Nursing Home Examination 4 - Direct and Cross of Expert Witness Doctor - Part 3

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BY MR. POWER:
Q. Doctor, do you recall when you - specifically on Page 25, Doctor, were you asked the following question and did you also give the following answers?
“What is your understanding as to Dr. Azaran's intent with respect to providing this patient with Humulin N?
THE COURT: A little slower.
MR. SHAPIRO: Thank you.
BY MR. POWER:
Q. “What is your understanding of Dr. Azaran's intent with respect to providing the patient with Humulin N? Answer: My understanding is that he was under the impression that the Humulin N was to be given. Question: And -
MR. SHAPIRO: Objection to this being read.
THE COURT: Overruled.
BY MR. POWER:
Q. And if a physician believes that Humulin N is supposed to be given for a patient and neglects to write the order for that, is that a violation of the standard of care?
MR. SHAPIRO: Objection.
THE COURT: Overruled.
MR. POWER: Answer: It depends on whose responsibility it is to write that order. When my patients are transferred from the hospital to a nursing home, the residents from the hospital write those orders. When my patients are transferred specifically to me from Rush to the Bowman Center, the geriatric facility that we have at Rush, it's the residents who write the orders. Whether it's the nurses -
THE COURT: Now, with regard to those questions and answers being asked, the objection will be sustained.
The jury will disregard those questions asked and answers given in the deposition.
BY MR. POWER:
Q. Doctor, were you ever asked whether the Humulin N ordered was directly pertaining to the February 1, 1995, time frame?
A. No.
Q. Doctor, Mr. Shapiro asked you to look at the physician's progress notes for Dr. Azaran on February 16th.
I'd like to direct you to Page 152 of the Imperial Nursing Home records, which I believe are the physician's orders for the 16th.
A. I'm sorry. Mine start with 153.
Q. I'm sorry. It would be 152. I've given you my Page 152.
A. Thank you.
Q. Doctor, have you had a chance to look at that?
A. Yes.
Q. Was Dr. Azaran's order on February 16th an order covering multiple issues that deal with a singleissue?
A. His orders deal only with the decubitus ulcer.
Q. Doctor, have you reviewed Dr. Azaran's deposition with respect to his intention for that visit?
A. I probably did, but I honestly don't remember it, sorry.
Q. Fair enough.
Now, Doctor, you were asked to look at several pages from the Ingalls chart with respect to the diagnosis of pneumonia.
What I'd like you to turn to is Page 255 of the Ingalls chart from the February 20th admission which is Plaintiff's Group Exhibit 16, specifically to the note from Dr. Santos, the infectious disease consultant.
A. I have it.
Q. What did the infectious disease consultant place on the chart with respect to whether it was pneumonia or infiltrate?
A. Dr. Santos' opinion was that the left lower lobe infiltrate equals atelectasis.
Q. Can you tell me what atelectasis is?
A. Atelectasis is a compression of the lung which will lead to an X-ray finding of an infiltrate.
Q. Does it have anything to do with pneumonia?
A. No.
Q. Now, Doctor, with respect to relying on a cardiologist's interpretation of pneumonia versus an infectious disease's interpretation of whether there is or isn't pneumonia, which would be reliable?
A. I don't know either one of these gentlemen, but I think the general perception is that an infectious disease specialist will be a little more attune to infectious disease processes.
Q. Doctor, with respect to the cardiologist's discussion on the MI, were there any clinical changes before or after the cardiologist treated with Cardizem to this patient during the February to 20th, 1995, admission?
A. I don't think so.
Q. What effect did that have on your opinion that the patient probably did not sustain a MI?
A. It didn't change my opinion.
MR. POWER: Thanks. I have no more questions.
THE COURT: Is there any recross-examination?
MR. SHAPIRO: Yes, just briefly, Judge.

RECROSS-EXAMINATION

BY MR. SHAPIRO:
Q. In terms of whose interpretation is better, Doctor, isn't it a fact that cardiologists routinely review chest X-rays, don't they?
MR. POWER: Objection as to generalizations.
THE COURT: Overruled.
THE WITNESS: Cardiologists do review chest X-rays, yes.
BY MR. SHAPIRO:
Q. Doctor, with respect to what your assumption was with respect to Dr. Azaran's order for the Humulin N, isn't it a fact that in forming the opinion about Dr. Azaran's intention that you relied on in giving your opinions -
MR. POWER: Objection, beyond the scope.
