Sample Deposition of Internist in Nursing Home Lawsuit

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EXAMINATION

BY MR. MACHALINSKI:

Q: Dr. Greenberg, am I correct in assuming that you have been deposed on a prior occasion?
A: Yes.
Q: I would like to go over some of the ground rules with you again. No. 1, if at any time you don't understand my question for whatever reason including if I'm using a medical term of art inappropriately, let me know and I'll rephrase the question.
Fair enough?
A: Fair enough.
Q: Would you allow me to finish my question before you begin answering and I will provide you the same courtesy, okay?
A: Yes.
Q: If you need to take a break for whatever reason, let me know and we can take a break.
A: Okay.
Q: I have what's been previously marked as Greenberg Exhibit Deposition No. 1 with today's date, a copy of your multiple page curriculum vitae which is 12 pages in length.
Do you know if that's an up-to-date curriculum vitae?
A: That is the current one. There is some additions on some talks and things like that, but nothing that's major and nothing germane to this case.
Q: All right. How long have you been practicing medicine?
A: I graduated medical school in 1981 so it's almost 20 years now.
Q: What area do you specialize in?
A: Internal medicine, and I have a subspecialty in geriatrics.
Q: How long have you been practicing that subspecialty?
A: Actually since I have been in practice, but there was a specialty board given ten years or so ago and I took the board.
Q: When did you receive the board certification?
A: It's in the CV. It would be, I think it's '89 or something like that.
MR. LEVIN: '88. It says April of '88.
THE WITNESS: Okay, yes.

BY MR. MACHALINSKI:

