Nursing Home Deposition 3 - Plaintiff's Deposition of Registered Nurse - Part 2

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BY MR. LEVIN:
Q But go ahead. You can answer.
A I don't know. I was just going to say I don't know. There are people, you know, nurses' aides walking back and forth, and there is nobody stationed right there.
Q I'm not talking about just getting out the front door itself. I'm saying in order for him to get out of the home, you had to go from the second floor, to the first floor, a number of things had to go wrong in order for him to get out of the home undetected, correct?
A Correct.
Q So would it be fair to say taking the whole scenario that in your opinion in order for Tony to have gotten out of thenursing home undetected on November 1, 1994 one or more people weren't doing their jobs, correctly?
MR. MACHALINSKI: I'm going to object. It calls for speculation. You can answer that if you can.
THE WITNESS: That's true.
BY MR. LEVIN:
Q And another way to put that is in order for him to get out of the nursing home undetected on November 1, 1994, one or more nursing home employees were not performing up to the appropriate standard of care, correct?
MR. MACHALINSKI: Same objection.
THE WITNESS: Pardon me?
BY MR. LEVIN:
Q You can answer.
MR. MACHALINSKI: Same objection. You can answer that if you know.
THE WITNESS: I don't know. That's a hard one because the nurses' aides at that time are preparing residents for bed. So they could have been in the room taking care of a resident, and not been out in the hallway just to notice anybody.
BY MR. LEVIN:
Q But we are talking about a number of different things. The standard of care in your opinion required the nursinghome to be aware of the fact that Tony was attempting to leave the home without supervision, correct?
A Correct.
Q And if they allowed him to elope from the home undetected, then the standard of care would have been violated, right?
MR. MACHALINSKI: Same objection.
THE WITNESS: That's correct.
BY MR. LEVIN:
Q Now as a result of -- You knew Tony before and after this fracture injury, correct?
A Correct.
Q And wouldn't -- Would it be fair to say, generally speaking, that after he suffered these fracture injuries both his physical and mental health declined?
A Well, certainly his physical health with the fractures. But mentally before he was confused, he was disoriented.
Q Before the fracture injury he was ambulatory, correct?
A Correct.
Q After the fracture injury he never walked again, correct?
A No, he was bedridden. Well, he got u in a Geri-chair. But basically he was bedridden.
Q So if the fracture injury occurred in November of '94 after the fracture injury, he was bedridden in November, December, January and February until he died, correct?
A Correct.
Q So he went from someone who was active and up and about every single day to never leaving the bed and occasionally going to a Geri-chair, correct?
A Right.
Q And that was a direct result of the fracture injuries he suffered, correct?
A Right.
Q Before the fracture injury he never had any decubitus ulcers or pressure ulcers, correct?
A Correct.
Q After the injury he began to develop pressure ulcers at various points all over his body, correct?
A He had several Stage IIs.
Q Do you know the different parts of his body where he got those pressure ulcers?
A I would have to look in the chart to be specific.
MR. LEVIN: You can show her the copy if that would be easier.
BY MR. LEVIN:
Q If we show you what we have marked as Deposition Exhibit No. 3, but maybe we can use the copy of it?
MR. MACHALINSKI: Sure. Do you want to mark that 3A?
MR. LEVIN: Yes. This we will mark this 3A.
BY MR. LEVIN:
Q Where would be best place for you to find his decubitus ulcers?
A Not in here, the last chart.
Q Tell us which one?
A That would be 3.
Q This one here (indicating).
MR. MACHALINSKI: Do you want to use the Bates stamp? For the record the witness is looking at --
MR. LEVIN: -- what we have marked as Deposition Exhibit No. 3 which is the chart from 11-10-94 until the time Tony died. But she is looking at a Xerox copy of it --
MR. MACHALINSKI: -- which has previously been marked Largosa Exhibit No. 3 dated 4-22-98.
BY MR. LEVIN:
Q Ma'am, let me interrupt you for one second. Before you go through the chart, would you agree that it is your opinion that the decubitus ulcers that he suffered resulted from the immobility from the fractures, correct?
MR. MACHALINSKI: I'm going to object to the extent it calls for a medical opinion. You can answer that.
THE WITNESS: You want to know if he got the decubs because he was bedridden?
BY MR. LEVIN:
Q Right.
A It's possible.
Q Do you have any other explanation for it?
A It is possible poor nutrition. Nutrition would play a part, mobility.
Q Mobility would play a part, and lack of nutrition would play a part, correct?
A Right.
Q And lack of nutrition could be related to lack of mobility, correct?
A He did have a G-tube in.
Q His interest in eating and hydrating himself declined significantly after the fracture injury, didn't it?
A Correct.
Q And it would not be a stretch to say that was a result in your opinion, at least a partial result, of the fracture injury, correct?
