Sample Deposition of Nursing Home Physician
BY MR. McKENNA:
Q. Ma'am, did you have a chance to bring your file with you today?
Q. And the documents that you've reviewed, are they the same documents that are listed here in these written disclosures?
A. Yes, with one addition.
Q. Okay. And what's that addition?
A. Dr. Tang's deposition.
Q. Have you reviewed the deposition of Dr. Beezhold?
A. No, I have not.
Q. Have you reviewed the deposition of Dr. Petrak?
Q. Have you requested those depositions?
Q. Is there any particular reason why you have not requested those depositions to read?
A. No reason that I can think of right now.
Q. Have you ever given a deposition before?
Q. Approximately how many times?
Q. And were those as an expert witness?
A. Two were.
Q. Today, I'm going to ask you some questions about your opinions in this case. If there's anything I ask you which you don't understand, please tell me and I will try to rephrase it for you. Okay?
Q. Now, in this case, can you tell us what was the treatment plan that was forwarded from the hospital to Manor Care regarding Betty Kunz?
A. The information forwarded was from the transfer sheet on the current medications, the diagnosis that they were going to be doing.
Q. Was there -- so the transfer form that you're talking about, that's, it looks in my chart, it's the last page of the chart, correct?
A. I don't -- I mean, I don't know if it's the last page of the chart or not.
Q. Okay. The patient transfer form you're referring to is this document and it's Bates numbered in my set 100116. You can take a look at that and tell us if that's the patient transfer form you are referring to.
A. Yes, it is.
Q. Was there any other documentation that you know of that went with this patient from Little Company of Mary Hospital to Manor Care?
A. I believe there was a history and physical.
Q. Whose history and physical?
A. From the hospital, the admission history and physical from the hospital.
Q. And do you know which physician or physicians prepared that history and physical?
A. No, not off the top of my head.
Q. Other than the patient transfer form and the history and physical from admission, any other documentation that you are aware of that went with this patient from Little Company of Mary Hospital to Manor Care?
A. There may have been more but not that I can, that I remember that I would consider the plan of care.
Q. And is the only document that discusses the medication that the patient is to be taking when she gets to the nursing home, is the only document that discusses that the patient transfer form?
Q. Who came up with the treatment plan that's indicated in the patient transfer form?
A. Who came up with the treatment plan?
A. The attending physicians from the hospital, the nurse transcribing those orders to the treatment plan, to the transfer order.
Q. Now, the treatment plan, did that call for Gentamicin?
A. It does here, yes.
Q. Okay. And the patient transfer form that you're looking at, to your way of thinking, that calls for the patient to be on IV Gentamicin when she gets to the nursing home, correct?
Q. And the patient transfer form that you're looking at, in your opinion, that-indicates that the patient is to continue receiving Gentamicin IV piggyback after her admission to the nursing home?
Q. And the patient transfer form there indicates that this patient Betty Kunz is to continue receiving IV piggyback Gentamicin during her stay at the nursing home, correct?
Q. Does the patient transfer form indicate when the Gentamicin therapy is to stop at the nursing home?
A. No, it doesn't.
MR. McKENNA: Let me have that back there. Thank you.
BY MR. McKENNA:
Q. Now, do you know which nurse prepared this patient transfer form?
A. I'd have to look.
Q. Is the notation that the patient is to receive Gentamicin, 120 milligrams IV piggyback every 12 hours, next dose 9:00 p.m. today, 6:10, is that based on any order from a physician?
A. Yes, it should be.
Q. And which physician gave an order that the patient is to receive Gentamicin 120 milligrams IV piggyback every 12 hours, next dose 10:00 p.m. today, 6:10?
A. The transferring physician from the hospital, the physician that wrote that order at the hospital.
Q. And which physician is that in particular?
A. I'm sorry, I can't think of his name. Dr. Beezhold's associate, I believe.
Q. Is doctor, the name Dr. Petrak ring a bell?
A. Petrak, yes.
Q. So the order upon which this notation of Gentamicin on a patient transfer form is based, that's an order that was issued by Dr. Petrak?