Q: When do you have to recertify?
A: Recertification which I decided not to do because I don't, it doesn't germane to what I do in terms of research and things like that.
I have not recertified in geriatrics although I do take care of a level of people.
Q: When did your certification lapse if you know?
A: It went for a full ten years so it was '98.
Q: Are you board certified currently in any other areas of medicine?
A: No, just internal medicine. That's a life long certification.
Q: What states are you currently licensed to practice in?
A: Illinois and Florida.
Q: Where do you currently practice medicine?
A: I practice in a group practice in Fort Lauderdale.
Q: What's the name of that group practice?
A: Cleveland Clinic.
Q: What's your position at Cleveland Clinic?
A: I'm an internist on staff.
Q: Do you have any ownership interest in that group?
A: No, I do not.
Q: Do you have any present plans to leave that group?
A: No, I do not.
Q: How long have you been with that group?
A: Two years approximately.
Q: Can you describe for me kind of and briefly what that practice currently consists of?
A: The practice of general internal medicine about oh 70 percent of my patients are probably over 70 and 30 percent are under.
I also do some sports medicine. I'm the team physician for the Bobcats. I also help out with the Panthers which is the hockey team. The Bobcats are the arena football team.
I cover for the geri nutritions although I'm in the section of internal medicine, and occasionally I go to nursing homes and I follow some of my patients at nursing homes.
Q: What percentage of your patients are currently in nursing homes?
A: Oh, it varies. I would say it's under three or four percent, probably less than that.
Q: Do you know why the ratio of the age of your patients in your current practice, is that because of the general population in that area?
A: That's the general population in Florida. Also where we work is we work along the beach.
As we move our practice out to Westin, it will get younger.
Q: Has it been your general practice the last two years in terms of the scope of the patients?
A: No.
Q: Prior to that time, did you have the same type of practice in terms of makeup of patients?
A: It was probably less. It was probably half were over 65 which would be considered retirement age and half under.
Q: Before your current practice, where did you practice?
A: I practiced in Skokie.
Q: How long did you practice in Skokie?
A: About two years.
Q: Again, that was in general internal medicine?
A: Yes.
Q: What percentage of your patients lived in nursing homes at that time?
A: Probably about the same, maybe one to four percent. It depends.You know, it's a variable thing.
Most of them were more rehab with the idea of going home than permanent members, permanent residents in nursing homes.
Q: Prior to practicing in Skokie, where did you practice?
A: I was at Illinois Masonic Hospital from 1990 I believe it is. It's on my thing, I will tell you exactly.
Q: That would be 1990 to 1996 approximately?
A: No. That would be 1990 to '96, that's correct, you are right.
Q: What did you do at Illinois Masonic?
A: I was the director of program development. I was also the director of student programs for the department of medicine.
Q: During that time in 1990 through '96 when you were working at Illinois Masonic, were you actually practicing medicine?
A: Yes, I was.
Q: Was that in addition to your duties as being a director?
A: Right. Well part of what it is is I was involved in the education program.As part of the education program, I saw patients in the hospital. I ran the teaching teams. I also did outpatient practice. I both supervised the residents and had a practice of my own.
Q: What type of patients did you have?
A: General internal medicine. I mean the mix varies of what was in that general internal medicine, but they would all be considered general internal medicine patients.
Q: Have you ever had a practice devoted primarily to treating geriatric patients in a nursing home setting?
A: No, I have not.
Q: I assume you have never been a medical director at any nursing home?
A: No, I have not. I have been offered positions. I have turned them down.
Q: Are you aware of whether or not there are any requirements to be a medical director at a nursing home?
A: There are requirements. It varies from different nursing homes and different people who own them.
Early on in my career, all you had to have was an M.D. for most of the time. More recently people are looking for people with geriatric credentials. That is one of the primary reasons why people get certified in geriatrics right now.
Q: In terms of state licensure, are you aware of any requirements concerning being a medical director at an Illinois nursing home?
A: Currently since I haven't lived in Illinois the last two years and I haven't looked at a position, I'm not aware of any requirements other than I believe you have to be a practicing physician in the State of Illinois and I don't believe that has changed.
Q: Have you ever applied to be licensed in any state to be a medical director at any nursing home?
A: No, I have not.
Q: Did any of your consultant practice involve nursing home care?
A: No, they do not. Most of it was for insurance companies and PPO and HMO, that type of thing, and also looking at, reviewing cases mainly for medical necessity.
Q: From an insurance perspective?
A: From an insurance perspective.
Q: Nothing devoted specifically to nursing home care?
A: No, there is nothing. The only thing that you can consider close to that which really isn't is Lambs Farm when I was the medical director at Lambs Farm. That's the only thing I can tell you. I took care of the residents at Lambs Farm.
Q: That's --
A: That goes back to let's see, 1983, '82-'83, something like that.
Q: What type of population or residents do they have at Lambs Farm?
A: It's all mentally retarded, primarily down syndrome.
Q: Any of your appointments, committees or academic endeavors that are listed on Page 3 of your curriculum vitae Exhibit No. 1 involve nursing home?
A: No.
Q: Then we go to Page 6, I believe hospital affiliations. I assume none of that involves nursing home care?
A: When I was at Illinois Masonic, occasionally I would cover for the medical director of the nursing home, but I was not the medical director. It is just a matter of supervising residents who were there and whatnot.
Q: How about any awards involving nursing homes?
A: No.
Q: Still on Page 6 of Exhibit No. 1 your curriculum vitae, abstracts and publications. Any of that involve nursing homes?
A: No.
Q: Any of that involve geriatric patients?
A: One of the psychotic patients I believe was older. I don't know if they were in a nursing home. I believe they may have been in a psych ward, but that's about the closest that it gets.
Most of these things on here are all about education. That was and is my primary interest educating doctors.
Q: Are you still involved in educating physicians?
A: Yes, I am.
Q: In what capacity?
A: I participate in the teaching program at Cleveland Clinic in Florida.
Q: That teaching clinic is focused on what kind of --
