Nursing Home Deposition 2 - Plaintiff's Deposition of Internist - Part 2
BY MR. MACHALINSKI:Q: In the event a psychiatrist or the attending physician prescribed that Haldol, in any event, that would not be from the nurse's actions or the nursing home's actions?
MR. LEVIN: I men --
THE WITNESS: Well, I think, let me answer that because I think I can phrase this in a way. I think that the nursinghome calls the doctor and says this is the behavior.
So in that sense, what that often is is a frustrated behavior on the part of the staff to care for this patient and looking for some way in which to calm, restrain this individual.
BY MR. MACHALINSKI:Q: Are you aware of what security measures they had implemented at the nursing home to care for this individual relative to his wandering and elopement?
A: Other than and there is no consistent pattern to any of it. Sometimes as I have said the redirection, sometimes they had a wander guard. It's unclear to me whether the wander guard was activated or not.
At any rate, it's unclear whether the wander guard, the wander guard certainly alerts them when he gets close to the door, it should go off and they should know about that. So that's one way of restraining him within the hallways and within his room and things like that.
Q: But beyond that are you familiar with what, if any, locks or buzzers they had on the doors?
A: There is nothing in the medical record that says that they have what locks, what buzzers, what went off. It just says Mr. Pietrzyk was there and we caught him and whatnot. There is nothing that says what went off or whatnot.
Q: If we go to actually the date of the incident, do you have any understanding as to when he was last seen in the hospital -- strike that.
Do you have any understanding of the date of the accident when he was last seen in the nursing home?
A: Well, evidently they had checked him within about 30 minutes and then he was gone.
Q: That 30 minutes would have been around what time?
A: I believe it was in the evening, but again it's something that I did not, I will just look up and tell you what time it was.
MR. LEVIN: Well, yes, make sure it's in there and don't speculate.
THE WITNESS: I'm not and that's why I'm sitting here because I remember specifically there is a note regarding this. So if we will just indulge me for a second, I will tell you what the note says.
Resident was being out of bed when he yelled --
MR. LEVIN: That's a different day. Are you talking about November 1?
THE WITNESS: November 1, pardon me. Here it is. It's here and here. Resident left facility and being notified. Facility was checked thoroughly outside area 8:30 p.m.
MR. LEVIN: You are just reading the note, correct?
THE WITNESS: Right, I'm just reading the note here. It says the resident was seen by his custodial nursing assistant between 7:30 and 8:00 o'clock p.m. So that counts for the 30 minutes that I told you that they had not seen him.
BY MR. MACHALINSKI:Q: What page number is that, sir?
A: That is 000100.
Q: I believe that's in the exhibit previously marked as Largosa Exhibit No. 2, dated 4/22/98.
When was he struck by the car, do you know?
A: It does not say. It has to occur somewhere between the time that he was last seen 8:00 and 8:30 but I don't see a time, and I don't believe a police report was given to me.
Q: You don't know what door he exited the facility from?
A: It doesn't say here. Oak Lawn Police arrived, and then there is a page placed by Christ Hospital about resident conditions, spoke with Dr. Mellin resident, something about broken leg.
There is nothing here that I see. Oak Lawn Police arrived, wife was notified. So there is nothing that I can tell.
Q: From your perspective does it make a difference which door he departed from?
Q: Do you have any understanding as to how the Oak Lawn Pavilion first became aware that he had left the premises?
A: It appears that the Oak Lawn Police Department arrived. I can't tell from this. It says resident left facility and without being noticed facility was checked thoroughly.
It doesn't say that they notified, it says something MS Baker notified, fire department chief also spoke to Mrs. Baker. It doesn't really say anything that I can tell.
Q: Are you presuming that the Oak Lawn Police Department would have notified the nursing home first of the elopement?
A: I'm going to guess that, but I don't know for a fact. Again, it doesn't really make much difference. He got out and he is not supposed to get out especially at night.
