Nursing Home Examination 2 - Direct and Cross of Expert Witness Doctor - Part 2

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(The requested portion of the record was read.)

MS. ODARCZENKO: Are you saying does the RAP - does the score on the RAP require the use of side rails for this patient?
BY MR. WOHLBERG:
Q. No. I'm saying should - the preferred method of dealing with that lady and her condition at that time in 1994 would have been to have side rails up?
MS. ODARCZENKO: I'm going to object to the form of the question. It's not an appropriate standard of care question. You're asking preferred method. That is not the same thing as reasonable what a reasonably prudent nurse or CNA would do under the same or similar circumstances. It's not an appropriate question to ask.
BY MR. WOHLBERG:
Q. I think my first question was I said to a reasonable degree of nursing certainty was the did the standard of care dictate - we'll put it that way to comply with your attorney
A. I think -
Q. Let me finish. Would the standard of care dictate that it would be more reasonable to have side rails up than down in her situation?
MS. ODARCZENKO: Same objection. More reasonable than not to have side rails up than down. It's not an appropriate standard of care question. If what you're asking her is did this - did the standard of care require the use of side rails for this patient, ask it like that.
MR. WOHLBERG: Okay. Go ahead. Stand on your attorney's question.
MS. ODARCZENKO: I'm not her attrorney. I'm representing her for a deposition.
MR. WOHLBERG: I'm sorry.
THE WITNESS: In my opinion, the standard of care would have been a use of judgment related to each individual patient. And Anna Prairie was definitely a judgment patient because she was getting up frequently.
The standard of care would have had a an ability for her to call for help like the call light, but there would have been - so I. - let me just stop it there. The standard of care would have been the use of judgment.
BY MR. WOHLBERG:
Q. In your opinion, was the judgment that they used incorrect in keeping the side rails down in her situation on June 5th, 1994?
A. I - I couldn't really say. I don't think it was incorrect. I would have liked to have seen and observed for myself.
Q. So, you can't give an opinion with regard to that issue?
A. I don't think I can give an opinion with regard to that issue.
Q. That would be whether the side rails were up or down?
A. More beneficial to her up or down.
Q. Or not?
A. Right.
Q. Now, with regard to the use of restraints, let's go over that a little, the actual -
A. Physically restraining with some type of a device.
Q. Right. Describe the methods back in 1994 that one could use in physically restraining a person.
A. Well, there are torso restraints. There are limb restraints. There are leather restraints and material restraints. And there are levels of restraint. It is - in a patient who is able to give permission, that patient would not be restrained as a reminder to keep them from falling.
Q. Would - given her condition when she entered and at the time up until January 5th -
A. Uh-huh.
Q. - would it be your opinion - what is your opinion with regard to the use of physical restraints on Anna Prairie?
A. I probably take a view that the patient should have the opportunity to make choices, and to ensure that Anna Prairie would never fall would require either 24-hour constant monitoring or totally restraining her in a way that she could not escape. So, if you absolutely wanted to guaranty-that she didn't fall, you could do it. Or drugging her, as sometimes happens. In the absence of choosing that, there is no guarantee that she's not going to fall. And that's the -
Q. Is that - would this also be a case where judgment, it's the -
A. Absolutely judgment.
Q. All right. So, the standard of care would entail the. judgment of the individual nurse in that situation?
A. Well, in terms of - anything beyond fairly short term or specific purpose restraint in someone who was cognitive would have required her consent or the consent of Robin, who is her granddaughter. Sometimes a family member on behalf of someone can make that.
Q. Should Robin have been the one to make that decision?
A. In my opinion, no.
Q. Anna Prairie, from your review of the records, seemed to be of sound mind at that time; would you agree?
A. Right.
Q. Would it not have been appropriate to have discussed with her the use of restraints?
A. My sense is that it was discussed with her.
Q. Did she - and did she sign a document, any document saying that she - that she did not want to use restraints?
A. I do not recall such a document.
Q. All right.
A. But that is not -
Q. I'm sorry. What fact did you base that this had been discussed with her, herself, the use of restraints? If you have to review something, ahead. You want to take a look?
MS. ODARCZENKO: Why don't we take a minute break.
MR. WOHLBERG: Sure.