Q. And it's your opinion that this nurse at Little Company of Mary put down the Gentamicin on the patient transfer form based on an order from that physician, Dr. Petrak, correct?
Q. Would the nurse who filled out the patient transfer form be able to place a medication on there without a physician order to do so?
Q. Why is that?
A. Because you're giving the current orders from the hospital. So if there wasn't an order for medication, a nurse wouldn't write that on the transfer form.
Q. And is it fair to say because the patient transfer form does not indicate a stop date for the Gentamicin, that for all intents and purposes, this form indicates that Miss Kunz was to continue receiving IV Gentamicin during her stay at the nursing home?
A. Yes, unless the order was changed otherwise.
Q. Was there any physician plan that you're aware of at Little Company of Mary Hospital that called for this patient to continue to receive Gentamicin after her discharge from the hospital to the nursing home?
A. None that I'm aware of.
Q. How did, how does this patient transfer form actually get to the nursing home from the hospital?
MS. MATHURA: Objection, speculation.
BY MR. McKENNA:
Q. Customarily, how does a patient transfer form like this get from the hospital to the rehabilitation nursing home?
A. Either with the patient or with a family member or with an ambulance or a transport service that's taking the patient to the nursing home.
Q. In your career as a nurse, are you familiar with these patient transfer forms?
Q. And do you deal with them on a daily basis?
A. Well, not personally daily, but routinely.
Q. Based on your routine exposure to these patient transfer forms, what's the purpose of these patient transfer forms?
A. For continuity of care. So you know what the patient treatment was at the sending facility so that ongoing care can be provided at the receiving facility or so that the patient being discharged home would have the information they would need.
Q. And what happens at the nursing home or the rehabilitation center when the receiving facility gets one of these patient transfer forms?
A. They're reviewed, transferred, reviewed with a physician, transferred to physician's orders and any orders that he would change at the time would be changed going onto the new physician order sheets and then you'd have ongoing care from there.
Q. Now, in this case involving Betty Kunz, in what way, if any, did the Manor Care nurses know what the treatment plan was when they received Betty Kunz from Little Company of Mary Hospital?
A. I'm sorry, other than the information they received in the packet, I don't know.
Q. And we mentioned earlier, one of the pieces of information that they received was the patient transfer form?
Q. And is there any other information that you know of that they received that discussed the treatment plan for the IV medications the patient was to receive at the nursing home?
A. I don't think so.
Q. Which nurse at the nursing home in particular initially received the patient transfer form?
A. I think that would be impossible to tell who actually first received it.
Q. Well, is there a nurse at the nursing home that initially transcribed in the nursing home chart the information regarding medications that's contained on the patient transfer form from the hospital?
A. Yes, there was a nurse that transcribed from the transfer sheet to the physician's order sheet.
Q. And which nurse was that?
A. I'd need to look at the chart.
A. Donna VanGampler.
Q. And I take it you've reviewed her deposition?
Q. And did she rely on the patient transfer form in filling out her initial receiving record there?
Q. What is that record called that you're looking at?
A. It says Plan of Care, dated 6/10/00, 9:00 p.m. And then it has a place for orders and instructions for ancillary orders.
Q. Did Dr. Petrak ever come in and see Miss Kunz before he issued his order that she be discharged on Gentamicin IV piggyback?
A. I don't believe so.
Q. How did Dr. Petrak obtain the information regarding the patient's history and physical condition before issuing that telephone order?
A. Through a conversation with a nurse at the hospital.
Q. And which nurse was that?
A. I think it's Helena Ciezkowski.
MS. MATHURA: I'm just going to object to foundation. It doesn't appear that the witness has reviewed Dr. Petrak's deposition transcript.
BY MR. McKENNA:
Q. The information that the nurse conveyed to Dr. Petrak, was that information correct as far as what Dr. Beezhold's plan was for this patient?