A: General internal medicine.
Q: How about on Page 8 and starting on Page 9, courses, meetings and seminars and lectures given to professional groups.
Does any of that involve geriatric patients and/or nursing homes?
A: There was one.Aggressive care of the elderly patient 1986.
Q: Which page is that, I'm sorry?
A: Page 9.
Q: Which number?
A: No. 6. That was given to North Chicago to the department of geriatrics.
Q: Did that lecture involve elopement or wandering issues, if you know?
A: Pretty much not. There may have been some, and I can't tell you. It goes back far.
But basically the premises of that lecture was that older people when you first saw them were at the highest level of function they were at and that everything needed to be done to be kept there rather than, you know, towards the later part of their lives it didn't make as much sense.
In other words, you wanted to treat the elderly people very aggressively, correct what you could and then at some point, you know, as they dwindled down towards the end of their life, it didn't make sense to be aggressive at that point. So the idea was it was actually a lecture in preventative geriatrics.
Q: What's the point of not being aggressive in later stages of geriatric conditions?
A: Well, you know, that's to take an old phrase, it's when the cow is out of the barn closing the door. It didn't make any sense.
For example, for many people and remember you have to go back, there wasn't nearly as much research. Many people would have a lazy fair attitude about things like managing blood pressure, and my point was you have to manage blood pressure because you want to prevent a stroke.
You don't want to treat an older person with a stroke.You much rather treat an older person with high blood pressure. It is much easier if you kept them out of nursing homes.
Most of that lecture was about how to keep people out rather than get people in. Some of that did include how to keep people with Alzheimer's disease out of nursing homes and things like that.
Q: So it really wasn't focused on geriatric care once they reached that stage in life where they were in a nursing home situation?
A: Well, it was right at the point where are they going at, are they headed in that direction, how to prevent that.
Q: Did any of that involve any quality of life issues in terms of aggressive care in a later stage elderly patient versus nursing home care?
A: In other words, hospice type care and that type of thing?
Q: Right.
A: No. It was really focused more on what we would call the go-go of the elderlies, the people who were out there, you know, driving cars and participating. That was really the focus of it.
Q: Does any of your curriculum vitae reference your consulting work in terms of a legal capacity?
A: Not really.
Q: We can discuss that a little bit right now. How long have you been providing medical/legal consultation work?
A: Probably around from 1986 or so.
Q: Currently what percentage of your income is derived from medical/legal consulting work?
A: Probably under 10 percent.
Q: Has that remained fairly constant since 1996?
A: Pretty much. I mean there are some years it might have been more, some less. But pretty much this is kind of a small thing that I do.
Q: Let's focus on the last five years. How much of your time has been devoted to cases on behalf of plaintiff?
A: Most of it has been plaintiffs at this point.
Q: When you say mostly, can you give me a percentage if you can?
A: 90 percent.
Q: Has that percentage remained fairly constant since 1986?
A: No. Initially actually I did some more defense.When I review a case, I don't review it as a plaintiff or a defense witness. I review it as an expert, and what I found was when I was an expert for the defense, I was asked to defend the case. I said well I can't defend this case, and so, you know, defense attorneys kind of got tired of that thing.
With a plaintiff case it's much easier. I just say you have no case. So I ended up doing far more plaintiff for that reason. But I have also done cases for private doctors to look at cases where it was filed and asked me to look as a consultant to them, can I look at their defense and is there a defense and whatnot.
Q: Over the past five years, how much of your medical/legal consultation has been regarding geriatric care in nursing home?
A: Not very much. It's been, some of it has been older people, but I think only in the last five years maybe two cases were actually in a nursing home that actually went to deposition.
Now there has been more cases than that and I don't have a number.
Q: Would that percentage be fairly constant since 1986?
A: No.
Q: When you say you have two cases involving depositions involving nursing home care, would that be two cases in addition to this case?
A: Going back, no.Actually this is the second case in the last couple years. The other case was a case that the patient was in a rehab nursing home.
Q: Have you ever rendered any consultation services relative to any issues of elopement or wandering away from a nursing home other than this case?
A: This is the first case in that regard although I have probably reviewed cases but I don't remember.
Q: Approximately how many active files do you have? When I say active files, I mean files that you are reviewing on behalf of various attorneys.
A: Probably less than ten right now.
Q: Again, has that understanding that it's flexible, does that remain fairly the same?
A: Yes. I mean let me tell you, I get about six or eight cases a year is about what it is. Some cases stretch longer. In Chicago they stretch longer. This case has been about three years, I think.
Other cases, you know, other places that I have been asked to review, cases go much quicker.
Q: Which states have you rendered consultation services in litigation?
A: Ohio, Michigan, South Dakota, Florida, North Carolina, New York.
Q: So basically a national consultation service?
A: Yes. For whatever reason I have gotten referrals from all those places.
Q: Have you ever had any cases with Steve Levin of Levin & Perconti before?
A: Yes.
Q: Do you know how many cases?
A: I think over the years probably about three or four.
Q: Three or four cases in addition to this case?
A: About that.
Q: I assume that's all been on behalf of plaintiffs?
A: Yes.
Q: Have you ever testified at trial in any of those three or four cases?
A: No. I think this is the first case that actually went to deposition.
Q: Did any of those other three or four cases involve nursing care home issues?
A: I believe at least three or four of those did.
Q: But again, none of those involve issues of elopement or wandering?
A: No.
Q: That's correct?
A: That's correct.
Q: Do you recall when you were first retained by Mr. Levin in this case, the Pietrzyk case?
A: I believe it is about three years ago, but I do not know exactly to be honest with you.
Q: I have what I have marked as Exhibit No. 2 with today's date which is a copy of the Plaintiff's Response to Supreme Court Rule 213 F and G Interrogatories.
MR. LEVIN: Is that your only copy, Don?
MR. MACHALINSKI: No, I have another copy.