(A brief recess was taken.)

MS. ODARCZENKO: What was the question?

(The last question was read.)

THE WITNESS: Robin did not consent to the restraints. I do not find documentation that she said that she did not wish restraints. However, (that's, I guess, an assumption that if you are getting up -and if you do not ask to be restrained because you're afraid you're going to fall, that you don't want to be restrained. So, that is my - that is how I formed that opinion. I don't see any documentation that she was asked and refused. I am just making that assumption.
BY MR. WOHLBERG:
Q. You did state, I think, a few minutes ago that the standard of care - I may be switching this
Did the standard of care at that time dictate that the nurses speak with Anna Prairie concerning the use or nonuse of restraints?
MS. ODARCZENKO: As of what date?
BY MR. WOHLBERG:
Q. As of June 5th, 1994.
A. I don't know that they would have had to ask her if she wanted to be restrained. I think - it seems as though they asked her to call for help getting out of bed at some points in the chart who they've documented that. I do not recall anywhere in the chart that they consulted with her.
Q. All right. My question is: Wouldn't the standard of care have dictated, the nursing standard of care at that time dictate that they do consult with her given her assessment when she entered that home?
MS. ODARCZENKO: I'm going to object to the question as already having been answered. She already said that it didn't require that. It required that they have a call button.
MR. WOHLBERG: I don't recall that answer. If you - I would like an answer to that question. I don't think that that was asked in that specific.
MS. ODARCZENKO: Read the question back.

(The requested portion of the record was read.)

THE WITNESS: Not necessarily. I don't feel that they violated the standard of care.
BY MR. WOHLBERG:
Q. In not consulting with her?
A. In not consulting with her or in not documenting that they consulted with her.
Q. What do you base that opinion on?
A. Restraints are something that are not always helpful in achieving - I mean - and restraints are used for a variety of reasons, not just to prevent someone from falling out of bed. They can be used for keeping someone from picking at an I.V. or doing harm to themselves in that manner, but they are also not anything to be used lightly. And so it's kind of not - restraints unless other - the standard is not restraints unless refused. The standard is no restraints unless something happens.
Q. Would you - are physical restraints more invasive than side rails?
A. Yes. Absolutely.
Q. You would agree that if she had, in fact, had restraints on, that she would not have been found on the floor, pulled out of bed either by a patient or fallen out of bed on June 5th?
A. Not necessarily. There is a body of research that says restraints do not always prevent falls. So, I would not agree.
Q. Okay. That body of research is in which article?
A. In this article (indicating).
Q. Number -
MS. ODARCZENKO: Androwich 6. THE WITNESS: Androwich 6. On the bottom of the first page, it says “Mechanical restraints should also be considered a environmental hazard. Research findings indicated that restraints do not reduce the incidence of falls and may increase poor outcomes.” And then there are a number of studies cited.
BY MR. WOHLBERG:
Q. And this article was written when?
A. Well, this is a synopsis of several research articles. It's a review - this was. written in ′98. The dates on the studies were ′83, ′90, ′93, ′83, ′86 and ′92. So, although they were not compiled in this article until ′98, the studio were published earlier.
Q. Okay. Now, with regard to the charting of vitals, it looks like you, calling your attention to -
MS. ODARCZENKO: It's not marked.
MR. WOHLBERG: I'll mark it. I'm going to mark Androwich Exhibit Number 7.
(Androwich Deposition Exhibit Number 7 was marked for identification.)
BY MR. WOHLBERG:
Q. You can refer - do you have your copy?
A. I can generally know -
Q. What's the significance of the charting you made here?
A. All I was doing here was kind of trying to more or less graphically - to see if there were any trends in the vitals that should have alerted the nurses to a condition that was deteriorating.
Q. Okay. Have you read the opinions of Dr. Bushman?
A. Yes.
Q. Mary Beth?
A. Yes.
Q. Do you know Dr. Bushman?
A. Actually, I believe that I met her in 1980 when I was at the University of Illinois. But I haven't talked to her that I know of since then. To say I know her -
Q. Okay. You don't have a personal relationship with her?
A. No.
Q. Did you have any classes with her or not:
A. I - I did, but I'm trying to - there are two faculties that are confused in my mind, and I believe she's one or the other, but I couldn't - marginally, yes.
Q. What class, if it were her?
A. She would have given a lecture on physiology.
Q. With regard to - let me go over - you have read her opinions?
A. Yes.
MR. WOHLBERG: You want me to mark this as an exhibit?
MS. ODARCZENKO: Her opinions or her deposition?.
BY MR. WOHLBERG:
Q. You've read her dep?
A. Yes. I don't know if I read her opinions.
MS. ODARCZENKO: Unless they were an exhibit.
MR. WOHLBERG: They might have been. I'll make this Number 8.

