Nursing Home Examination 2 - Direct and Cross of Expert Witness Doctor - Part 3

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(The requested portion of the record was read.)

THE WITNESS: So, I - if there was no other evidence that the patient was being monitored, it would - I would expect that vitals would be taken once a day. It would not be an unreasonable standard of care. However, there was evidence that this patient had a baseline of stable vitals since she had returned from the hospital and there was evidence in her behavior that she was profusing adequately and -
BY MR. WOHLBERG:
Q. That's not her -
A. And that her vital signs -
Q. That is not responsive to the question I asked. I asked specifically, and you've given the same answer on a number of different occasions to a number of different questions. I think the question was fair. Did the nursing home violate the nursing home standard of care, the nurses on duty, given the fact that this patient had come back on June 9th from the hospital with diagnosis of atrial fib, was to restart on Digoxin the following Monday, did they violate the standard of care by not - in not taking the vital signs at least once a day?
A. Asked that way, I would have to say no.
Q. If it turns out that they took - the vitals that they did take were done radially instead of apically, would that fact, the fact that - assuming that was done radially, did that violate the standard of care -
MS. ODARCZENKO: Objection.
MR. WOHLBERG: - between June 9th and her death?
MS. ODARCZENKO: Objection as to form. Not only is it an incomplete hypothetical, but I also object because she's answered that question previously.
MR. WOHLBERG: I'll correct the form.
BY MR. WOHLBERG:
Q. To a reasonable degree of nursing certainty, did the nursing home - did the nurses at Snow Valley violate the standard of care in not taking an apical - apical vital signs of this patient? With that I want you to assume that they did not take it apically; they took it radially.
MS. ODARCZENKO: I have to object to form. She can't possibly answer that question because she already indicated that the chart does not indicate whether it's apically or radially. So, she can't answer that question.
MR. WOHLBERG: I'm saying with that assumption. I think she can answer.
MS. ODARCZENKO: Objection. Incomplete hypothetical.
THE WITNESS: In my opinion, it wouldn't have made any difference with this particular situation.
BY MR. WOHLBERG:.
Q. I'm talking about the physical act of doing it. Did that violate - not that it may not have made any difference, but did that physical act violate the nursing home standard, not taking it apically?
A. The written standard says to take an apical pulse if there is an arrhythmia, and apical fibrillation is an arrhythmia. However, there is no indication she was in atrial fibrillation when she returned to the nursing home, and the fact that she was discharged from the hospital and returned to the nursing home indicates that that was the appropriate level of care for her, and the nursing home is not designed as an intensive care, so -
Q. Does it make any difference to a nurse as to where she's working if the standard of care dictates that an apical rate is the appropriate procedure? -
MS. ODARCZENKO: In the event of an arrhythmia. She's already indicated the foundation for her answer.
THE WITNESS: There was no evidence that she was in atrial fib when she came in, that she was having an arrhythmia.
BY MR. WOHLBERG:
Q. There was clear evidence that - that it was -
A. When she was in the hospital.
Q. - that it was a likelihood, was it not, to redevelop that?
MS. ODARCZENKO: There was evidence that there was a likelihood that she would redevelop?
MR. WOHLBERG: Yes.
THE WITNESS: People that have atrial fibrillation are more - well, to say more - that's a difficult question to answer. Not - because the assumption would be that she was not having an arrhythmia at the time that she came in to the nursing home. And the assumption was that if she was having or getting into an arrhythmia, there would be perhaps changes in her vital signs that would indicate that.
BY. MR. WOHLBERG:
Q. Doctor, tell me your background in nursing experience with the elderly.
A. I have about three years experience working in the cardiac intensive care unit. I have been a certified nurse practitioner in the past, and I -