A Right.
Q So now as a result of the fracture injury, he lost his mobility, he started to lose interest in eating and hydrating himself, and as a result of that, from those two fractures he developed these decubitus ulcers, correct? Possible.
Q I mean that would be your opinion, correct, as his nurse -- or as a nurse there?
MR. MACHALINSKI: Same objection.
THE WITNESS: Yes.
BY MR. LEVIN:
Q Now describe for me if you can inasmuch detail as you can, -- I'm sorry to put you through this, but it may be an issue in the case -- in as much detail as you can what type of decubitus and pressure ulcers he developed secondary to these fractures that he sustained in November of '94?
MR. MACHALINSKI: I'm going to object to the extent it calls for the witness to simply read off the medical chart.
THE WITNESS: Shall I read this?
BY MR. LEVIN:
Q Yes. I'm trying to get in a fair detail as you can exactly what type, and where and the severity of the decubitus ulcers that he experienced, when he started getting them, and how they progressed, and where they were at the time that he died?
A I thought this was in order.
Q It is not?
A 11-8 he had a decubitus on his right hip. 1-3 he had a reddened area to his scrotal area which Mycolog cream was applied, M-Y-C-O-L-O-G cream was applied. And he had a bunion area which was small, hard tissue on his bunion area, right foot. And that wasn't open.
And then 1-18 his buttocks were reddened with no open areas. On 1-18 also he had -- left hip there a necrotic area, small necrotic area And then the scrotal area was healed 2-10. These are treatment sheets.
MR. MACHALINSKI: For the record could you just refer to the Bates stamp page number again to start with?
THE WITNESS: Here. I'm sorry. 000331 and this is in December.
BY MR. LEVIN:
Q You see I thought it might be easier to just go through the care plans because they sort of summarize them. But go ahead. Do you want to just take a second look at it, and then maybe you can summarize it. I don't want you to have to read every page. And then we will go through some care plans, too?
MR. MACHALINSKI: Okay.
MR. LEVIN: Let's take a break.
(WHEREUPON a recess was taken, and the deposition continued as follows:)
BY MR. LEVIN:
Q Go on the record. We have taken a little break, and you have looked through both the chart and some of the care plans, and you're going to tell us some of your thoughts regarding Tony's skin subsequent to the fracture injury?
MR. MACHALINSKI: Before we begin, why don't we mark the second -- the document she is referring to as 3A which is a copy of --
MR. LEVIN: -- of 3.
MR. MACHALINSKI: -- of 3.
MR. LEVIN: -- with Bates stamped page numbers.
MR. MACHALINSKI: Correct.
(WHEREUPON Chisholm Deposition Exhibit No. 3A was marked as of 9-20-00.)
MR. MACHALINSKI: Let's go back on the record. Ms. Chisholm, whenever you are referring this group of documents, Exhibit No. 3A, with today's date.
THE WITNESS: This is 3A then (indicating)?
MR. MACHALINSKI: Right.
THE WITNESS: With 151.
MR. MACHALINSKI: Right. When you are reading off a specific document, if you would refer to the page number, please.
THE WITNESS: Okay.
BY MR. LEVIN:
Q Now to introduce your question, we have take a little break. You have reviewed some records, including the chart from November 10-94 until Tony died.
And you have also looked at Deposition Exhibit No. 3 which are care plans and other things. And you are going to give us your thoughts about his skin condition subsequent to the fractures. Please go ahead.
A Right. This is page 151. He was a high risk for skin breakdown as seen, and his age was over 80. He was very confused. He was incontinent. He was only bed to the Geri-chair.
He had impaired physical mobility due to the fracture. He had an alteration in nutrition and hydration, and he had an inability to eat due to swelling, and a G-tube was inserted 1-18-95. Do you want me to read the approaches? This is nursing care. This is what they have done now.
Q And this is their assessment of him after he got back from the hospital after the fractures, correct?
A Correct.
Q And they are noting now his condition has changed?
A Yes.
Q And they may have to do certain things. And one of the things that they have to do is now be of a concern for the formation of pressure ulcers, correct?
A Correct, correct. He was a high skin risk.
Q Now tell me what types of mechanisms did they now have to employ to try to prevent the decubitus ulcers or pressure ulcers?
A He was turned and positioned every two hours.
MR. MACHALINSKI: You are referring to page 151.
THE WITNESS: Oh, 151, 3A.
MR. MACHALINSKI: Yes. Thank you.
BY MR. LEVIN:
Q Go ahead.
A Encourage repositioning by self when able. They used pillows. Therapeutic mattress and cushion and skin check Q shifts. He wore heel and elbow protectors, and used a draw sheet in bed, so there should be no shearing.