(Androwich Deposition Exhibit Number 8 was marked for identificatioi.)

BY MR. WOHLBERG:
Q. I'm going to show you what I'm marking as Androwich Exhibit Number 8. Just take a minute to review that.
A. Okay.
Q. You've had a chance - you've seen those in sum probably at the deposition, too.
A. I might have or else that's consistent with her deposition.
Q. So, obviously, your opinions disagree with the doctor, Dr. Bushman's?
A. Yes.
Q. What criticisms other than - well, let's do it this way. Why don't we - we started a minute ago on the vital sign issue. With regard to vitals were you - you were aware that she was taken back to the nursing home on a Wednesday, which was June 9th?
A. Right.
Q. Having just undergone treatment for her atrial fib which began on June 5th, and the incident of being pulled or falling out of bed.
A. Yes.
Q. Are you with me so far?
A. Uh-huh.
Q. Yes?
A. Yes.
Q. Now, would it be within the nursing ... standard of care upon her return to have reviewed her chart and the doctors' orders which at that time were given?
MS. ODARCZENKO: For whom? Within whose standard of care?
MR. WOHLBERG: The nursing standard of care, the nurses that were on the staff of the nursing home.
MS. ODARCZENKO: The nurses and the staff? So you're asking about RNs and LPNs and CNAs, all three classes? Should they have reviewed the chart?
BY MR. WOHLBERG:
Q. Should the nurse, just RNs?
A. The RN. RNs would have reviewed the - records that were available.
Q. You're assuming that they did?
A. I am assuming that they did.
Q. And based upon a reasonable degree of nursing certainty, wouldn't it have been the standard of care at that time - well, I am going to withdraw that question.
The nurses would have also, having reviewed that, would have been aware that she was digitoxic -
A. Digitoxic?
Q. - digitoxic at a certain point in her hospitalization, and the orders that were given to the nursing home were to reinstitute her on Digoxin the following Monday?
A. Presumably those orders would have been available.
Q. They were in the records, the nursing home records; is that correct?
MS. ODARCZENKO: Which orders?
MR. WOHLBERG: The doctor's orders.
MS. ODARCZENKO: Which doctor's orders?
MR. WOHLBERG: Dr. Marwaha.
MS. ODARCZENKO: The Digoxin?
MR. WOHLBERG: Yes.
THE WITNESS: I did not actually find doctors' orders.
MR. WOHLBERG: You did not. Okay. Well -
THE WITNESS: Other than the one paragraph. I did not.
MS. ODARCZENKO: Nursing notes.
BY MR. WOHLBERG:
Q. Hold on. Let me show you - I'm going to show you - I'll mark this as -
A. Those wouldn't be the -
MS. ODARCZENKO: That's not doctor orders.
THE WITNESS: That's the medication administration sheet.
MR. WOHLBERG: Okay. I'm going to mark this.
MS. ODARCZENKO: Hold on. I want the question read back.
(The requested portion of the record was read.)
(Androwich Deposition. Exhibit Number 9 was marked for identification.)
BY MR. WOHLBERG:
Q. Let me show you Androwich Exhibit Number 8.
MS. ODARCZENKO: Number 9.
MR. WOHLBERG: Number 9?
MS. ODARCZENKO: Yes. You already have an 8. RX sheet, right?
THE WITNESS: Uh-huh.
BY MR. WOHLBERG:
Q. You've seen this sheet?
A. Uh-huh.