Q. Have you ever worked in a nursing home?
MS: ODARCZENKO: Hold on a minute. Let her finish her answer.
MR. WOHLBERG: I thought she was done.
MS. ODARCZENKO: No, she's not done, and I'm tired of you interrupting her answers. One of the ground rules was you wouldn't interrupt her and she wouldn't interrupt you.
MR. WOHLBERG: Fine. You don't have to get huffy about it. I apologize if I interrupted. Go ahead.
THE WITNESS: Apology accepted. I have had students in nursing homes during the time that I've been teaching.
BY. MR. WOHLBERG:
Q. Okay. Have you, yourself, ever worked in a nursing home?
A. No.
Q. When you talk about the standard of care of a nurse, an RN, the standard of care back in 1994 * for an RN would - doesn't depend on whether it was in a nursing - does it depend on where that nurse practices?
MS. ODARCZENKO: The standard of care for what?
BY MR. WOHLBERG:
Q. The general standard of care that a nurse should follow in any circumstance, is it dependent on where that nurse practices?
MS. ODARCZENKO: I'm going to object to the form of the question. You haven't specified what kind of patient or what particular area of nursing care you're talking about. I don't think it can be answered globally. If you can answer it, go ahead.
THE WITNESS: Yes. It would be a very global answer because it would - there is a different standard of care for different environments.
BY MR. WOHLBERG:
Q. Tell me about - you said you monitored students who work in those nursing homes.
A. Yes.
Q. When did you do that?
A. Mostly in the early years of my teaching, and I would be basically with them two days a week while they were providing care in the nursing home, and I would be supervising them.
Q. Aside from - have you recently taught any courses in nursing as it relates to nursing homes: itself?
A. No, sir. The most recent experience I had was a few years ago when I was administrative director for education and support services at Loyola, and that was for the institution - they did not have a skilled nursing facility. They did have home care and ambulatory, and I was responsible for organizing the training for the nurses and the aides and responsible for the policies.
Q. Let me get to your CV itself. It looks like -
MS. ODARCZENKO: Do you want do mark it?
MR. WOHLBERG: Yes., I may not have made a copy. Let me mark it Number 10.
MS. ODARCZENKO: Yes.
THE WITNESS: When you go for promotion, they count by the pound.
MS. ODARCZENKO: I wish it worked that way.
(Androwich Deposition Exhibit Number 10 was marked for identification.)
BY MR. WOHLBERG:
Q. Why don't you just peruse - it's kind of attached to other documentation that Sonia has sent to my office. Just take a quick look.
A. Okay.
Q. Do you have any additions to this, or is this pretty fairly up to date?
A. Reasonably up to date. There is a few minor additions, but none that would have bearing on in case.
Q. It looks like, just briefly, you attended Loyola University from ′76 through ′78 and got your Bachelor of Science in Nursing from Loyola, correct?
A. Yes. That is correct.
Q. Where did you graduate from high school?
A. Dominican High School in Milwaukee, Wisconsin.
Q. Are you from the Milwaukee area originally?
A. Yes.
Q. What year did you graduate?
A. 1960.
Q. Between ′60 and ′78, just tell me what you aid. What was your -
A. I went to college at Rosary and Marquette, uiversity of Minnesota, got married, had four children, went to two years of an associate degree, and got my Associate's Degree in Nursing in ′70.
Q. In ′70. Okay. And that was from Morton?
A. Yes.
Q. Correct?
A. Yes.
Q. So, you were kind of taking courses and then got that while were you raising a family?
A. Yes.
Q. And then did you practice as a - is that like an LPN or what, ADN in nursing?
A. That's an associate degree. That's a registered nurse.
Q. So, you were a registered nurse. Did you practice between ′69 and ′78?
A. Yes.
Q. Where?
A. At Loyola University. It's listed on there.
Q. All right. And then, obviously, concurrently about in ′76 you began taking courses?
A. Uh-huh.
MS. ODARCZENKO: Correct?
THE WITNESS: Yes. Correct.
BY MR. WOHLBERG:
Q. Now, let me just go over the - look at B of your opinion.
MS. ODARCZENKO: Starting on Page 6?
BY MR. WOHLBERG:
Q. Yes.
A. Yes.
Q. Do you stand by that opinion as it's stated there?
A. Yes. With the possible exception of the written policy is somewhat less restrictive than once a day. It says routinely, and one place it says once a month.