A. The information that that nurse gave to Dr. Petrak, was it correct?
A. As to Dr. Beezhold's?
A. Written plan, I don't know.
Q. Well, did Dr. Beezhold ever plan for this lady to be discharged from the hospital on IV Gentamicin?
Q. Did Nurse Ciezkowski, did she convey to Dr. Petrak that it was Dr. Beezhold's plan for Miss Kunz to be discharged on IV Gentamicin?
A. I believe she said that she gave him the information from the plan.
Q. And would the plan -- or strike that. Did the plan call for Miss Kunz to continue to receive IV Gentamicin after discharge from the hospital?
A. The plan that Dr. Beezhold had written?
A. Did not include Gentamicin.
Q. If Nurse Ciezkowski informed Dr. Petrak that Dr. Beezhold's plan did call for this patient to be discharged from the hospital on IV Gentamicin, would you agree that that is a breach of the standard of care for that nurse?
A. If she did that, then it would have been not what was written, so it would have been not standard of care.
Q. I take it the standard of care calls for nurses to accurately convey to a physician over the phone the information that's contained in the chart, correct?
A. The standard of care requires that nurses convey the information that they're asked for, not all of the information in the chart.
Q. So if Dr. Petrak asked for the nurse in this case Nurse Ciezkowski to give him the information regarding his partner Dr. Beezhold's plan, the standard of care required Nurse Ciezkowski to correctly convey the information regarding that plan, correct?
A. Yes, it would require her to read back that plan of care to him.
Q. And in reading that plan back to Dr. Petrak, if Nurse Ciezkowski informed Dr. Petrak that the plan called for Miss Kunz to be discharged from the hospital on IV Gentamicin, would you agree that that's a breach of the standard of care?
A. If she read back the information improperly, it would be a breach of the standard of care.
Q. Now, is it -- strike that. Now, from the perspective of the nursing home nurse, Nurse VanGampler, does this patient transfer form here in your opinion indicate to Nurse VanGampler that the Gentamicin 120 milligrams IV piggyback should be discontinued as of 9:00 p.m. on June 10th of 2000?
Q. And why not?
A. Because as you're reading it, the Gentamicin 120 milligrams IV piggyback, Q12 hours, next dose 9:00 p.m. today 6:10. She's giving the date of today as was with the next dose of the Vancomycin, which was 03:00, 6/11.
Q. In your opinion, is there any significance to the fact that this date 6/10 is written in this column that says DC date?
A. Not from the way this form is filled out, no.
Q. And why do you hold that opinion?
A. Because it goes along with the 9:00 p.m. today, the 6/10. The Vancomycin has an 03:00, 6/11. And other medications are written across through that period, so it does not appear that the DC date is being followed.
Q. In your experience as a nurse, how long would it take to completely infuse an IV of 120 milligrams of a medication like Gentamicin?
MR. FURA: Objection as to incomplete hypothetical.
MS. MATHURA: Join.
BY MR. McKENNA:
Q. You can go ahead and answer.
A. 30 to 45 minutes.
Q. Would you expect that a patient that's scheduled to receive IV piggyback of Gentamicin at, for example, 9:00 a.m. would continue to be receiving an IV drip of that drug for the next 12 hours?
MR. FURA: Same objection.
A. You're asking me if they were to give 120 milligrams of Gentamicin, it would run for 12 hours?
BY MR. McKENNA:
Q. Why not?
A. Because it's a dose of medication. It's not IV therapy.
Q. So just for us as lay people, so we're clear, when we see a notation of something like Gentamicin 120 milligrams IV piggyback, that is a dose that's to be given at one time?
Q. And in general, a dose of this size will be completely run through or infused within about to 45 minutes?
Q. Now, the Nurse VanGampler when she wrote out this plan of care here, did she under the nursing standard of care, did she need to get the approval of a physician?