If it's like most nursing homes that I have been at, 8:30 at night the nursing home doors are usually locked, the visitors have left and so it would be more difficult to get out at that time than less difficult.
Q: Do you have any understanding as to whether or not he was wearing his wander guard bracelet at the time he departed the facility?
A: There is no reference to that that I can find.
Q: From your perspective -- I'm sorry.
A: From my perspective --
Q: Did I interrupt you?
A: No, that's fine.
Q: From your perspective does it make any difference whether or not he had the wander guard bracelet on?
A: Well, if the wander guard was working, it should have notified the staff when he walked out the door. They should have known immediately. There shouldn't have been a 30 minute lapse.
MR. MACHALINSKI: Back up for a second, do you need to make a call?
THE WITNESS: Can I just answer this?
MR. MACHALINSKI: Sure.
(Whereupon, a short break was taken.).
MR. MACHALINSKI: Can you read the question and answer back?
(Whereupon, the record was read.)
BY MR. MACHALINSKI:Q: You have previously mentioned side rails and the use of Posey vests. Were there Posey vests ordered?
A: He had been Poseyed on occasion, and if I remember correctly the staff had called for those. Side rails were documented to be up on several occasions.
The use of side rails is, you know, somewhat controversial because people when they climb over them they have a larger fall than if the side rails were not up. But the side rails vary.
Q: What about the use of Posey vests?
A: Obviously people have documented significant injuries with Posey vests and things like that because it's, if a person struggles against them, particularly older people if they are fragile enough, they can break bones and things like that.
Q: Any indication to you that Mr. Pietrzyk had ever injured himself while being restrained by a Posey vest?
A: There was some documentations of some bruises and some falls. It's hard to say whether those were from the Posey vest or not. Older people's skin is fragile.
Q: In any event you need a physician's order to use a Posey vest?
A: There are some people who write PRN orders, but the physician does need to write for them, yes.
Q: Concerning the subject pedestrian auto accident, what type of injuries did Mr. Pietrzyk sustain?
A: He sustained a fracture of his leg which breaking both bones in the leg, both the tibia and fibula and it required an open reduction of surgery in order to piece those bones back together and I believe he had a steel plate and multiple screws and hardware in his leg.
Q: Do you know if there were any complications from that surgery?
A: There were no complications reported in the chart.
Q: Was that fracture consistent with being struck by a car?
Q: The surgery was performed approximately how many days after the accident?
A: I believe three days. The injury is 11/1, the surgery is I believe on 11/4.
Q: Do you know why they waited three days to perform the surgery?
A: I think there are several reasons. They wanted to make sure that he was medically stable. There is a note that they wanted a cardiologist to see the person.
Surgery was performed on 11/4. Dr. Zellinger I believe was the cardiologist and I think that was part of what they were delaying for in making sure, otherwise he was medically stable.
Q: He was, in fact, medically stable as of 11/4?
A: Yes, he was.
Q: As a result of the auto accident immediately, did he sustain any type of cardiac problems?
A: No, not that there is a documentation of. He had a history of atrial fibrillation. He was found to be atrial fibrillation. There was no other injury that appears.
Q: What is atrial fibrillation?
A: Atrial fibrillation is a condition, it's a funny heart rhythm of the conduction system.
The main conducting system is through the atrium or upper storage chamber of the heart is where this thing resides, and it's a chaotic rhythm; therefore, the valve that goes from the atrium which is the upper storage chamber to the ventricle which is the lower storage chamber opens kind of chaotically.
Q: He had that condition before the 11/1/93 accident?
A: Right. It may be one of the predisposing things to this multi-infarct dementia.
Q: Did that condition have any impairment on his life expectancy?
A: Atrial fibrillation is a chronic disease for which if you don't suffer strokes and things and if you are appropriately treated, you will have a slightly lower life expectancy but it may be normal.
Q: But it does cause or contribute to cause to strokes?
A: It does contribute to strokes, yes.
Q: What was his mental condition in that three-day period between the accident and the surgery if you know?