THE COURT: Overruled.
BY MR. SHAPIRO:
Q. - that you relied upon the following deposition testimony from Dr. Azaran at Page 114? “Question: I guess I'm just asking this question. Was it your assumption when Mr. Carter entered Imperial on February 1st that his orders already in place were for daily Humulin N and then blood glucose monitoring with additional Humulin R as needed? Answer: That's correct.” Isn't that what you were referring to regarding Dr. Azaran's testimony?
MR. POWER: Objection, not impeaching.
THE COURT: Overruled.
THE WITNESS: I probably would rely on that, yes.
BY MR. SHAPIRO:
Q. And, Doctor, also with respect to the February 16th order, do you still have those in front of you, which is Page 152 of Defendant's Exhibit No. 1 for identification purposes - no, wait - I'm sorry, yeah, Defendant's 1 which is the Imperial Nursing Home records.
Those refer to the orders that were written on February 16th by Dr. Azaran?
A. Yes.
Q. And I believe that you told Mr. Power that the orders that day that he wrote were solely with respect to the decubitus ulcers, do you remember telling him that a few minutes ago?
A. Yes.
Q. That's not true, is it?
A. There's an order above that for stopping Tylenol.
Q. That's got nothing to do with decubitus ulcers, correct?
A. I don't believe so.
Q. With respect to the fact that the doctor doesn't write orders with respect to other aspects of the patient's care, that doesn't mean that the doctor didn't have an obligation to review the patient's chart on a patient that he hadn't seen for 16 days in order to see how the patient was doing in the nursing home, does it, Doctor?
A. I don't know what Dr. Azaran's responsibilities that day were.
Generally we see patients on a 3.0-day basis. This would not have been his monthly visit. I think the standard of care that I was brought up in in his all the nursing homes I practiced in, and I've been in at least a dozen of them, was that monthly you review your records.
You leaf through the nurse's notes, you leaf through the laboratories, check the patient's weight, see if there's been a temperature in between. That's a monthly event.
If he is called in to see this problem and it's two weeks after the patient was admitted, I don't know that I would have done that, I would have leafed through the whole chart.
Q. Doctor, as far as we know, that was the monthly visit for this patient, correct?
MR. POWER: Objection.
THE COURT: Overruled.
THE WITNESS: I don't think two weeks makes a month.
BY MR. SHAPIRO:
Q. I understand that, Doctor.
But the doctor comes in at least on a once-a-month basis. That's a visit within the month, correct?
A. Well, this would have been the second visit of that month, would it not?
Q. Well, he didn't see him on February 1st. So that would have been the only visit the entire 20 days he was in the nursing home, correct?
A. That's correct.
Q. And he did not limit his examination of the patient at that time solely to decubitus ulcers, did he?
A. That's correct.
MR. SHAPIRO: That's all I have. Thank you.
THE COURT: Is there any re-reredirect?
MR. POWER: No, your Honor.
THE COURT: Thank you, sir.
(Whereupon, the witness was excused.)
THE COURT: If you'll just remain for a moment.
Ladies and gentlemen, we're going to break now for lunch. I would ask that you be back here at 1:30. That would give you about an hour and a half for lunch.
Do not discuss this case with anybody, not amongst yourselves, your family, your friends, not with anybody until all the evidence in this cause has been concluded, the attorneys make their closing arguments and I instruct you as to the law to be applied to this case.
Have a nice lunch. We'll see you at 1:30. (Whereupon, the jury was dismissed for lunch.) (Whereupon, the following proceedings were had in chambers outside the presence and hearing of the jury:)
THE COURT: The defense was going to have the clean copy of their No. 1 which was their 1501.
MR. POWER: I do, your Honor.
THE COURT: And I've already ruled on that, that was refused.
MR. POWER: Right.
THE COURT: Okay. And also you were going to be doing a clean copy of your No. 2 which was the 36.01.
MR. POWER: Yes, your Honor.
THE COURT: And that instruction will be given.
Did the defense have any other instructions they were offering?
MR. POWER: No, your Honor.
THE COURT: And the plaintiff was redoing their No. 10 which was the 12.05 instruction.
MR. SHAPIRO: Yes, we have that.
THE COURT: And their No. 9 which was the 1204. Which do you want to -
MR. SHAPIRO: We'll start with Plaintiff's 9.
THE COURT: This would be Plaintiff's Instruction No. 9A, LIPID No. 12.04 with both the first and second paragraphs.