A. For these orders to be carried out?
Q. And, ultimately, did Nurse VanGampler get that permission from any physician?
Q. And who was that?
A. Dr. Tang.
Q. Now, do you know how it was that Nurse VanGampler actually communicated with Dr. Tang regarding this patient at the time of admission to the nursing home?
Q. Is it in a nursing home setting like this, what duties, if any, does the receiving nurse at the nursing home have to make sure that the medication orders that are received from the transferring facility, that those are accurate?
MS. MATHURA: Just objection to calling the medications on the transfer form orders.
BY MR. McKENNA:
Q. Do you understand my question?
A. How does the nurse know that this is an accurate transcription of what was at the hospital.
A. By current practice. The facilities are filled -- the forms are filled out at the hospitals and they are transferred to thenursing homes and it's using the professional standard that the nurses are filling them out accurately.
Q. So the receiving nursing home nurse needs to rely on the accuracy of the patient transfer form in order for the receiving nursing home nurse to accurately fill out her plan of care, correct?
Q. And then I take it at some point after the receiving nursing home nurse drafts the plan of care, she gets that plan of care reviewed by a physician?
A. She usually would review the patient transfer form and go over all of that, write that onto as they call it Plan of Care or physician's orders from the physician after he has had them reviewed.
Q. Generally in -- strike that.
So then based on this Plan of Care that was drafted by Nurse VanGampler and signed by Dr. Tang, Betty Kunz was to receive Gentamicin 120 milligrams IV piggyback every 12 hours at the nursing home?
Q. And could a nurse stop giving the Gentamicin 120 milligrams IV piggyback every 12 hours without a physician order?
A. No. It would need a physician's order.
Q. And in a nursing home setting, I take it medications are always given as ordered until there is a direct order from the physician to stop the medication?
A. Nursing homes give the medications as ordered, yes, unless there's an order to change the medication.
Q. And I take it that any order regarding stopping or changing a medication must be ultimately put in writing and placed on the chart?
A. Yes, it's supposed to be.
Q. The receiving nurse wrote down in the Plan of Care in addition to the medications here also the names of some physicians that had been caring for Miss Kunz at the hospital?
A. She wrote follow-up appointments, yes.
Q. And it looks like she wrote down the phone numbers for these physicians?
Q. Do you know what day of the week Miss Kunz was transferred from the hospital to this nursing home?
Q. And it looks like there's a note here follow up Dr. Beezhold, infectious disease, call for appointment on Monday and then it lists a phone number?
Q. So I take it that the nursing home staff was aware as of the time Miss Kunz was transferred to the nursing homethat Dr. Beezhold was the infectious disease doctor that had been treating Miss Kunz?
Q. It's also fair to say that the nursing home staff knew how to contact Dr. Beezhold by phone as of the time Miss Kunz was transferred to the nursing home?
Q. At admission, was there any type of Gentamicin peaks or troughs that were ordered to be done for Miss Kunz?
A. No, there weren't.
Q. Would the nurses be able to do that without a physician order?
Q. Regarding measuring inputs and outputs, is that something nurses in a nursing home setting can order without a physician order?
Q. When did the nurses who were caring for Miss Kunz at Manor Care begin measuring inputs and outputs?
A. I'll have to look. Actually, they began measuring some intake and output on the 13th. The order was written on the 16th.
Q. Do you know why the nurses began measuring some inputs and outputs on June 13th even though it appears that there's no physician order to do so?
A. Because the patient was claiming, complaining of not being able to urinate.
Q. And what help if any -- strike that. What role does measurement of inputs and outputs have when a patient is complaining of difficulty in urinating?
A. I'm sorry, I don't.
Q. Let me ask it a different way. Why as a nurse would you begin measuring inputs and outputs when a patient starts complaining of an inability to urinate?
A. It could be many reasons. They could become dehydrated. They could have a urinary tract infection and with a patient on Vanco and Gent, they could have some problems from the drug.
Q. One of the problems associated with Gentamicin is renal failure, correct?
A. Yes, nephrotoxicity.
Q. In this case, can you tell approximately what time the nurses first began measuring some inputs and outputs for Miss Kunz?