A: There are different periods where they say he is confused, and there are other places where they say he is smiling and he appears oriented.
There are also periods where they say he is talking in Polish, and there are places where he is talking in English.
Q: Is that fairly consistent with his mental status prior to the accident?
A: I believe so. I don't see any major difference here. I think they held up the surgery for the reasons to make sure that nothing else came about, anything else was they were worrisome probably for surgical schedule reasons and trying to get the cardiologist to see him.
Q: Then how long was he hospitalized?
A: He was hospitalized I believe he goes back to the nursing home on the 10th which is the, the 10th is when I believe he goes back.
Q: Again, what, if anything, did they do at the hospital for him in that six-day period?
A: What did they do for him? They basically operated on him and they watched him on his post recovery period and they also started some physical therapy.
Q: What type of physical therapy did they start at Christ Hospital?
A: Trying to get him up and mobile.
Q: Do you know if they were successful?
A: I could not tell. I think they had him standing a little bit. They wanted to begin to let him move some of his hip and other things just so he can keep those muscles strengthened.
They wanted to teach him how to transfer so it would make it easier for staff. It is hard to tell from those notes whether they were successful.
Q: You never saw Dr. Flynn's records, did you?
A: There are I think a few notes of Dr. Flynn's here but nothing that I remember specifically as being important to this case.
Q: Dr. Flynn was his orthopedic physician?
Q: You never saw Dr. Flynn's discovery deposition transcript, have you?
Q: What prognosis did he have if you know when he was discharged from Christ Hospital back to Oak Lawn Pavilion on or about 11/10/94?
A: One of the things we know in general about nursing home patients or older patients when they fracture long bones that most of the research and most of the studies and discussions have been about hip but also if you fracture and you put a person in a cast and things like that, that their life expectancy is decreased.
Q: Why is life expectancy decreased?
A: Well, one of the reasons is they are immobile, and you take these people who are immobile and they are in bed, they have a tendency because there are changes in the elderly and their skin, it thins out because of nutritional status.
This gentleman was confused. He didn't always eat. He ate somewhat less after he came back and actually progressively less because he ended up requiring a G-tube. Because of that nutritional status, the patient lays in bed and they develop bedsores.
Q: He was transferred out of Christ Hospital in a cast?
Q: What was the length of that cast?
A: The cast went from just above the ankle to the mid thigh as it is described. His knee was slightly bent in flexion if I remember the exact description.
Q: He died on what date?
A: He died in February. I will give you the exact day, 2/20/95.
Q: Do you have any opinion based on a reasonable degree of professional medical certainty as to the cause of death?
A: Well, I think a couple things happened that evening which are difficult to ascertain. He was progressively going downhill. His family had made him a DNR. Prior to that he was given the last rights of the Catholic Church on 1/23 so it was obvious to the family that he was not going to survive for very long.
Interestingly he made it a month after that, but his decline was obviously progressive and it was noted by the family.
MR. LEVIN: Your question is what is the basis, what was your question again? I don't know if he has answered your question.
MR. MACHALINSKI: I don't know either.
BY MR. MACHALINSKI:Q: What day was the DNR executed, do you know?
A: No, I don't.
Q: Do you know if that was before or after the --
A: He has a DNR before, but, you know, it's clear to me that --
MR. LEVIN: You are pointing to a section in the chart that says DNR? His specific question is is there a document --
THE WITNESS: I don't see it.
BY MR. MACHALINSKI:Q: You don't know when the DNR was executed?
Q: Specifically you don't know if it was executed before or after the subject pedestrian auto --
A: No, I don't remember and it wasn't something that I put down.
Q: Then I think if I back up to my other question I will just reask it.
Do you have an opinion based upon a reasonable degree of medical certainty as to the cause of death?
A: I believe that he probably had some chronic pneumonia, aspiration and he became septic which is the usual way that these people die.
Q: What is septic?
A: Septic means that bacteria got into his blood stream either from his lung. The two most common sites are the lung and the urinary tract.