Q. Yes. You have seen that sheet prior to today's deposition, correct?
A. This is, I do not believe, a nursing home order sheet. This is perhaps a Good Samaritan Hospital - I'm not sure what that was.
Q. Well, it was in the nursing home - at least these are nursing home records. I believe it was previously marked as Deposition Exhibit Number 6. In whose deposition, I don't know. The prior page -
MS. ODARCZENKO: What's your question? Is this an order?
THE WITNESS: Yes. I have seen this. Yes. Yes. I have seen this, and it indicates that the “dig” is to start on the 13th. I did not see an order to do that by the doctor. This is the type of thing that the nurse would fill out on the sheet to sign off. Yes. Yes. I have seen that.
BY MR. WOHLBERG:
Q. That would have put the nursing staff, RNs on notice that this person had atrial fib and was to restart on Digoxin the following Monday; would that not have?
A. Right.
Q. Now, would it not have been appropriate to a reasonable degree of nursing certainty that the standard of I probably should rephrase.
MS. ODARCZENKO: You're going to withdraw or not?
MR. WOHLBERG: Well, let me see if I can make something sensible. Maybe I should withdraw it.
MS. ODARCZENKO: Could you? Thank you.
BY MR. WOHLBERG:
Q. Wouldn't the appropriate standard of care for the nurses on the staff back on the Wednesday that she was returned from Edwards - from Good Samaritan Hospital, to have instituted thrice daily, three times daily, taking of her vital signs between that point in time upon her return and the following Monday, having known that she was in atrial fib and was to restart on the medication in a few days?
MS. ODARCZENKO: Is your question did the standard of care require thrice daily vitals?
MR. WOHLBERG: Yes.
MS. ODARCZENKO: Taking?
MR. WOHLBERG: Yes.
THE WITNESS: Okay. The standard of care in the nursing home said, routine. In fact, the standard of care for blood pressure, I think, was up to monthly if the patient was on an antihypertensive drug. It would not be unusual for most patients probably in the nursing home to be on “dig.” The biggest concern from a nursing standpoint when a patient is on “dig” is that the heart rate would drop too low because the action of “dig” is to slow and strengthen the heartbeat. So, most of what is being checked is to make sure that it doesn't go below 60 without some alertness to that. So, give her vital signs, which were relatively normal, I would not say that there was anything to alert the nurse that she would necessarily need more frequent vitals. They were taking them daily, essentially, which was kind of beyond what the written standard was.
BY MR. WOHLBERG:
Q. I'm not asking for any written standard. I'm saying the appropriate standard of care. In fact, I don't know if you answered that directly. I would like -
MS. ODARCZENKO: She did.
MR. WOHLBERG: No. I don't think it was. I want my - I don't think it was responsive. So, I would ask that be - if you could give a direct answer.
MS. ODARCZENKO: Why don't you ask your question again?
MR. WOHLBERG: I want her to reread it.

(The requested portion of the record was read.)