And thorough peri care after each episode of incontinence and apply moisture barrier. He had passive range of motion to all extremities twice a day, and provide adequate nutrition and hydration. And treat per M. D.'s orders and document weekly. And he was on psychosocial one to one.
Q And ma'am, this was a much different care plan than the one that he had prior to the fracture injuries, correct?
A Correct.
Q Before the fracture injuries he needed help from the staff, but he could get in and out of bed by himself, correct?
A Correct.
Q He could take care of certain of his needs himself, correct?
A Not many. He had to be changed frequently because he was incontinent.
Q But he could certainly walk around by himself, correct?
A Correct.
Q He didn't have to be turned, correct?
A Correct.
Q I mean he wasn't confined to a bed or a Geri-chair, correct?
A Correct.
Q And he wasn't having nutritional or hydration issues, correct?
A Correct.
Q Tell me the progression. So that's the plan to try to prevent decubitus ulcers. What happened?
A As far as skin breakdowns?
Q Right.
A 12-27 he had a Stage I necrotic area on his bunion area superficial.
MR. MACHALINSKI: I'm sorry again to interrupt.
THE WITNESS: 3A.
MR. MACHALINSKI: 3A, page 147?
THE WITNESS: 147. And then he had the reddened area on his scrotum which was healed. This was 1-3-95, and the goal was met 2-9-95. And then 1-18 he had some redness near his rectum and some scattered pinhole openings. Treatment was ordered.
Also the same date, 1-18-95, he had a right hip decub, Stage I with a dried area. And then 1-18 his left hip also had a Stage I with dried eschar two centimeters by a half a centimeter. And then 1-26 it increased in size to two centimeters by three centimeters. I seem to be missing a sheet here. I have gone to February.
BY MR. LEVIN:
Q Yes. I sort of had the same problem myself. There is a numbering system to these sheets that I don't understand. See where it says like page eight on the top? I'm assuming you have the same things I have because they were copied for me.
MR. MACHALINSKI: Off the record.
(WHEREUPON a discussion was held off the Record, and the deposition continued as follows:)
THE WITNESS: Shall I continue?
BY MR. LEVIN:
Q Please.
A We have gotten to 1-18. And then 1-26 they had increased in size. This is from the original care plan now. 1-24, right outer ankle, he had a necrotic area on his right ankle, three centimeters by five centimeters. And then 2-3 he had a Stage II on his sacrum.
Continue with 2-7, he had the right foot, and that was the bunion area. And treatment he had whirlpools daily. He was given whirlpools daily for all of the decubs along with cream. And he had wet to dry. That I know, he had wet to dry saline dressings. And he had the Stage II on his left heel 2-6, four centimeters by three centimeters. And he was a high fall risk also.
Q He was a high fall risk after the fracture injury?
A No. This is 11-30-94.
Q That's after.
A Return from the hospital he was on antidepressant. He was on Zoloft.
Q Do you know if he was on that before he was in the hospital?
A No. Before he was in the hospital he was on Haldol.
Q Do you know if the depression resulted from the consequence of the fracture injuries, is that a reasonable assumption?
MR. MACHALINSKI: I'm going to object to the extent that calls for a medical opinion.
THE WITNESS: I have no idea. I don't know.
BY MR. LEVIN:
Q And is that --
A That's the decubitus. That's what I have on decubitus care and prevention and treatment that was rendered to him.
Q Would it be fair to say -- Is it your opinion despite the appropriate efforts taken by the nursing home to prevent his decubitus because of his immobility and other risk factors, they just form and got worse?
A A lot of times it is just inevitable.
Q And in this particular case it is secondary to the immobility and nutritional problems resulting from the fracture injury in your opinion?
A Right. And then he had the G-tube inserted for more nutrition and hydration. But even that didn't work, correct?
A Apparently not.
Q In essence from the time of the fracture injury until the time that he died, his skin was deteriorating, correct?
A Correct.
Q Do you know if these decubitus ulcers were causing him pain?
MR. MACHALINSKI: Object, speculation.
THE WITNESS: I have no idea.
BY MR. LEVIN:
Q In your experience are decubitus ulcers painful?
A That would be a presumption.
Q What is your presumption?
A Anybody that had a skin tear -- Somebody up and about if you hurt yourself, you know it is going to hurt.
Q Right.
A So I don't know now if he did or not. I have no idea.
Q There is a note I'm going to take you through this, Deposition Exhibit No. 3A on page 22?
MR. MACHALINSKI: Can we break for a second?
MR. LEVIN: Yes.
(WHEREUPON a discussion was held off the Record, and the deposition continued as follows:)
BY MR. LEVIN:
Q When Tony was admitted to the nursing home, he was termed to be a wanderer, correct?
A Correct.
Q And a wanderer means somebody who moves about without any rational purpose, oblivious to needs of safety, correct?