BY MR. MACHALINSKI:

Q: Beyond Page 15 there is some information referencing you.
A: That's not my current address by the way.
Q: What is your current address?
A: My current address is 1777 Victoria Point Circle. That's in Westin, Florida.
Q: Do you have any present plans to move?
A: No. I just moved there last week.
Q: If you look at Exhibit No. 2, Page 15, references the fact that you have reviewed the Oak Lawn Pavilion Nursing Home records?
A: Uh-huh.
Q: Is that a yes?
A: Yes.
Q: And the Christ Hospital records?
A: Yes, I have.
Q: Other than those two records, have you reviewed any other records relative to this case?
A: No, I have not.
Q: Specifically did you ever review the IDPH material, Illinois Department of Public Health records?
A: No.
Q: Have you ever reviewed any deposition transcripts?
A: No.
Q: Have you ever asked for any information from Mr. Levin that was not provided to you?
A: No, I have not.
Q: Have you brought with you today a copy of your file relative to this matter?
A: Yes.
Q: Could I take a look at it, please?
A: Sure. That's the hospital record on top and then the two nursing home records.
MR. MACHALINSKI: Off the record.
(Whereupon, a discussion was had off the record.)

BY MR. MACHALINSKI:

Q: Dr. Greenberg, I have taken a look at your file relative to this matter and for the record it consists basically of three sets of records. Two of the records are the records from the Oak Lawn Pavilion, Bate Stamps No. 1 through 388 which I believe were previously marked at an earlier deposition as Largosa Exhibit No. 2, dated 4/22/98 and then a second set of Oak Lawn Pavilion records beginning Bates Page No. 219 through 382 which were previously marked as Largosa Exhibit No. 3 dated 4/22/98.
We also have a separate set of the, what I believe to be the Christ Hospital Medical Center records beginning Bates Page 389 through 555 which I don't believe have been previously marked in any deposition.
Do you know what Pages 1 through 388 are of the Christ Hospital records?
A: No, this is all I have.
MR. LEVIN: Can I see those records? I don't know either, Don. I mean, I have a feeling they were probably other records not the Christ Hospital. These are, my guess is these are all of Christ Hospital records but we probably just marked all our records.
THE WITNESS: I think, Steve, my guess is that these were sequential. This is Oak Lawn 1 Hospital and then followed by --
MR. LEVIN: Do the numbers make sense though?
THE WITNESS: Not on the ones that you sent me, but I think on the old records, you know, records and then these --
MR. LEVIN: What I did was I gave him all of the original records and then used for the sake of hopefully clarity which obviously isn't working, I gave him the Largosa records, but I have a feeling if you look at our initial Oak Lawn records, this will be right in the middle of those records. Come to think of it that makes sense.
MR. MACHALINSKI: That makes sense too because the Oak Lawn records end at 382 and Christ Hospital starts at 389, so there are seven pages. Who knows what those are.
MR. LEVIN: Right.

BY MR. MACHALINSKI:

