation are you referring to in that sentence when you say that the transfer sheet does not need to be signed by a physician to comply with the appropriate regulations?
A. Which regulation exactly?
Q. Yes.
A. It's 483.40. It's F tag 385. And it's the physician must personally approve in writing a recommendation that an individual be admitted to a facility.
Q. Can I take a look at that?
MR. McKENNA: Thank you.
BY MR. McKENNA:
Q. Does this -- this applies to long-term care facilities?
A. Yes, it applies to long-term care facilities.
Q. Does this specific tag apply to hospitals?
A. No, it does not. This is nursing home regulations.
Q. So this nursing -- this regulation applies to the nurses in the nursing home, correct?
A. That a physician must have an order to be admitted to a nursing home -- a patient must have an order.
Q. This particular regulation does not apply to hospital nurses, correct?
A. I don't believe that it does, no.
Q. And which, you mentioned Section 483.40 is the section that you're pointing to. And which -- this is pretty long here. So can you point out for me which specific portion of that that you're relying on?
A. It's right here, the very first. A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of that physician.
Q. Maybe you can explain. And tab that, because we'll make a copy of that after the deposition. But how does that apply at all to the patient transfer form that we've been talking about in this case?
A. There is no requirement that I could find anywhere, no regulation that says the transfer form must be signed by a physician. If -- the hospital may have their requirements, but there is no requirement that the nursing home have a physician signed transfer form.
Q. Okay. So you're -- just so we're clear, you're saying that the nursing home staff did not need to make sure that a doctor signed Little Company of Mary Hospital's patient transfer form, correct?
A. I am saying that, yes.
Q. You're not saying anything about what Little Company's nurses needed to do at all regarding this patient transfer form?
A. Not at all.
Q. Now, the patient transfer form has an area on there for a physician's signature, correct?
A. Yes, it does.
Q. And do you know why the patient transfer form has an area for a physician's signature?
A. Usual and customary, if the physician that signs the transfer form is also going to be the attending at the facility, then we have written orders and we don't have to call to verify them.
If the physician is not the attending at the nursing home, you would have to call the attending to verify those orders. If there's no physician's signature, you must call a physician to get verification of those orders.
Q. Okay. So if the form is not signed and the doctor who issued these medication orders is not going to be the attending physician, does that mean that the receiving facility must contact the transferring facility's physician who issued the orders?
A. No.
Q. Okay. Clear that up for me then.
A. He would call the resident's doctor who is going to be taking care of her in the facility and he would validate those orders.
Q. Okay. So you're saying that because this wasn't signed, the nurses at the nursing home needed to contact Dr. Tang to verify these orders?
A. Yes.
MS. MATHURA: Let me just state my objection to calling anything on the transfer form as orders.
MR. FURA: Join.
BY MR. McKENNA:
Q. Do you know what, if anything, Dr. Tang did to verify the accuracy of the need for the listed medications on the patient transfer order?
MS. MATHURA: Same objection.
MR. McKENNA: Strike that. Let me ask you a different question.
BY MR. McKENNA:
Q. Do you know what, if anything, Dr. Tang did to verify that Miss Kunz had been ordered by her prior physicians to be on the medications that are listed on the patient transfer form?
A. I don't know if or if he did anything additional.
Q. So as far as what?
A. I don't know.
Q. What he did or didn't do to verify whether or not Miss Kunz needed to be on Gentamicin, you don't know?
A. No.
Q. What type of nursing home is the Pavilion of Waukegan?
A. A skilled facility.
Q. Is that different from the type of facility that Manor Care is?
A. I don't believe it is.
Q. Are they similar facilities?
A. They provide skilled care and rehab, so I would -- they were similar in that fact. As to size, I don't know.
Q. You're an RN here, licensed in Illinois?
A. Yes.
MR. McKENNA: Those are all my questions. Thank you.
THE WITNESS: Thank you.
MR. LITTMAN: No questions.
MS. MATHURA: No questions.
MR. FURA: Nope.
MR. DELORA: No questions. We'll reserve.
THE VIDEOGRAPHER: Going off the record at 11:37 a.m.
THE REPORTER: Did you want to order this?
MR. McKENNA: Yes, with an ASCII.
THE REPORTER: Does anyone want a copy?
MR. DELORA: Yes, mini and a disk.
MR. LITTMAN: Regular and mini.
MR. FURA: Mini and E-mail or disk.
MS. MATHURA: ASCII and mini.
AND FURTHER DEPONENT SAITH NOT...
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