A Yes. They need to be directed.
Q And because in his particular case at least some of his wandering behavior was described as looking for his wife, correct?
A As far as I know. I don't know for sure.
Q That's not unusual for someone who comes to a nursing home and is not familiar with the setting that may either look for their wife or their spouse, or try to get back to their home, correct?
A Correct.
Q And the problem is people like this or like Tony if they get out of the home, they are absolutely incapable of taking care of their own safety issues, correct?
A Correct.
MR. MACHALINSKI: I'm just going to object. It calls for speculation. You can answer.
BY MR. LEVIN:
Q You answered yes, yes?
A Yes.
Q And do you know if Tony had dementia or Alzheimer's, or if those are different or the same thing?
A I believe his admitting diagnosis was dementia.
Q Right. It says somewhere in there dementia, not Alzheimer's. And I was going to ask you if you know what that means?
A To differentiate?
Q Yes. It's hard to differentiate, correct?
A Very hard.
Q Dementia and/or Alzheimer's basically refers to forgetfulness, or inability to appreciate the seriousness of situations, things like that, correct?
A Cognitive is low.
Q And again one of the initial plans for Tony before he got hit by the car was to provide for him a safe, structured environment that could accommodate his wandering, but would not jeopardize his safety, correct?
A Correct.
Q Do you know what that program for Tony involved leading up to November 1, 1994 when he got hit by the car, what kind of safe, structured environment or wandering program was instituted for him?
A Well, he was placed on the second floor. The doors were alarmed. He had a Wanderguard on, and staff was aware of his problem of wandering.
Q How did they accommodate his wandering? That would be the safety issues which we have discussed. How did they accommodate his wandering? What did they do?
A He had to be redirected either back to the dining room, you know, like for his meals or for an activity; or if it was time to go to bed, to his room.
Q He wasn't medicated to prevent his wandering, was he?
A Not to my knowledge, no.
Q And he wouldn't have been restrained to prevent wandering, correct?
A No, it is not a jail. They are not tied down.
Q He was medicated and he didn't have restraints. Do you know why?
A It their right. It's the patient's right.
MR. MACHALINSKI: I don't know if you understood the question. Could you read the question back, please?
(Record not read.)
BY MR. LEVIN:
Q He was restrained at times, and he was medicated. Do you know why?
A He was restrained in bed. He had a posey vest on in bed, and at that time it was to prevent him from crawling over the bed rails. And then that was discontinued.
Q I see. Let me direct your attention to page 22 which may be one of the little forms you filled out, and it is in the bottom right-hand corner.
MR. MACHALINSKI: That's Exhibit 3A.
BY MR. LEVIN:
Q It is Exhibit 3A. And there is a note that says pain. That's not the first page obviously of that report. But I think the first page is page 20. And then it says, resident complained or shows evidence of pain daily or almost daily. Do you see that on the bottom right-hand corner?
A I do.
Q And is that something you filled out? I know your name is somewhere on this page?
A No. Ms. Baker filled that out.
Q As far as you know, is that form supposed to mean that -- what it says, that since the fracture injury, he either complained of or was in pain almost daily?
A That was her summation.
Q Right. Your name was on the front of --
A Exactly.
Q And on page 20 your name is there, right?
A Uh-huh.
MR. MACHALINSKI: Is that a yes?
THE WITNESS: Yes. Also the section here, see E? That's what I filled out.
MR. MACHALINSKI: That's on page 20 --
BY LEVIN:
Q Yes, on page 20 it says E. Which of these pages did you fill out?
A I filled out page 21.
Q 21. So there on page 21 you are noting that as a result of the fracture, he has a partial or total loss of voluntary leg movement, correct?
A Correct.
Q He has a partial or total loss of his ability to balance himself while standing, correct?
A Correct.
Q And if Nurse Baker accurately recorded her portion of this form, then Tony was in pain every day, correct?
A Correct.
Q And I think we covered this. I apologize. But after -- I'm looking at page 24 now. Is that your notes on 24?
A Correct.
Q Would you just read that additional note you wrote there under additional notes?
A Readmitted from Christ Hospital with fracture of the right leg, has long leg case on right leg, has become dependent on staff for ADLs and transfers from bed to Geri-chair.
Q Again you are reflecting the change in his condition as a result of the fracture, correct?
A Correct.
Q And again on page 25, is that your writing?
A Correct.
Q You say, totally dependent on staff. Recent fracture right leg requires supervision and verbal cues with eating, correct?
A Correct.
Q That's also a change in condition?
A That's correct.
Q Again on page 26 did you fill that communication?
A That's Ms. Baker's.
Q What she is under ADLs is since the fracture there has been a decrease in his self-performance in the amount of -- I think she -- in his body control problems and in his ADL potential, correct?