A. On the 13th at 12:30 when they did the straight cath.
Q. And were they able to take any measurements at the time?
A. They measured 100 ccs of urine.
Q. And what, if anything does that number tell you?
A. That was a low amount of urine.
Q. What is a normal amount of urine for a patient like Mrs. Kunz at her age?
A. It could be 200, it could be 150 to 200.
Q. But, clearly, a urine output of 100 is considered abnormal, correct?
A. It's considered low.
Q. When is the next input and output that was measured?
A. 6/14, there's a straight cath with 100 ccs.
Q. So, again, on 6/14 when urine output was measured, that was measured as low?
A. It was measured at 100 ccs.
Q. And 100 ccs is considered low, correct?
A. It's considered low.
Q. And when is the next time that input or output was measured for Miss Kunz?
A. 6/15 at 6:00 a.m.
Q. And what was that measurement?
A. That was that she valued three times the ccs during the night shift.
Q. So 75 ccs, would that be considered low?
Q. The 100 ccs of urine output that was initially measured at around 12:30 p.m. on June 13th, does that indicate possible renal compromise?
A. It could.
Q. And is there any indication that the nurses conveyed to Dr. Tang the input and output measurements from 6 -- from June 13th to June 15th?
MR. LITTMAN: I'm sorry, can we have that question back, please.
(Whereupon the question was read as requested.)
BY MR. McKENNA:
Q. Do you know of any particular reason why Dr. Tang had not ordered any input and output measurements before June 16th?
A. Reasons why, I don't believe I know his reason.
Q. In your practice as a nurse when a patient is on IV Gentamicin, are input and output measurements done routinely during the entire time that the patient is on that IV medication?
Q. Under what circumstances in your practice do you measure inputs and outputs on a patient that is on IV Gentamicin?
A. If they were having some difficulty, you might monitor it. You're always monitoring it. You may not always be measuring it. If the person is not having any problems, you know, you take them to the bathroom and they're urinating fine, if they're on IV fluids along with an IV Gentamicin, you would put them on an I&O because you're monitoring the IV fluid intake also. But, again, you're going to continue to monitor it even if it's not always measured.
Q. Is use of a straight cath, is that something that generally requires a physician order?
Q. Generally, how -- strike that. There are blood tests that measure creatinine; is that correct?
A. Yes, there are.
Q. And in general for a non -- strike that. In your practice, how long does it take to get back a stat lab result which measures creatinine?
A. In a rehab facility?
A. The stat is to be drawn within three hours, which is different than in an acute care facility, so it can take a while to get it back.
Q. What type of facility was Manor Care?
A. A rehab facility.
Q. And in a rehab facility like Manor Care when a stat, an order -- strike that.
In a rehab facility like Manor Care when there's an order for a stat laboratory result which measures creatinine, approximately how long would you expect it to take to get that result back?
A. Probably three to four hours minimum.
Q. And in a facility like Manor Care when a laboratory test is ordered to measure creatinine that is not a stat request, in general how long would you expect that result to come back?
A. 24 hours.
Q. Clearly, a stat request, the turnaround time is much shorter than a nonstat request?
A. Usually shorter, yes.
Q. Do the nurses have any input in deciding whether or not a test is stat or not stat?
A. Most generally, the physicians would order the stat.
Q. Could the physicians -- strike that. Could the nurses at Manor Care, could they decide whether or not a test, a lab test such as a test for creatinine was stat or not stat?
A. Generally not without the physician ordering it.
Q. What are the clinical signs of kidney compromise?
A. You can have decreased urine output. You can have increased blood pressure. You can have increased creatinine and blood urea nitrogen. You can have some confusion. You can have retention of fluids. So you would have an extremity edema.