Q. I'm talking about your opinion, not any written policies. Your opinion of the standard of -care -
A. Yes.
Q. - is as stated in B?
A. Yes.
Q. And that incorporates - I'm reading. “The Standard of care requires vitals charting once a day in a nursing facility,” correct? That was your opinion then?
A. Right. In general in this facility, I thought that was the standard of care, and I now realize that was a little more - it is less ostrictive than that.
Q. But your opinion to your - what you believe -
A. Right.
Q. - what you believe was the standard of care, not what the nursing home puts down, is what's contained in B; is that correct?
A. I meant in this facility because I believed at the time that I rendered this opinion that the standard of care at that facility was once a day. Some nursing facilities, the standard, the written standard is once a month for some residents who are stable. It always, in my opinion, requires nursing - judgment. So, if the patient is showing any signs of problems, it is always appropriate for the nurse to validate what's going on.
Q. So, you're saying the standard of care is dependent on the facility you're in; is that right?
A. Yes.
Q. Now, with regard to the incident report, that has never been located?
A. Right.
Q. You're aware that a number of the nurses said there should have been an incident report for a fall or somebody being pulled from the bed? You Would agree with that?
MS. ODARCZENKO: That that's what the nurses said?
MR. WOHLBERG: Yes. Two - that the nurses did say that.
MS. ODARCZENKO: Is that the question you're asking, did the nurses say that?
MR. WOHLBERG: No. My question is - I believe it's a compound question. Let me rephrase it.
MS. ODARCZENKO: Then you're going to break it down.
BY MR. WOHLBERG:
Q. Is it your understanding that the nurses themselves believed that there should have been a nursing report, that at least a number of the nurses, there should have been an incident report made for the June 5th incident?
A. I have not reviewed the nurses' testimonies. The only testimony was the one aide.
MS. ODARCZENKO: That's all that's been written.
BY MR. WOHLBERG:
Q. Assume that at least two or three of the - I think the nurses said that normally in the normal course that an incident report would have been made for the June 5th incident. Would you have any -
A. Dispute with that?
Q. - dispute with that?
A. No.
Q. Would it be your opinion that in a circumstance such as this where somebody has been pulled out of bed or fallen out of bed and taken to a hospital, that normally the standard of care would require that you at least write up an incident report?
A. I would differentiate between a standard of care and an organizational internal mechanism for tracking. An incident report is not designed to be applied to the care of any patient nor would an incident report - if there had been an incident report about Anna Prairie's fall, it would not have been in her chart. It's a facilities mechanism to see how many falls they are having, once a week or once a month. Rather, some risk committee will meet and say, is there something going on that is putting us at risk. So, theoretically future patients could be helped ha,d there been an incident report and they; said, gosh, there is a lot of patients falling out of bed. But -
Q. Okay.
A. - it had no impact on Anna Prairie's care.
Q. Let me show you what has been previously marked as Gorski Exhibit Number 3. I think that's good enough. I'm not going to remark it. This is a physician's order. And ask you if you've seen that document.
A. I do not recall seeing this document. May I take a closer look at it?
Q. Sure. It's an order prescribing the Digoxin.
A. “May participate in scheduled activities.”
Q. I'm really concerned down at the bottom concerning the Digoxin order.
A. Uh-huh.
Q. Do you see that?
A. Yes.
Q. Okay. And there is a second page. Maybe I should mark this because it's not marked. That follows this. Verapamil
A. And the“dig.”
Q. Let me put Androwich Exhibit Number 12.
MS. ODARCZENKO: That's 10. I'm sorry. 11. You didn't mark it with another sticker.
MR. WOHLBERG: That's 11? I wasn't going to mark it.
MS. ODARCZENKO: I'm just trying to keep the numbers straight.
MR. WOHLBERG: So, this would be 11?
MS. ODARCZENKO: Yes.
MR. WOHLBERG: I'll put it on there.