A Correct.
Q In your opinion did he become more withdrawn after the fracture injuries?
A He was quieter. I don't know how withdrawn, but he was quieter.
Q In fact on page 29 which is not something I think you filled out, but it is at least part of the assessment it says, resident is withdrawn from leisure activities and self-care, correct?
A Correct.
Q Generally speaking in your opinion based on your seeing him and the forms you filled out and the assessments you made, would it be fair to say that subsequent to the fracture injuries, Tony's physical and mental capacities declined?
A Correct.
Q And he went downhill from the time of the fractures until his death; is that a fair statement?
A Correct.
Q And it is your opinion that that was secondary to the fractures and the immobility, and the problems caused by the fractures; is that correct?
MR. MACHALINSKI: I'm just going to object to the extent that it calls for a medical opinion.
BY MR. LEVIN:
Q I'm just asking for your nursing opinion on that subject.
MR. MACHALINSKI: Do you want the question read back?
THE WITNESS: Please.
BY MR. LEVIN:
Q Let me try to ask it again. Based upon your experience as an ADON and a DON in dealing with residents atnursing homes and dealing with Tony specifically, would it be fair to say that the decline in his physical and mental condition subsequent to the fractures were a result of the fracture injuries?
A Physical, yes. Mental, I don't know if he would have declined mentally anyway.
Q You don't know one way or the other?
A Right.
Q Is it common in your experience that when an older person like Tony sustains a fracture like he does that they do decline?
A Not all the time, no.
Q By the way do you know if he developed pneumonia subsequent to the fractures?
A Somewhere I saw it.
Q I saw something about it. But I don't know if that was the care plan to prevent it, or if that was a recognition that he had it.
MR. MACHALINSKI: What's the page?
THE WITNESS: 3A 143, 1-16-95, pneumonia right lower lobe, infiltrate, chest x-ray report. IVs were started for antibiotic therapy.
BY MR. LEVIN:
Q Is there any relationship in your opinion as the ADON or DON of this facility between lack of mobility and pneumonia?
MR. MACHALINSKI: I'm just going to object again. I think it calls for a medical opinion. You can answer that if you can. Do you want the question read back?
THE WITNESS: It is possible, probable all the time.
BY MR. LEVIN:
Q What is your understanding when there is a relationship between lack of mobility and pneumonia? How do those two things relate?
A They can be related for lack of mobility.
Q Could you explain when they are related how it is? Explain it to me like I'm a lawyer, and don't know anything about fractures and lack of mobility and pneumonia. How do these two things relate?
A From not moving properly -- I don't mean not properly. But mobility, your mobility is impaired, so that you could develop pneumonia from that.
Q How does that happen? Why does lack of mobility lead to pneumonia? I'm not challenging you I'm just trying to understand.
A I don't know how to answer that really.
Q That is just something in your experience that you have seen?
A It could be, yes.
Q I take it subsequent to the fracture injury, would it be fair to say it was an involved process in transferring Tony from the bed to the Geri-chair, it required the assistance of more than one person?
A As far as -- I think two people transferred him.
Q Do you know if that process would have been a painful process for him?
A I don't think so. The girls they are trained for transferring.
Q Did you ever speak with Tony?
A Yes.
Q And in English?
A Sometimes he would start in English and then go into Polish. He kind of went between the two. He was confused, you know, disoriented. And he just sometimes didn't make sense sometimes.
Q And sometimes he did?
A Not really.
Q You are talking about after the fracture or before?
A Before.
Q You know it seems like after he got back -- Let me just go to page 53 for a second of Deposition Exhibit No. 3A which I think are your notes, right?
A Correct.
Q It says, was readmitted from hospital with Zoloft antidepressant, very quiet, doesn't resist care. In other words, he had gone from being somewhat boisterous to very quiet, somewhat knowing his own mind, to more malleable after the fracture; is that a fair statement?
MR. MACHALINSKI: I'm going to object again. It mischaracterizes her prior testimony. You can answer that if you can.
THE WITNESS: I don't know.
BY MR. LEVIN:
Q When you say initial notes here, aren't you reflecting the change in his condition?
A Yes, that he was quiet.
Q So if you are saying very quiet, doesn't resist care now, that was a change in his condition from prior to the fracture, correct?
A Correct.
Q Did it seem like the fracture sort of broke his spirit?
A I really can't remember. I'm trying to think how -- He just was very quiet when he came back from the hospital. So I don't know mentally how he was, but he was quiet.
Q After he came back from the hospital after a fracture, did he seem more quiet, more docile, --
A He was quiet.
Q -- more malleable?
A Yes, he was quiet.
Q Did he seem to have less spirit?
MR. MACHALINSKI: I'm just going to object as to what spirit is. You can answer that if you can.
THE WITNESS: I really don't know.