Q: What was the cause of the pneumonia?
A: Aspiration most likely. G-tubes even though you think that they don't prevent aspiration and they are just put in the stomach and frequently these people if they are lying down, if they turn funny and they have tube feedings, that those feedings will come up and they will lodge and get in the lung. It's not an uncommon event.
Q: When was the G-tube first ordered?
A: It was placed -- let me go back to his chart because it's not very clear. He had a swallowing evaluation done in January. Let me just find it. I don't know if it's in the Christ record or not.
This is '94, this is after he gets back. Let me just find it for you. I will find it, just give me a second.
I believe it was done in January. Difficulty swallowing noted, unable to eat 1/10, G-tube placed 1/14, appointment to be made for G-tube placement for Dr. Port, that's around 1/14 or so, swallowing evaluation done was 1/13.
So I believe it was 1/13 or so. Resident very weak, pale, short of breath noted. So it's not clear that they don't have a note that says patient left and came back from a G-tube placement, but we know that a G-tube was placed and there are orders for such.
Q: So he would have had the G-tube between 1/14/95 --
A: Probably 1/14. It's my guess from looking at this chart.
Q: All the way through the time of death at 2/20/95?
Q: Was that G-tube permanently placed or was it?
A: That G-tube was permanently placed.
Q: When they placed the G-tube, is the patient sedated at that time?
A: The patient is given Versed.As a matter of fact, here is a note that says Christ Hospital GI lab to inform nursinghome that resident tolerated the procedures given on 1.5 milligrams of Versed and that was on 1/18.
Q: What is Versed?
A: Versed is like a short-acting Valium compound.
Q: After that wears off --
A: It wears off very shortly. It's about 30 minutes.
Q: After that is there any type of sedation?
A: No. This is a local procedure. It's like doing an endoscopy and what they do is they make a puncture through the endoscopy tube and bring the tube out with the endoscopy.
Q: Can you describe for me the process of the G-tube itself?
A: In terms of what?
Q: What the procedure is and the --
MR. LEVIN: How you place it and how it works and what it does?
MR. MACHALINSKI: Right.
THE WITNESS: Yes, okay, I can do that.
MR. LEVIN: Basic G-tube from beginning to end.
THE WITNESS: Basic G-tube is under an upper endoscopy which is a tube that they put in to look at the stomach. They identify where the stomach is and then they make a puncture up through the abdominal wall and they bring the tube up, and then they sew it in. That's how simple it gets.
It's a tube that is probably oh, like that, about the size of your pen, and it's actually often a Foley catheter and they sew it in and they blow up the balloon so it doesn't come out.
BY MR. MACHALINSKI:Q: It's placed down the throat?
A: No. The G-tube is placed in the abdominal wall where the stomach is directly into the -- so food, it bypasses the swallowing mechanism. That's the purpose of it.
Q: Was he ever intubated?
A: No, he was not. During his, let me correct that. He was intubated during his surgery although he had a spinal. They did not say in the operating report, they could have put an ET tube in during that operation, but he was not intubated for a G-tube that's for sure.
Q: Is it your opinion that the leg fracture was the initiating cause of death?
A: Yes. I think it starts a downhill spiral, and it's very clear at that point he can no longer get up.
He develops bedsores. He actually begins developing those bedsores in the hospital because they note some redness because his scrotum and his rectum and then those bedsores then become much bigger and larger and more frequent once he gets to the nursing home.
He develops some around his foot, his ankle, his hips, both of his hips, his sacrum and that's because he is lying on his back and he is lying in his urine and stool because he becomes essentially incontinent at that point.
Q: It is your opinion that but for the leg fracture he would not have encountered that downward spiral at that period of time?
A: I don't believe so because if you read the prior chart, he is up busy walking and he is eating more and he is certainly never in bed.You have to have a certain amount of pressure in order to produce that. So he is never in a position where he is sitting long enough in order to produce those.
Q: Did the bedsores themselves actually contribute or cause his death?