(Androwich Deposition Exhibit Number 11 was marked for identification.)

BY MR. WOHLBERG:
Q. This is just a prelude to - this was a physician's-order, apparently.
A. Right. This is odd in that it's not signed where this order came from.
Q. The next page, that's all
A. I know, but usually you sign at the bottom.
Q. I don't know. This was Exhibit Number 11. All right. Taking into consideration that -
A. I guess I would have no way of knowing when or how this was given because on my sheet there is no date.
Q. Well, this was the sheet - they are in order.
A. Well
Q. Exhibit Number 11, Androwich Exhibit Number 11 was dated June 9th.
A. Right. But every sheet in a medical record should be -
Q. All right. And there is nothing - I'm not disputing this. I'm just saying that it doesn't show whether this was a telephone order, whether this - I mean you could make some guesses that it probably was part of this telephone order, but -
Q. I'm assuming that they were done at the same time. That's in the same handwriting, and they are the physician order - both of these medications were to start on June 13th?
A. Right.
Q. Assume that's correct.
A. I'm willing to make that assumption, but there is no basis in the sense that it isn't signed.
Q. I think each of the defendants will verify these are their records.
A. And I'm perfectly willing to make the assumption.
Q. Assume that. Would the fact that there were physicians' orders in the record when these nurses got Anna Prairie back in their care on Wednesday, June 9th -
A. I don't know. Does it - I need to look to see what time that order was. Its admitting date we don't know what time of day this order came. It looks like it was taken on June 9th. I mean I would - I would say with a reasonable degree of certainty that order was given on June 9th.
Q. Okay.
A. And - but I don't know what time of day.
Q. Okay. To a reasonable degree of nursing certainty, would it be fair to say that the nurses were aware of her condition and the future orders that were to be carried out with regard to Anna?
A. Uh-huh.
Q. Yes?
A. Yes.
Q. Now, would that additional fact I know we talked about nursing home, you know, they charted the medication was to begin on June 13th. Would the fact now that they had orders that this was a patient who was to be started back on Digoxin, would that affect your opinion in any way, your prior opinion, prior expressed opinions?
A. Not in any way. Those are very benign orders. I mean as far as - most of those are stool softeners.
Q. No. I'm just talking about the last two entries, Digoxin and Verapamil. These other ones, I'm not concerned with them. I'm talking about the Verapamil and Digoxin. Wouldn't that tip off an RN that this is something that - this is a patient that should - who is going to be started back on this because obviously she has a problem? Shouldn't they be on notice that they should take a little extra care with this particular patient?
MS. ODARCZENKO: I'm going to object to the form of the question. A little extra care with this patient? It's not an appropriate standard of care question.
BY MR. WOHLBERG:
Q. Go ahead, if you can. She'll have it stricken anyway at the appropriate -
MS. ODARGZENKO: Right.
THE WITNESS: In my opinion, those orders do not convey a sense of urgency. The “dig” in and of itself is an extremely common drug, and she's not even on it. She's not going to it be on it until a future date. It says resume - resume usual activities. Can participate in activities. They've got OT and PT ordered. That - that would send no triggers to me as a nurse.
BY MR. WOHLBERG:
Q. It wouldn't send you a trigger as to ask?
A. No.
Q. All right.
A. No. I would say the diagnoses that are written on the bottom, I mean the arthrosclerotic heart disease, all of this, that would not be uncommon in a patient that age to have that.
Q. Let me ask you, your 213, your prior written opinions as described in Androwich Exhibit Number 6 talk about that you can be expected to expand upon your opinions at time of your dep. Let me ask you to -
A. Expand?
Q. Are there any opinions that we haven't expanded upon? I think I've asked you most of the opinions you've discussed. Do you have any additions as you Sit here today that you would like to expand upon other than what you've written down and talked about earlier today?
A. I cannot think of anything.
Q. Okay.
A. I think the biggest thing in a nursing home environment is the presumptive vital sign stability. What you're really looking for is adequate profusion, and someone that's up and reading the newspaper and wanting to go into that's an indication that this patient is not markedly compromised.
Q. Well, at some point on June 11th -
A. She got - June 12th, I think, obviously.
Q. 12th?
A Became compromised. But -
Q. And you're saying to a reasonable degree of cortainty I'm looking at the bottom of Page 7, very last sentence - there would have been no change in the outcome even if vital signs had been taken more frequently?
A. I am very comfortable with that. I stand I stand by that.
MR. WOHLBEBjG: Okay. I don't think.I have hold on.

(A brief recess was taken.)