MR. WOHLBERG: Why don't we redo it.
MS. ODARCZENKO: He's going to reask the question.
BY MR. WOHLBERG:
Q. I'm going to reask the question.
To a reasonable degree of nursing certainty, Doctor, did the nursing standard of care entail upon Anna Prairie's return to the nursing home on June 9th, entail the taking of vital signs at least once per shift between June 9th and the date of her death?
A. No. I would not consider that the standard of care would require once-per-shift vitals. As it turns out, they really did - when she first came in, they probably - within the first 24 hours, they did take them three times or close to it. They tooK them on the 3:00-to-ll:00 shift on the 9th. Then it looks like they took them at 4:00 in the morning, which would be the following shift on the 10th, and then they took them again on the 10th. So, they now have a trend of three normal sets of vital signs. And -
Q. Was it within the standard of care to take no vital signs on the date of her death -
A. Well -
Q. - given her condition of being atrial fib within a week?
A. I was telling Sonia, vital signs are used as an indicator of condition, and the frequency with which they are taken is a nursing judgment. The - there are other ways to - I mean there is actual vital signs and then there is presumptive vital signs. And I was telling Sonia earlier today in terms of a lab - - I tell my students, don't be concerned if you can't get the blood pressure if the patient is running up and down the hall skipping. He probably has an adequate blood pressure. And so the fact that Anna wanted to get up and go into the dining room, the fact that it was documented that she was reading the newspaper all would lead someone that - you would have to make the assumption that her blood pressure was adequate to profuse oxygen and her heart rate was okay because that is consistent with her behavior. So, while vital signs can be one objective measurement, so can the physical activity of the person.
Q. Are you aware of any studies or - that would indicate that a person who has developed atrial fib may be likely to redevelop it at some point, especially when they are not on Digoxin?
A. Atrial fib is something that once you have developed it, you are more apt to have it, yes.
Q. Okay.
A. However, you wouldn't necessarily pick up atrial fib from the vital signs.
Q. But you can? It can be picked up?
A. It - under certain circumstances and with the right skill of the person that was taking the vital signs, it could be picked up, but it would not necessarily be picked up. For example, when you're taking a radial pulse, which is what the aides would be doing, they are perceiving the beat of the. - the ventricular response of the heart. The fact that the atrium may be fibrillating above that, that is not pulsing out and that would not be perceptible with someone with their hand on your wrist. So, the sway that the vital and the atrial fib -
Q. Well -
MS. ODARCZENKO: Let her finish her answer.
THE WITNESS: People can be in atrial fib for a long period of time. It's - nobody thinks it's a good thing to be in partly because you can get a rapid ventricular response and then you don't get very effective pumping of the heart. So, if the heart is responding 80 times a minute, you're probably getting adequate pumping and profusion and the blood pressure seems reasonable, that's - what you could pick up would be is if you got a heart rate of 140 or 50 and then you would be wondering why that is happening, why that tachycardia was going on.
BY MR. WOHLBERG:
Q. Assuming that she, on the date of her death, that she did, in fact, develop atrial fib again and died as a result of that. Assuming that, would it not have been - wouldn't the fact that the - that no vital sign was taken for the entire day of her death be - and I think she died in the evening, wouldn't that have violated the standard of care, nursing standard of care not to have taken he vital signs?
A. I do not think the nursing standard of care was violated in any way. Had she - the only thing that could have really been detected had her vitals been taken would have been such a drop in blood pressure or such a rapid heart rate that would have been apparent by her behavior. If she were suffering from either of those conditions, she wouldn't be going into the dining room reading a newspaper. So, taking the vital signs would -
Q. I'm not saying -
MS. ODARCZENKO: Let her finish her answer, Mark.
THE WITNESS: Within all likelihood, given any other information. There is another way.
BY MR. WOHLBERG:
Q. You're saying it - you're saying it was totally appropriate that they didn't even take her vital signs?
MS. ODARCZENKO: I want the question read back.

(The requested portion of the record was read.)