Q: Have you prepared any written report, Dr. Greenberg?
A: No. Everything that I have is here.
Q: Have you prepared any handwritten notes of any kind?
A: No.You will see that in some parts I have just highlighted.
Q: That's on the records themselves?
A: Yes. There is some highlighting on the records themselves. I think you will see, like that.
Q: Beyond that you don't have any separate pieces of paper concerning your notes?
A: No.
Q: Have you ever reviewed any or seen any summaries of any medical records prepared by Mr. Levin's firm?
A: No, this is what I have.
Q: The opinions expressed on basically Page 16, those are, in fact, your opinions that you provided to Mr. Levin?
A: Yes.We spoke over the phone after I reviewed this case and spoke once again about this case, and this was basically my opinion. I certainly have no disagreement with what's written here.
Q: So it would be my understanding that you provided an oral opinion to him, and then he prepared a typed version of those opinions?
A: Yes, he did.
Q: Is your work completed as of the date that these opinions were expressed to Mr. Levin?
A: Unless you bring up something that we discussed, but this is pretty much how I view the case at this point. There is more detail to it but this is it.
Q: You have never interviewed any witnesses, have you?
A: No.
Q: Did you look at any applicable standards concerning nursing homes, either state or federal rules or regulations, guidelines?
A: You know, I know those guidelines in a relative sense and when I need to go to them, I go to them. I did not look at anything specifically regarding this case.
Q: Concerning Mr. Pietrzyk, what's your understanding -- let's talk about Mr. Pietrzyk prior to the leg fracture pedestrian auto accident. What's your understanding in terms of his condition when he was admitted to Oak Lawn Pavilion?
A: Initially he was admitted because the family, I just want to make sure I've got the right ones here for us. This is 7/1/94, the accident was 11/1. So this is Phase I, this is I believe Phase II.
Yes, in Phase I, if you want to, this gentleman obviously was difficult to manage at home. He was disoriented, confused. I don't like the word Alzheimers because Alzheimers describes something entirely different.We will just say that he had dementia such that it impaired the ability of his wife to care for him and his family, and that he was a known wanderer and that was in the initial notes, and that the nursing home was taking on the responsibility for watching him and caring for him and making sure he didn't hurt himself.
That basically they were putting him in a nursing home because they can no longer manage continuing to watch for him. He apparently was able to feed himself and participate in all his activities of daily living. So the main problem was his disorientation.
I assume because of some notes that were put in there that there were some periods of anger and confusion that often occur in people who are demented, and that made it relatively difficult and potentially unsafe both for the patient and for his wife if he was prone to violence.
There was some behavior noted in the record where the people had to restrain him and where he became agitated and struck out at personnel.
Q: Let me back up for a second if I may. If at any time I ask you a question and you need to refer to the documents, feel free to do that by all means. If you could, would you reference what the document is and preferably by the Bates number?
A: Sure.
Q: Thanks.When he was admitted to the nursing home, was he oriented as to a person?
A: I believe that he was oriented to his wife and at times he is intermittently oriented to staff.
I don't think he is oriented to time. It wasn't apparent. I don't think there is not, for example, for any mental exam in the chart that I noted. So I would say that he was generally oriented at least to himself and to relatives, you know, people there.
I think he became oriented to staff because there are notes in there by the staff saying that the patient recognizes them and things. I believe he is not oriented to time.
There are two issues there. One of which he speaks Polish, and intermittently as people who are becoming demented because their long-term memory is so much better than their short-term memory, they tend to lapse into the foreign language. So if he were oriented, it may have been lost on the staff who was caring for him.
Q: I assume that his dementia kind of flowed in terms of his cognitive skills, there would be periods where he would be more loosened and had greater cognitive skills and there would be other periods of time where his cognitive skills would be reduced?
A: Yes, that's true. The labeling of him and again without there is not, for example, CAT scans in here of the brain and things like that. They have labeled him as a multi-infarct dementia. Multi-infarct dementia usually appears in people who have poorly controlled high blood pressure. That was an example of preventative geriatrics.
What happens is that these people kind of plateau and then they suddenly drop down and then they plateau for a while. What they have is probably mini strokes or deep strokes in the brain and it's thought that this is what they have kind of a stuttering type of dementia as opposed to more of an Alzheimers where people see a more progressive decline without the stuttering.