BY MR. WOHLBERG:
Q. Have you reviewed this in any way - have reviewed any of the actions of Dr. Marwaha?
MR. PAPIN: I object to any line of questioning - these opinions are beyond this witness' competency. This line of questioning is irrelevant.
MS. ODARCZENKO: Same. Dr. Androwich is a Doctor of Nursing.
BY MR. WOHLBERG:
Q. I understand. The correct answer is no. Let's move on.
A. Do I have any opinions? I answer even though you object?
MS. ODARCZENKO: It is beyond your scope of competency, but if you have any - answer the question. Do you have any criticisms of Marwaha?
THE WITNESS: No.
BY MR. WOHLBERG:
Q. His records have been referred to in me -
A. There was nothing that I reviewed in the cions of Dr. Marwaha that caused me to be cerned.
MR. PAPIN: In that case, I withdraw my Action.
MR. WOHLBERG: I don't have any further questions.
MR. PAPIN: Nothing.
MS. ODARCZENKO: I just have a couple of points of clarification.

EXAMINATION

BY MS. ODARCZENKO:

Q. In addition to the opinions that you that are written up in what we called the 213 Answers, am I correct that an additional opinion you love is as to the signs and symptoms that Anna Prairie exhibited on June 10th, 1994, in colation to her medical care - her medical condition
A. June 10th or -
Q. June 10th - I'm sorry. June 12th.
A. Okay.
Q. Is that correct?
A. The day she died?
Q. The day she died.
A. What are you asking me about those signs and symptoms?
Q. I'm asking if you have an opinion as to how nose signs and symptoms related to how she was functioning that day?
MR. WOHLBERG: I don't know if that - if that goes - you're asking an opinion
BY MS. ODARCZENKO:
Q. To a reasonable degree of nursing certainty. I'm not asking her for a medical opinion. Was there any significance to the conduct of Anna Prairie, the signs and symptoms she exhibited on June 12, 1994, from a nursing perspective?
MR. WOHLBERG: I would object to that.
MS. ODARCZENKO: Basis?
MR. WOHLBERG: Basis? First of all, she can give her opinions as to the nursing standards of care. I don't think she can give an opinion as to causation or anything, which seems to be what you're doing toward. MS. ODARCZENKO: I have ho causation opinions to ask. All I'm asking is from a nursing tandard of care, were the signs and symptoms that the exhibited on June 12, 1994, significant in any say? From a nursing perspective.
MR. WOHLBERG: I stand on my objection. it's beyond the scope of the nursing standard of care. But go ahead and answer.
BY MS. ODARCZENKO:
Q. You can go ahead and answer.
A. Actually, observing the patient's behavior would not be beyond the scope of nursing judgment in my opinion. But there were several things. If I could please see the chart.
MR. WOHLBERG: You are looking at now - that are you looking at?
THE WITNESS: I am looking at the nursing progress notes of the 12th. “Patient demanded that one eat in the dining room.” Quote. “I don't care that my granddaughter wants. Patient ate only 25 percent of breakfast and lunch received. Patient up in wheelchair. Sitting in the dining room reading Newspaper. Color and respirations good.”
I can't read this. At another point - This was 6:30 at night. She ate 50 percent of her mod for supper. Alert and - something. No attress noted. “Alert and oriented. No distress noted. At 7:10 she was wheeled back to her room and instructed to wait for the nurse. Verbalized understanding of instruction. Color and nopirations good. No complaints made.”
It seems to me she was clearly not in any distress or compromised in terms - and the fact she was reading the newspaper and engaging in that level of cognitive activities would say to me that her profusion was good.
MR. WOHLBERG: We actually did cover that, I think, earlier in one of your answers. So, that's kind, of an additional observation you're making, in opinion form?
THE WITNESS: Yes.
MS. ODARCZENKO: I thought you were done.
MR. WOHLBERG: Yes. I thought you were done.
MS. ODARCZENKO: I'm asking questions. No, I'm not done.
BY MS. ODARCZENKO:
Q. You used a word to describe - you said there are vital signs and then there are - there are vital signs that you look for and then there are other conduct that you look to, other things that you observe about the patient. Would that include the types of things you've just discussed, whether the patient is engaged in activities?
A. Yes. Those would be other objective indications of the patient's condition.
Q. Also now having had an opportunity to review the chart, do you recall any additional documentation that related to whether or not Anna Prairie was visually impaired?