A: Well, I think the bedsores are a problem for several reasons. No. 1, they are obviously a source of infection. No. 2, they are obviously a source of discomfort because as they go through the different tissues of the skin down to the muscles and even into the deepest layers of the bone, that's going to produce discomfort.
I think the other problem is it's a sign of malnourishment or malnutrition. That's not to say that he isn't being nourished, but he is not getting enough calories in order to heal those things. Part of that problem is also because he can't get out of bed, he can't be toileted well. He has the constant contact with urine and stool and the bacteria that's associated with death.
Q: Those conditions can occur in the absence of negligent nursing care?
A: It is thought that good nursing, you know, let's put it this way. The nursing care contributes because obviously they need to make sure that his diaper is clean or whatever they are doing to keep him clean is done and that has to be done frequently, and that requires good skin care.
But even in the setting of malnourishment once you get to a certain point and you are constantly resting on those bones, it then requires frequent turning.You may need to turn the patient as frequently as an hour or every hour or so.You have to rotate them on certain schedules and things. That's to prevent it.
Q: But even in the best nursing care, bedsores can still develop?
A: Yes, that's absolutely the case. Even under the best circumstances, but usually you don't see it in somebody like this who is up and about.
Bedsores are people who either have come in with terrible strokes or somehow confined to a bed, whatever. People who are active and moving, you rarely see these kinds of ulcers unless they sustained an injury.
You know, people can be up and about and malnourished and they can sustain an injury, and it takes longer to heal in certain factors like diabetes and peripheral vascular disease, none of which he had.
Q: Once you're bedridden --
A: When you are bedridden, then yes, it's a problem and it does happen. But these happen I will tell you very quickly.
From the time he comes in, he is dead in three months, and they are documenting bedsores almost within the week of him being back from the surgery.
Q: I think you indicated they actually started at the hospital themselves?
Q: What level were the bedsores at the time of his death?
A: They were only described pretty much Level II which is down to the, pass the dermis into the fascia, the muscles, so they are through the skin.
You know, beauty is frequently in the eyes of the beholder whether they are Level II, Level III or, what they are a sign of is malnourishment and they are not going to heal.
The other thing that they are describing is they are getting larger, so they are moving out in that direction. The other problem with the descriptive method that we use is sometimes there can be an ulcer beneath the tissue that you see. You only see a thin layer of tissue and it's like the tip of an iceberg.
Q: We don't know if that's the case here or not?
A: No, we don't. I'm just trying to explain to you the problem, the description of how people describe bedsores, and usually nurses describe them as more optimistically, you know, because obviously they are in charge of that particular portion of their care.
Q: Did he develop contractures at all?
A: There was a contracture that they described of his leg because his leg was set somewhat in a flexion position. He couldn't totally straighten out his knee and they were working on that so that he can totally straighten his legs.
Q: Was the cast ever removed?
A: The cast was removed.
Q: Do you know what the date the cast was removed?
A: Again, it was in January. If you want me to look, I will look. If it's germane to your discussion, I will be more than happy to go through and find it.
Q: Sure. If you could, Doctor, if you see that date where the G-tube was placed, I think you said on --
A: I believe it was 1/17 or so.
A: The exact date was --
Q: If you see the Bate Stamp number --
A: Yes, I will be more than happy to tell you.
MR. LEVIN: Just collect all your thoughts.
THE WITNESS: I'm just trying to find where he was looking. Christ Hospital on 1/18 procedure will be done by Dr. Sitler. Has to be at GI lab at 8:15 a.m. so it was done on --
MR. LEVIN: For the record you are referring to Page 282 of the second Oak Lawn Pavilion admission?
THE WITNESS: Right. That was 282. Then on Page 284, it says Nurse Seal called from Christ Hospital GI lab to inform nursing home that resident tolerated the procedure well.
BY MR. MACHALINSKI:Q: Then the cast removal?
A: The cast removal is a good question. Let me find it for you. Because these things are always in the record, I don't always make note of them.