Q: You don't have any question about the multi-infarct dementia diagnosis?
A: No. I think at some point dementia is dementia, and I think what it really is is in a case like this is dementia that can be cared for at home, dementia which cannot. He falls into the dementia which cannot.
He's wandering, he has some behavior patterns that are difficult for the wife to manage. The family is busy doing whatever as frequently as the case, going to work and whatnot. They felt that the best thing for him was to put him in a nursing home.
Q: You would agree that placement at the nursing home was appropriate?
A: Yes.
Q: You also indicated that the dementia would plateau, but over time it would gradually keep diminishing in terms of his cognitive skills?
A: What I said as he may have some strokes, and multi-infarct dementia is he has these repeated deep strokes. He may plateau and then when he has one of these strokes, his behavior or his cognitive abilities may decrease and then go down so it's a stuttering pattern.
Q: But a pattern that continually goes down?
A: If he has no further strokes, it may maintain itself for several years. Whereas Alzheimers is by definition a much more progressive relentless course where people will continually decline regardless of whether you control their blood pressure and other risks.
Q: Prior to his accident, do you have any other understanding of what his prognosis was for the future?
A: I think that you can't tell. I mean clearly his prognosis was he was going to live out the rest of his life in a nursinghome.
In a nursing home, prognosis may be different than, slightly different than the community but still generally speaking he was forming his ADLs, he was up and he was mobile and he was moving.
That's a different kind of nursing home patient than the nursing home patient who returns and who really doesn't get up and walk again. So the prognosis significantly changes with that fracture.
What furthermore do you know want from me in terms of prognosis? Would you like a time that this man may survive in a nursing home?
Q: Let's talk about life expectancy prior to the leg fracture.
Do you have any opinion based upon a reasonable degree of professional medical certainty as to what his life expectancy was immediately prior to the leg fracture?
A: I think you are looking at a man who basically had well-controlled medical problems, who was not on a lot of medications. I think you can have expected him to live approximately, you know, somewhere around five years or so.
Q: In terms of, you mentioned the ADLs, that's assisted daily living?
A: Activities of daily living, I'm sorry.
Q: That's all right. Prior to the leg fracture, what assistance did he need in terms of his daily living?
A: You know, I think his assistance were really not of toileting although he was incontinent at times. There is no mention in the chart that they had to constantly take him to toilet or clean him up or he was incontinent.
There are a few mentions of incontinence of bowel and bladder but nothing --
I think he was feeding himself. He was dressing himself. There is no mention that they were dressing him or at least doing it pretty much on his own. He was basically able to, you know, get himself around. I think, you know, the basic eating, sleeping. He was able to do most of those things.When he comes back, he is basically dependent on help.
Q: What about bathing prior to the leg fracture? Was he able to do that by himself do you know?
A: It doesn't really say, but my guess is that he was probably directed to the bathroom and some attendant stood in there which is what they should do for nursing home patients anyway to make sure that they are bathed properly and they don't slip and whatnot.
But I did not see anything where they were bathing him. There were no specific notes regarding that.
Q: In terms of, what was your assignment in this case?
A: Well, Mr. Levin contacted me and told me the story and said can you look at this case and tell me if you thought there was any negligence and what areas did you think there was negligence in.
Q: Then you looked at the records that we have already described?
A: Right, I did.
Q: Then you rendered some opinions?
A: I rendered those opinions.
Q: I would like to address some of the, your knowledge of the facts of this incident.
What's your understanding as to the date of the accident?
A: The accident was in November and I will look at the exact date because I have a problem with reminding myself what exact dates are.
He was admitted if I can have the hospital, and then I will just use that because it is simpler. He was admitted, his admission date is on 11/1 and he had surgery on 11/4, believe he goes back to the nursing home on 11/10 or 11/11.
Q: Prior to the accident, how long had he been at the nursing home?
A: He was admitted I believe in June of '93, June 23rd of '93.
Q: The accident happened November of what year?
A: November of '94.
Q: Do you know what, if any, changes occurred in his overall condition between that period of time between 6/93 and 11/94?
MR. LEVIN: Before the accident?
MR. MACHALINSKI: Correct.
THE WITNESS: That was pretty clear to me. I think in general he showed some decline. He was up and mobile and moving obviously because that's what leads to this. I think he had some weight loss and it was somewhere between 10 and 15 pounds or so, I believe.