A. There was, upon review fairly, a extensive list of her visual impairments - that her unaided vision was 2100 to 2200. Age-related optic atrophy, age-related macular degeneration, multiple peripheral iridectomies, laser capsulotomy, archusenilus, (phonetic spelling) hypertrophic stigmatism over implants and secondary cataracts.
She - she had substantial visual problems. MR. WOHLBERG: Does that impact in any way in any of the opinions? MS. ODARCZENKO: Hang on a second. Mark, I'm not done asking questions. Trust me. When I'm tendering, you'll know I'm tendering.
MR. WOHLBERG: Okay.
BY MS. ODARCZENKO:
Q. You indicate one of the things. you considered in evaluating whether Anna Prairie - in evaluating the statements that Anna Prairie made is contained in the medical records was not only her orientation but her ability to see and her ability to hear at the time of the event on June 5th, 1994, is that correct?
A. Yes.
Q. So, the fact that she was visually impaired, substantially visually impaired, as the eye consultation indicates, does that impact on your opinions on whether or not Anna Prairie could perceive that on June 5, 1994, that she was being pulled from bed by another patient?
A. As I indicated, the cognitive abilities is based on frequently the sensory indicators that one is getting. If you're not hearing and seeing, you may imagine something is happening although you are still oriented and alert.
Q. So, the fact that Anna Prairie did have Substantial visual and hearing problems does affect whether she was able to cognitively process the events on June 5th, l994?
A. That's somewhat of an assumption. It certainly could have a bearing. There could have been an aide standing by the bed and she could have thought it was Vivian and subsequently fallen, but that is supposition.
Q. Prior to you reviewing - doing the literature search for the use of restraints, was it your understanding based upon your experience, training, and work in the nursing field that there were studies showing that the use of restraints and side rails had questionable merit in restraining patients or keeping them from getting out of bed prior to the date that article was written?
A. Yes. That is why I looked for that or some such - it was my impression, and I looked for documentation to support that.
Q. In other words, you under -
A. I feel I have read those studies at some, point in the past or skimmed them or seen them or -
Q. But that body of knowledge was available in 1994, is that correct, the studies having been done in ′83, ′86, etcetera?
A. The studies were done prior to that time. And my perception was that I had read those studies, but I - I searched to find them.
Q. What signs or symptoms in terms of behavior or conduct would a RN look to in evaluating whether patient was experiencing atrial fib?
A. Would you repeat the question?
Q. I can rephrase it hopefully a little more artfully.
What are the signs or symptoms of atrial fib that a nurse would look for in watching and observing a patient?
A. Let me think if I can artfully answer this. The biggest concern with atrial fib is that in addition to microemboli, in addition to an uncontrolled ventricular response, would be inadequate profusion, either because the ventricular response rate was too rapid, which would cause not only a rapid heartrate but it would typically cause the blood pressure to drop and there would then not be adequate profusion. People can be in a controlled atrial fib for - it's kind of - it's just not a normal good thing to have and can get out of control.
Q. Do people that are experiencing atrial fibrillation, can they experience anxiety?
A. Very much so. Many people will tell you they know exactly when they go into atrial fib.
Q. And coldness or clamminess?
A. That is one of the signs that would indicate that the blood pressure was dropping, some of these cardiovascular instabilities occurring.
Q. And shortness of breath?
A. Shortness of breath would indicate there was inadequate profusion.
Q. Did Anna Prairie, based on the chart that you reviewed, did she have any of these signs or symptoms of atrial fib?
A. I did not see any sign of those.
MS. ODARCZENKO: That's all I have.

FURTHER EXAMINATION

BY MR. WOHLBERG:

Q. So, you're not saying that to a reasonable degree of nursing certainty that her visual impairments made her - on June 5th made her cognitively unaware, are you?
A. No.
Q. You suggested that there is possibilities that maybe it had something to do with her perceptions, but you can't say to a reasonable degree of nursing certainty that they did?
A. Right. No. I would not say that.
MR. WOHLBERG: Okay. I don't have any further questions.
MS. ODARCZENKO: Signature - do have you anything?
MR. PAPIN: No, I don't.
MS. ODARCZENKO: Signature is reserved.

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