BY MR. LEVIN:
Q Subsequent to the fractures in addition to suffering multiple decubs the loss of the mobility, the lack of nutrition, the pneumonia, he also suffered weight loss, too, correct? His appetite went down and he lost weight?
A I would have to see. I don't know for sure.
Q Look at page 64 for example. This is what I'm sort of getting at. See where it says, cast removed from left leg, decreased appetite, weight loss, choking, unable to swallow, swallow study done, severe dysphagia?
A That's when he had the G-tube inserted.
Q Right. G-tube inserted, pneumonia. It says right lung I think, antibiotics started, multiple decubs noted, decrease in cognitive something -- OCC response, what is that?
A Occasionally? I don't know. Occasionally responds to verbal stimuli.
Q And then it says, significant change. So again that is reflecting the significant change that occurred after the fracture?
A Correct.
Q Now on page 76 if we could turn there, I know that's not your note, but it may have been something you reviewed. And here they are talking about his -- the problems that could occur from his wandering before the incident occurred, correct? This is January 10, '94. Remember he wandered away on November 1, '94. So this is about 11 months before?
A Previous.
Q And somebody who is talking about him writes down, this behavior, referring to his wandering behavior can endanger the resident if he gets out the door.
He can fall down the stairs. If he does go outside, he could become lost or could get struck by a car because he doesn't know where he is or where he is going. And that was from November of '94, correct?
MR. MACHALINSKI: No.
BY MR. LEVIN:
Q I mean that's from January?
A January.
Q That's exactly what happened to him in November of '94, correct?
A Yes.
MR. LEVIN: Off the record.
(WHEREUPON a discussion was held off the Record, and the deposition continued as follows:)
BY MR. LEVIN:
Q So there was clearly a recognition that even when Tony was admitted to the nursing home in January of '93 by the staff, that if he got out of the home he could easily get lost and get hit by a car because he couldn't appreciate the dangerous situations he may find himself in, correct?
A Correct.
Q You don't have any quarrel, you agree with what this nurse wrote on page 76, correct?
A That's psychosocial. So she is not a nurse.
Q But you agree with what he she said, right?
A That was his behavior.
Q And again on page 87, it appears the same psychosocial person is talking about, his wandering appears to be motivated by trying to find a way out of the building, so he can go home to his wife. Do you see that notation?
A Yes.
Q And you don't have any quarrel with that observation, do you?
A No, I don't.
Q And again for some reason on page 88 is that just a copy of the other one because it seems like the person is saying the same thing again?
A No.
Q No, it is a different one?
A It's dated 12-22-93 and then again 1-10-94.
Q But it looks like page 76. Now that I'm looking at, it is the same note as page 88. Are they the same exact thing? I think they are.
MR. MACHALINSKI: Yes, it looks like it.
MR. LEVIN: We could look at the original. Off the record.
(WHEREUPON a discussion was held off the Record, and the deposition continued as follows:)
BY MR. LEVIN:
Q If there is a question pending, I'm going to withdraw it, and I'm going to ask another one. But again I guess on page 89 another psychosocial person is making this observation talking about his wandering.
This behavior is an endangerment to resident. If he got out of the building, he doesn't have any idea where he is. He could get lost on a main street and get hit by a car, correct?
A Correct.
Q And that's April of '94, yes?
A Correct.
Q So again this is part of-- It is not technically in the care plan, but this is something that the whole nursing home staff should know in caring for Tony, correct?
A Right.
Q And then on page 119 in the middle there, it looks like it talks about Wanderguard bracelet applied to wrist to set off first floor alarms. Do you see that?
A Correct.
Q Does that mean that there was more than one first floor alarm that would be set off by the Wanderguard if you know?
A I don't know. As far as I know, it was the one, the front door.
Q You don't know if it was one or more?
A I don't know.
Q Just so we can get a clear answer, you don't know if the Wanderguard bracelet that was supposedly applied to Tony's arm would set off one or more of the alarms on the first floor, correct?
A Correct.
Q Is there something in the chart that would check off each day whether he was wearing the Wanderguard bracelet or not?
A No.
Q No? So we couldn't look at the chart, and find out what days he was wearing it, and what days he wasn't wearing it, could we?
A No.
Q Did you try to do that by any chance?
A Well, that is something -- No, there is no record.
Q We have been use the term Wanderguard, correct?
A Correct.
(WHEREUPON a discussion was held off the Record, and the deposition continued as follows:)
BY MR. LEVIN:
Q We have been using the term Wanderguard, correct?
A Correct.
Q And Wanderguard technically is a trade name, correct?
A Yes.
Q But it has sort of become like Kleenex where people use to it to refer to a device that's put on people like Tony to prevent wandering, correct?
A Correct.