BY MR. MACHALINSKI:

Q: What about his dementia? Had that greatly diminished or increased?
A: From my point of view I don't -- in other words, how do you quantify it? There are typical ways of doing it, many mental exams, serial exams.
There is nothing in there that is charted per se. I read the chart and I see him pretty much as the same. He is a little bit, at occasion he gets a little bit more confused. He gets a little bit more disoriented.
Is it 10 or 15 percent more at the time, maybe. But there is nothing that says -- I think we also see some more aggressive behavior patterns I think that were documented where he was holding off the staff and things like that where he got kind of a little bit agitated.
But in general, I mean this is kind of a -- again, it's a disease that whacks and wanes. There is nothing there that says this man had a specific stroke or anything. There are periods where he gets confused, and there are periods where he seems to hyperventilate, and what those periods are exactly nobody seems to know. The doctor doesn't seem to address.
Q: In terms of his aggressive behavior and specifically aggressive behavior with the staff, that would be attributable to his confusion?
A: I believe so.
Q: And specifically his orientation as to place?
A: And person.Also it could be in a sense looking for family members and things like that. One of the things that isn't brought out in this chart that you may have privy to and I don't is the fact that this man obviously immigrated here, he's from Poland.
Was he from, for example, was he in concentration camps, was he in labor camps? Did he immigrate before World War II or after?
All those would play a certain amount of experience in determining how his behavior plays out his aggressiveness and things like that because all those prior experiences are important and how he views the people who are caring for him.
Q: Obviously when he was admitted to the nursing home, they were advised of his propensity to elope or wander?
A: In the chart it does say that the nursing home was aware that he was wandering because that is what led the family to bring him.
Q: Are you aware of what, if any, actions the nursing home took to prevent his elopement or wandering?
A: It's not clear. There are different things that are said in different places. There were some places where he had a wander guard. There are some people where they say he was directed and reoriented. There are some places where they say he is Poseyed or restrained.
There are places where he gets out or gets to the door and they catch him, and of course there is the event where he gets out and gets struck by a car.
Q: How many instances are you aware of from your review of the documentation where he was actually able to physically leave the building in addition to the November '94 incident?
A: I believe there was one and I don't remember the date, but I believe there was one other one. The fact whether he actually gets out or not from my point of view, if you know you have a wanderer, all it takes is one, one time.
But I know there was one other date where at least he either made it outside the doors or had gotten right at the doors.
Q: Do you know what date that incident occurred?
A: No, I don't.
Q: Other than that one incident, you are not aware of any other incidences?
A: I'm not aware of repeated incidences where he made it to the door, but I'm aware in the chart there are repeated incidences where they say this gentleman is wandering, we have caught him, he is at the elevators, he is there, he is, you know, walking away, he is in a different person's room, that type of thing, and patient was reoriented, you know, redirected.
Q: And that redirection in charting was appropriate?
A: You know, it's a generalized statement. What actually occurred I can't tell you. It could have been hey, you know you are not supposed to go there, is that enough?
Or as opposed to a reorientation where it says you are not supposed to go there, this is where you are supposed to be now, let me take you down there. Those are two different things, and there is no way of telling that from the chart.
Q: Assuming it was the latter situation, that would be appropriate care?
A: Well, I think that it's more appropriate. I mean the problem is you have a wanderer and you can't watch him 24 hours a day unless you take some other precautions. Those precautions include some type of wander guard, repeated checks by the nursing staff, having side rails up, and actually, you know, making, putting the rooms should be right in front of where the nurses hang out and things like that as much as you can to watch this type of person because these are not uncommon events. These happen. I mean this is not the first person who has ever wandered and gotten hit by a car.
Q: The side rails would be an appropriate preventative measure?
A: The side rails becomes appropriate if the patient doesn't climb over. If he's going to climb over them then it's not appropriate. Then you have to work around that.You have to be careful because sedation can also confuse these kinds of patients. It's a very tricky and difficult problem.
Q: What about, are you aware of any chemical restraints ever used?
A: Well, they have, they did use frequently Haldol.
Q: That was prescribed by a physician?
A: That was prescribed by the physician.
Q: Do you have any concerns about the appropriateness of that medication?
A: Well, Haldol has a multiple number of side effects, and they can include things something called dyskinesia where the patient becomes uncoordinated, where they can have problems with their speech, when they can have different kinds of motions of their heads and things, but it can also cause in a sense where we don't use Thorazine it can also cause some low blood pressure, it can also cause some problems with coordination in general.
Q: Is there anything in the records that would indicate to you that he was, in fact, suffering from those complications?
A: From the Haldol, no, but he was clearly confused and it's a two-edged sword.You can be confused from the medication, you can get better with the medication.
Haldol was primarily used in this kind of setting in order to calm the patient. So in that sense if it calms him and he goes to sleep and they are able to put him to bed, that's one thing, if he's combative and things. But it was being used in a sense as a restraint much as a Posey would be but, you know.
Q: Is it your opinion that the use of Haldol was inappropriate for this individual?
A: I think that there were other drugs at this time that became available that may have been safer, that may have been safer to be used on a chronic basis.
I won't quarrel per se because a lot of people do use Haldol, but there are drugs particularly in somebody who's mobile who you might want to try instead especially if he's hyperagitated. They were using Haldol not only on a regular basis but on a PRN basis, in other words, as needed for agitation.
Q: That was prescribed by a psychiatrist?
A: I'm not sure who did. There are at least psychiatric notes and there are general doctor's notes. I believe both of them had prescribed it.
MR. LEVIN: Are we getting a little off the subject about opinions prior to November '94 and as to other people's conduct?
MR. MACHALINSKI: Yes, I was going to wrap it up anyway.

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