Q. Any other clinical signs and symptoms of kidney compromise?
A. You can have confusion.
Q. Are registered nurses trained to recognize the clinical signs of kidney compromise?
A. Generally speaking, yes.
Q. And are registered nurses trained to react to and treat the clinical signs of kidney compromise?
A. We can recognize. We don't treat.
Q. I take it the standard of care for registered nurses at a nursing home requires them to report to the physician immediately when they, when the nurses recognize clinical signs and symptoms of renal compromise?
A. I don't think there's a specific standard written that way. I think your standard is that you notify physicians of changes in condition of the patient.
Q. I guess another way to put it that a nurse in a nursing home acting in a reasonable fashion will generally report to the physician when the nurse recognizes clinical signs and symptoms of kidney compromise?
A. Yes, they would.
Q. And in situations like that in a nursing home where the patient is exhibiting clinical signs and symptoms of kidney compromise, the nurse will generally have to rely on the direction and orders of the physician in order to do anything and correct the cause of the problem?
A. The nurse would report to the physician the symptoms that she's seeing. The physician would take action as appropriate for the care of the patient.
Q. And as a nurse, what do you do in a situation where the physician doesn't take any action to rectify the issues that might be causing the clinical signs and symptoms of kidney compromise?
A. Okay, this is hypothetical?
A. First of all, you would discuss with the physician what your concerns are. If he had good explanation for what he was doing in his plan of care, you would follow his orders. If you didn't agree with him, then you would know to go up your chain of command.
Q. In the hypothetical nursing home, what is the chain of command?
A. The nurse would probably then go to either the nursing supervisor or the director of nursing or to the medical director.
Q. In your career, have there been any instances where you have gone up the chain of command when an attending physician has not responded to your request for some type of order action in response to a patient's condition?
Q. Approximately, how often has that happened in your career?
Q. And were you able to get a response to your satisfaction from the person you went to up in the chain of command?
Q. Are nursing home nurses trained to go up the chain of command if a patient's attending physician is not being responsive to the patient's condition?
Q. Who was the medical director at Manor Care Nursing Home when Betty Kunz was a patient there in June of 2000?
A. Dr. Tang.
Q. In a situation where the attending physician is also the medical director, where can the nurse go up the chain of command as far as talking to another physician if the attending physician who is also the medical director is not being responsive to the patient's condition?
A. Complex question. I think the nurse would first of all go to the director of nursing and see if there's not some way to work out that situation from there. I have not seen those kind of situations not be resolved.
Q. Is it possible for the nursing home nurse to contact one of the outside consulting physicians?
A. Sure. But I think that would be after consultation with the director of nursing.
Q. In this case involving Betty Kunz, the nurses at the nursing home who were caring for Miss Kunz, they could take and carry out orders from the outside consultants who were treating Miss Kunz, correct?
A. Generally, they are confirmed by the attending.
Q. In this case, the nursing home nurses actually took telephone orders from Dr. Petrak and Dr. Beezhold, correct?
A. Yes, I believe they did. But I also think they updated Dr. Tang to those orders.
Q. Well, there is an order from Dr. Beezhold dated June 21, 2000 in the chart. Do you see that? It's up at the top. Do you see it there?
A. On the top?
Q. You can take a look at this right here. It's an order from June 21, 2000.
MR. LITTMAN: 48?
MR. McKENNA: Yes.
THE WITNESS: Okay.
BY MR. McKENNA:
Q. Looking at page 48, which is an order in the nursing home chart, this appears to me to be an order written out and signed by Dr. Beezhold; is that correct?
A. It's an order that's written out by the nurse. I don't know if that's Dr. Beezhold's signature or not.
Q. You see Dr. Beezhold?
Q. In the area where it says physician?
Q. And you would agree with me it doesn't appear Dr. Tang signed off on this order, does it?
Q. You would agree with me that it was possible for the nurses who were caring for Betty Kunz at Manor CareNursing Home on June 13th of 2000 to contact Dr. Beezhold's office regarding this patient?
A. I'm sorry, I would agree with you that the nurses?
Q. I'll ask it again.