You have Dr. Flynn's notes.You mentioned Christ ER because you would have that in the cast -- cast was removed 12/27 from the right leg. That's Bates 272.
Q: Was the fracture sufficiently healed then at the time of the cast removal?
A: You know, that's a surgical judgment and since I don't have any x-ray reports I can't tell you. I believe that he would have not taken that cast off unless it was adequately healed.
It is about six weeks from the time. Most people use six weeks as the time when the cast comes off.
Q: So at least as of 12/27 the fracture had healed?
A: I'm going to assume that's the case. There is nothing to say elsewhere that it happened.
Q: In any event, even after the cast was removed, he wasn't able to ambulate?
A: No, he was not.
Q: Do you have any opinion as to the cause as to why he was no longer able to ambulate?
A: You know, this is not documented in the chart. I can speculate that maybe he was afraid. His leg was contractured somewhat from the positioning of the cast.
He wasn't able to fully participate in physical therapy; therefore, he couldn't gain strength in his muscles. He was lying in bed for approximately two months.
If we are to put you to bed for two months essentially and give you a bed pan and things like that, you would find it very hard to gain your legs and feel secure and whatnot.
Q: Why was he not able to participate in physical therapy, if you know?
A: I can't tell, but I think part of it was there was a note somewhere that said he was afraid, that patient seemed frightened to put his leg down.
I think part of it was because he was demented and he was frightened and he wasn't fully able to cooperate. I think he's intermittently confused. That certainly contributes to it.
The fact that he speaks Polish at times and they may not have had a physical therapist who spoke Polish and could communicate to him, that kind of reassurance. All those things contribute to it.
Q: Following the automobile accident, we talked about his various injuries and I'm going to paraphrase them if I could. We know he had a leg fracture requiring an open reduction in the cast. He developed bedsores from being bedridden. He had some leg contractures and he belched which you believe was caused by the aspiration of the G-tube, correct?
Q: Any other injuries that you believe he sustained as a result of the auto accident other than the ones we have already discussed?
A: Which included the decubitus ulcers and things, yes.
MR. LEVIN: Go through his entire body and let's get it all out now.
THE WITNESS: If you want, let me just go to those pages for you because I think that will probably be, we can go right through this and these are all on Bates pages, let me just give you the wound things and then we can go through all of that if you wish.
The wound care sheets which by the way are not in order in terms of their dates, but the wound care sheets begin on Bates 000306. There is a note there 12/27, two by two sonometer ulcer on right foot back of heel.
Then they have two and a half on 12/30 on right foot.Again, right foot as I'm just going through the pages 307, right bunion area. So now we have not only the heel, we have the right bunion or first toe area.
Then there is one to the right hip which is two sonometers. I can't read that exact size, but they are applying Duoderm to it and that's on 000308. Duoderm is like a second skin by the way That's right hip.
There is also one about the left hip on 1/3/95,000309. They are now talking about a reddened area on the scrotum. By the way, I think as I read this and I can't prove it, but as I read this, I don't think they fully document each day all the different ones. They just kind of rotate which day they are going to document.
But if it's on the right hip, it's on the left hip. If it's on the scrotum, it's on the sacrum. It comes later that there is a bigger one on the sacrum. That just did not develop overnight on the day.
So I kind of believe that these ulcers were not well documented in terms of their progression.
Again, we see two by two sonometer pressure ulcer on the right heel.We go from sometimes calling it the right heel to the entire right foot. There is a note in the nursing notes that they paged the doctor because they thought although it doesn't say here, they kind of felt that it was involving the whole foot and not the heel. Of course, that was the thing.
Then we have one excoriated near rectum and buttocks. This is 312, granule to that area. Left hip finally comes up on 1/18. Duoderm to the left hip. Necrotic tissue, superficial. This is on the right outer ankle, but the size of it speaks to the fact that this has been there for a while. Three by five sonometers, that's a big hunk of tissue.
Then there is one note that I don't understand at all, 000315, D/C healed. I don't know what was healed there.