MS. ODARCZENKO: That is not a proper question. Appropriateness is not a proper question of the standard of care or what a reasonable nurse would do under the same or similar circumstances. So, I don't think the question can be answered in its present form. As it is, it's useless.
MR. WOHLBERG: Well, then let's rephrase it.
BY MR. WOHLBERG:
Q. To a reasonable degree of nursing certainty, wouldn't it have been - would the appropriate standard of care have dictated that vitals be taken on the date of her death, sometime on the date of her death?
MS. ODARCZENKO: Objection. Asked and answered already twice. She said no. Standard of care didn't require it.
MR. WOHLBERG: Let her answer that.
MS. ODARCZENKO: She's already answered it twice. I don't think she has to answer it three times.
MR. WOHLBERG: I don't think so. You objected to the question I just posed a few moments ago. That was the only question I asked with regard to that day. Go ahead.
MS. ODARCZENKO: Your questions both previously related to that same exact date.
MR. WOHLBERG: And you objected.
MS. ODARCZENKO: She answered the question.
MR. WOHLBERG: Go ahead. I would like a -
THE WITNESS: Could you read the question, please?
(The requested portion of the record was read.)
THE WITNESS: No.
BY MR. WOHLBERG:
Q. Now, with regard to - I'm looking at a procedure that you've indicated. You were talking about radial pulse in some of the answers you just gave. This policy at least in 1996, policy indicates that an apical rate should have been appropriate for Anna Prairie with her condition.
A. Uh-huh.
Q. Would you agree with that?
A. Yes.
Q. So, they weren't taking - they were taking radial at this time?
A. It is not indicated whether it was apical or radial.
Q. Okay. Assume that it was radial pulse. That would have been an inappropriate - would that h:.ve violated the standard of care back in 1994 as for as taking the pulse of the patient such as Anna Prairie and the condition she was in on June 9th?
MS. ODARCZENKO: To take it one way instead of the other?
MR. WOHLBERG: Yes. To take it radially instead of apically.
MS. ODARCZENKO: Your question doesn't make any sense because she's already testified the standard of care didn't require the taking of it at all. Objection as to form.
MR. WOHLBERG: Go ahead. If you could let her -
MS. ODARCZENKO: I'm making my objection.
MR. WOHLBERG: I know.
MS. ODARCZENKO: Objection as to form.
THE WITNESS: If you're asking if an apical pulse would have been preferable, the answer is yes. The apical pulse still might not - relative to arrhythmias, there is a whole range of arrhythmias. Even an apical pulls would not necessarily have tipped someone to atrial fibrillation. BY MR. WOHLBERG:
Q. I understand you're saying that it may not have made a difference. I'm asking you whether or not the standard of care would dictate that the nurses should have made sure back in 1994 when - upon her return on June 9th to the nursing home that her pulse being taken apically?
A. The written standard of care says “on a routine basis,” and in my experience and my opinion that routineness is to the judgment of the nurse and the - in a nursing home, it is not infrequent for vitals to be taken once a month.
Q. But we're not talking about routine. We're talking about a lady who had just come back from the hospital suffering from atrial fibrillation and who was to go back on her medication within three or four days. In that situation, did the nursing standard of care dictate that an apical rate be taken at least once daily?
MS. ODARCZENKO: Apical once daily? That's your question?
BY MR. WOHLBERG:
Q. Yes.
A. That would not be unreasonable.
Q. Would a failure to not take it at least once daily be a violation of the nursing standard of care?
A. A lot of the -
Q. Can you answer that yes or no?
MS. ODARCZENKO: Read it back.

(The requested portion of the record was read.)

BY MR. WOHLBERG:
Q. I think that's a fair question. Go ahead.
A. In the absence of evidence of other monitoring of what was going on with this patient's condition, and I would maintain -
Q. Yes or no? Can you answer that yes or no?
MS. ODARCZENKO: Let her finish her answer.
MR. WOHLBERG: I think -
MS. ODARCZENKO: No. Your question was not specifically a yes or no. Let her finish her answer to the question.
Can you read back her partial answer, please?
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