Q You don't know -- or I don't think you know the make or model of whatever device that he supposedly had on, correct?
A Correct.
Q Just by way of another example on page 154, that's a part of a care plan, correct?
A Correct.
Q And it is referring to on 12-27 someone wrote, severe loss of range in motion, decreased strength in right lower extremity. And then it says maximum transfer, unable to walk, lacks standing balance, correct?
A Correct.
Q And again this is a reflection of the difference in his condition subsequent to the fractures, yes?
A Correct.
Then just going back to page 153, here is someone in his care plan as saying, resident does not verbalize much since return from hospital. Resident does not use his physical ability which consists mainly of use of his hands, correct?
A Correct.
Q Again someone is describing the change in his condition subsequent to the fracture injuries, right?
A Correct.
Q And then for some reason it goes from 11-30-94 to 2-22-95, that's because it is a quarterly?
A Quarterly.
Q And by the way on page 154, it says that he is at high risk for the development of contractures, correct?
A Correct.
Q Did he develop contractures subsequent to the fractures, do you know?
A I don't know.
Q To your knowledge, other than whatever we have discussed or you have talked about today in this deposition, do you have any other opinions concerning the care and treatment provided Tony Pietrzyk, or what if any injuries he suffered as a result of anything that occurred?
A No, I have nothing to add.
MR. LEVIN: Let me just take a second if I can to look through the original chart.
MR. MACHALINSKI: I have a couple questions. Steve, do you have any questions?
MR. HELIS: No, I don't have any.
MR. LEVIN: I'm not done. But go ahead.
MR. MACHALINSKI: I understand.

EXAMINATION

BY: MR. MACHALINSKI
Q Ms. Chisholm, Counsel just asked you if you had any other opinions. And I just want to clarify something that I believe you testified earlier that the nursing care that was rendered to Tony Pietrzyk following his return from the hospital after the fracture was appropriate?
A Yes.
Q With respect to Tony's mental condition between that period of time when he was originally admitted in June of '93 up until the date of his accident, specifically let's go to 10-31-94, did his mental condition deteriorate over that period of time?
A I think it was starting to deteriorate.
Q So that he was more confused in October of '94 than he was when he was originally admitted in June-of '93?
A Correct.
Q And would you described him as being fairy -- or very confused in October of '94 before his accident?
A Yes, he was confused.
Q And when you would speak to him at times he didn't make any sense even when he was speaking in English?
A Right.
Q Was he also combative with the staff?
A Yes, he struck out.
MR. MACHALINSKI: That's all the questions I have.
FURTHER EXAMINATION
BY: MR. LEVIN
Q Okay. If there had been a significant deterioration in his condition between June of '93 and immediately before the fracture injury, that would be noted somewhere in the chart, correct, or it should be noted?
A It was just a very gradual change. It wasn't like a significant change. When he fractured his leg, it was a significant change.
Q That's the point I'm trying to make. There may have been a gradual change between June of '93 and October of '94, but it wasn't of a moment that you would have noted in the chart, correct?
A. Correct. It wasn't measurable.
Q The really significant change occurred after his fracture injury, correct?
A Correct.
Q That's what I thought.
MR. MACHALINSKI: Let's go off the record for a second.
(WHEREUPON a discussion was held off the Record, and the deposition continued as follows:)
BY MR. LEVIN:
Q Ma'am, I'm going to read you from the -- hopefully that's in here on 11-10-94 one. Yes. That's it. It's that's the first page. Is that Dr. Largosa's --
MR. MACHALINSKI: That's the discharge summary.
BY MR. LEVIN:
Q Yes. That's Deposition Exhibit No. 2?
MR. MACHALINSKI: Dr. Largosa Exhibit No. 2, dated 4-22-98.
BY MR. LEVIN:
Q We are looking at page two. And she is describing the patient's, Antoni's, course in the facility. And she is saying 82-year-old white male readmitted from Christ Hospital per ambulance.
On admission presents as very weak and pale, is Polish speaking, unable to answer questions asked in English or Polish, is confused and disoriented. What is that POP on right leg up to mid thigh? Does that refer to a cast?
A A cast. I don't know. Where are you?
Q I thought we had the same one. Do we have the same one?
A 11-1-94?
Q Let me see what you have here. We gave you the wrong one. No wonder.
MR. MACHALINSKI: Is it this one (indicating)?
MR. LEVIN: Yes.
BY MR. LEVIN:
Q Now I'm showing you -- Correcting it, we are showing you Largosa Exhibit No. 3 at page 221. And I was starting to read POP on right leg up to mid thigh. POP is curved at the knee. Toes to the right leg are swollen, pink and warm to the touch. Upper right thigh is very bruised and discolored. Is that a fair description of Antoni's condition when he returned to the home after he got hit by the car?