Is there any objection?
MR. POWER: No, not with this modification.
THE COURT: It will be given.
MR. SHAPIRO: And then I have 10A.
THE COURT: And Plaintiff's Instruction No. 10A, which is IPI 12.05 with both the first and second paragraphs. Is there any objection?
MR. POWER: No objection to the modification.
THE COURT: It will be given.
And the plaintiff was also redoing their No. 18 which was the verdict form A.
MR. SHAPIRO: I'm sorry, what was the number, Judge?
THE COURT: It would be 18A.
MR. POWER: This is a little different than what we discussed to begin with, your Honor, and I don't think it follows the form A from IPI books.
It's my understanding you're supposed to leave in that first paragraph, we assess the damages in the sum of X and then itemized as follows.
THE COURT: Well, but they - assess damages as follows and then they have the elements and they have a total, so it serves the same purpose.
Are you objecting to it?
MR. POWER: I am. I think they should follow the IPI form unless there's some reason to modify it.
THE COURT: Well, in its form it's close. enough. The elements are the same with what they're telling the jury, if they find in Verdict Form A for the plaintiff that they're assessing damages, very different elements and you give a total which is going to be given over objection.
Any other instructions being offered?
MR. SHAPIRO: No, sir.
MR. POWER: No, your Honor.
THE COURT: Okay. That concludes the instruction conference.
MR. SHAPIRO: Thank you.
(Whereupon, which were all the proceedings had in this cause on this date.)
REPORT OF PROCEEDINGS at the trial of the above-entitled cause before the Honorable IRWIN J. SOLGANICK, Judge of said Court, on the 5th day of September, 2001, at the hour of 1:30 o'clock p.m
REPORTED BY: KIMBERLY A. OTTO, CSR
LICENSE NO.: 084-003713
(Whereupon, the following proceedings were held in open court.)
THE COURT: Counsel, you may call your next witness.
MR. POWER: Thank you, your Honor. At this time I would like to call Mr. Carl Skrabacz. THE COURT: Sir, would you come up here, please. Will you please raise your right hand to be sworn.
(Witness sworn.)
You may be seated. While testifying, sir, will you please keep your voice up so all the jurors, the court reporter, the attorneys and I can hear you?
THE WITNESS: Yes.
THE COURT: You may proceed.
CARL SKRABACZ, called as a witness herein, having been first duly sworn, was examined and testified as follows:

DIRECT-EXAMINATION

BY MR. POWER:
Q. For the record, could you tell the ladies and gentlemen of the jury your name?
A. My name is Carl Skrabacz.
Q. Mr. Skrabacz, you are currently the CEO of Jacobs Healthcare Systems?
A. That is correct.
Q. Can you tell us what Jacobs Healthcare Systems is?
A. We are a pharmacy that services long-term care facilities exclusively, nursing homes.
Q. Did your pharmacy service the Imperial Nursing Home of Hazelcrest in February of 1995?
A. Yes, we did.
Q. In February of 1995 you were the COO or the chief operating officer of that corporation?
A. That is correct.
Q. Can you tell me what your job was at that time with respect to the knowledge of the policies and the procedures at that institution?
A. I was instrumental in developing the policies and procedures and in carrying them out and knew all of the interworkings of the company.
Q. On February 1 - Strike that.
Did you bring records with you that reference the Jacobs Healthcare interaction with Imperial of Hazelcrest for Mr. Carter?
A. Yes, I did.
Q. I believe we previously entered into the record Plaintiff's Exhibit No. 6, which are paginated in numbered pages for those original records.
Please feel free to either look at the originals or the numbers paged at any time.
Sir, before coming here, did you review those records to familiarize yourself with your company's involvement with Mr. Paul Carter during February of 1995?
A. Yes, I did.
Q. I want to take a step back before we actually talk about this case in particular.
Tell me what system was in place for the Imperial orders to be submitted to Jacobs so that you could fill those pharmacy orders back in February of 1995?
A. Okay. Orders could be received by us in any one of three ways. Nurses could telephone us and call orders in, speak with a representative in the pharmacy and give them the order verbally over the telephone.
The other method that we could utilize was an actual pick up of the orders. When our driver delivered medications to the nursing home, he would ask for orders to be taken back to the pharmacy which were to be filled; so that was the second means by which we could get orders.
Lastly, orders could potentially be faxed to us.