A I can't remember. But if she said so --
Q You don't quarrel with that at least, correct?
A Correct.
Q Do you know if the home was cited by the Illinois Department of Public Health for any reasons as a result of this incident?
A No, I don't know.
Q Is that something that would typically be brought to your attention if there was an investigation by the Illinois Department of Public Health and you were cited, and a care plan was developed?
A You mean a plan of correction?
Q Plan of correction I mean. Yes.
A I just draw an absolute blank.
Q But is that something --
A It could be.
Q -- if it did happen that in the ordinary course of business would be brought to your attention?
A Yes.
Q From the time of he got back to the home until his death, he lost like about 30 pounds. Does that sound right to you?
A What page?
Q Mine doesn't have a number. But I'm looking at the monthly record of vital signs and weights. It is about 20 pages in. You can't find it in here.
A I don't know where it is.
Q Here. It is on the regular chart. Off the record.
(WHEREUPON a discussion was held off the Record, and the deposition continued as follows:)
BY MR. LEVIN:
Q But at any rate, ma'am, you are now looking at the original chart, and it does show approximate a 30-pound decline in the weight from the time that he came back after the fracture until he died, correct?
A Correct.
Q Do you know if an incident report was ever generated concerning this incident involving Tony, if the nursing homeever prepared something called a incident report? Do you think it might be here?
A No, it is not included in their chart.
Q So you don't know if one was or wasn't completed?
A No, I don't.
Q One should have been completed, correct?
A Correct.
Q If one was completed, you have never seen it, correct?
A Correct.
Q If you have seen it, you don't remember it, correct?
A Correct.
Q And the incident report would have to be prepared because this was a significant event where a resident got injured, and a whole report has to be prepared concerning this, correct?
A Correct.
Q And that has to be sent to among other places the Illinois Department of Public Health, correct?
A Correct.
Q And whether one was or wasn't sent, you don't know, right?
A Correct.
Q What nurse is this? I'm looking at an entry of 11-1-94 in the first chart. It looks like an S. Jones or something. Do you recognize that person's signature?
A I don't know who that person is.
MR. LEVIN: Do you, Don?
MR. MACHALINSKI: S. Jones, L. P. N.
BY MR. LEVIN:
Q Do you know if there was an S. Jones, L. P. N., working at the home in November of '94?
A There had to have been --
Q -- if she is charting?
A -- if she charted.
Q But you don't remember her or know her?
A I don't really know. She could have been agency also.
Q So sometimes the home in November of '94 was using agency nurses?
A I don't know in '94 if they were or not.
Q They might have been?
A They might have been.
Q And agency nurses means if your own staff I doesn't show up or something, you call an agency and get a nurse?
A I call an agency for a replacement.
Q Do you know if they had any staffing problems in the home in November of '94, if they did or they didn't?
A I'm not aware of any.
Q When were they using agency nurses?
A They don't use it on a regular basis. It is as needed.
Q And how frequently, for example, in November of '94 were they using agency nurses if you know?
A I don't know.
Q And the reason you would use agency nurses would be if regular staff couldn't make it, correct?
A If some nurse had called in, and then we would call the agency.
Q I mean in November of '94 if a resident -- if a nurse or a C. N. A. discovered that a resident was not in the home, what were the steps that were supposed to have been taken?
A Well, the charge nurse would be notified immediately, the director. And then they look around the grounds, you know, try to look around the area, and call the Oak Lawn Police report a missing person and give a description and have a photo.
Q In the year 1994, do you know if any residents other than Tony had wandered out of the home?
MR. MACHALINSKI: I'm going to object as to relevancy. You can answer that.
THE WITNESS: Not to my knowledge.
BY MR. LEVIN:
Q Do you know who the charge nurse would have been that should have been notified at the time Antoni went out of the home? Do you know the name of that person?
A The director would have been Ms. Baker.
Q So if this happened at night, would Mrs. Baker have been present?
A Not present, but she would have been phoned.
Q So the procedure would have been that as soon as a C. N. A. or an R. N. or L. P. N. noticed that Antoni was gone, they should have telephoned the DON Nurse Baker, correct?
A Correct.
Q And obviously you don't know if that was do or not done in this case, correct?
A Correct. Did she chart?
Q No. And obviously when a resident is discovered missing, that should also be charted, correct?
A Correct.
Q And I don't know if you have ever looked at the chart from November 1, '94, have you, to see what they did chart?
A I perused it quickly, scanned it.
Q What I can't tell frankly by looking at the chart is is this being charted after the police told them that they found one of their residents, or if they discovered the resident before the police found the resident. Do you know one way or the other?
A I don't know.
MR. LEVIN: I don't have anything else.
MR. MACHALINSKI: We will waive signature.
(WHEREUPON said deposition was concluded and the witness was excused.)
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