Q. Was there a policy in place or a procedure in place at the Jacobs Pharmacy for certain forms to be used if orders were going to be faxed to your facility?
A. That is correct. We have a standardized form that was used for either orders, new orders or for reorders of medication.
Q. Doctor, were those forms circulated to Imperial in Hazelcrest before February 1 of 1995?
A. Before?
Q. Sure. In other words, were they already there?
A. Yes, they were.
Q. Sir, you brought with you all of your original records from Jacobs Healthcare Pharmacy.
Did you find any evidence when reviewing your business records that Jacobs Healthcare Pharmacy ever received a faxed order on February 1, 1995 from the Imperial of Hazelcrest with respect to any orders pertaining to Mr. Paul Carter?
A. I did not find any faxed orders on any date in the orders that I looked through, so the answer is no.
Q. Would that review of records included the entire February admission for Paul Carter?
A. Yes.
Q. Now, sir, if you received a fax order, tell me what the policy and procedure was at Jacobs with respect to maintaining that fax order if you later received the actual hard copy or the original?
A. Okay. All orders that were received by us either faxed or phoned or picked up were all stamped with a serialized number.
After processing the order the paperwork is combined - was and still is combined with a computer printout of that day's activity and the orders are filed alongside the computer printout day by day, nursing home by nursing home that I service.
Q. Sir, tell me when an order is received by phone what the procedure was at Jacobs in February of 1995 with respect to processing that phone order.
A. Very much the same as I just described. The phone order is stamped with a serialized number, given to the pharmacy technicians and the pharmacists to process, and after the day's business, it is joined together with the computer printout and filed in the pharmacy for future use reference.
Q. First a phone order - the blank order is received by the person receiving the phone call and it's filled out?
A. Filled out by one of my employees.
Q. When that form is filled out, how is it then that anybody in the warehouse knows how to pick up the drugs? In other words, does that form. go to processing -
A. That form would go to - okay.
After the order is written, the form is placed in a tray, if you will, that is then utilized by various technicians who will enter the order into the computer order system.
Then a label is generated, and the label is given to a pharmacist alongside the original order so that the pharmacist can verify that the technician did everything correctly on the order.
Once the pharmacist signs off on the label, the label and the order sheet go down to another group of technicians.
Those technicians will fill the order much the same as they would at a Walgreen's drugstore, albeit in a different system. We use a carded system rather than the little vial prescriptions and that order would then proceed to a pharmacist for further checking and authorization to be sent to the nursing home.
Then it will go on to packaging where it will be packaged and delivered to the nursing home in question.
Q. Sir, back in February of 1995, were there normal times that you would send vans out to Imperial to deliver medications that were ordered throughout the day?
A. Yes, there was.
Q. Can you tell me what those normal delivery times were?
A. I believe that in 1995 we were delivering to Hazelcrest at - the run would leave my drugstore at 12:00 noon and at 8:00 o'clock at night.
Q. Were there published cutoffs for use at Imperial to have those orders transmitted to you so you could process them, fill them and get them on that noon or a.m. truck?
A. Yes. There was a one-hour cutoff time before the run would normally leave. So the cutoff would have been 11:00 o'clock and 7:00 o'clock.
Q. Now, sir, on February 1, 1995, your business records do reflect that you received some telephone orders with respect to Mr. Carter?
A. I'd have to check the date.
Q. I believe it's Page 7 of the Xeroxes that are in front of you which is Plaintiff's Group Exhibit 6?
A. Okay. I want to compare those to the original if you don't mind because the originals are a little bit clearer than the faxed copies.
Q. Sure.
A. Yes. February 1st we received nine orders on a telephone call from Hazelcrest, and that was scheduled for an 8:00 p.m. delivery at the time we received the call. So I would guess that the call came in between 11:00 and 7:00 o'clock at night.
Q. Now, sir, of those nine orders, are any of those orders for Humulin R?
A. There are no insulin orders here, none for Humulin.
Q. Based on your review of your records for the entire February admission, was there ever any order for Humulin or any order at all received for Paul Carter by Jacobs Healthcare Systems?
A. No, there was not.
Q. Based on your review of the record, these nine orders were the full extent of the orders received by Jacobs on February 1?
A. Yes, sir.
Q. Sir, if you received a phone call later than the normal cutoff time for a truck, was there. a procedure in place to take care of these emergency or stat orders?
A. Certainly.
Q. What did you communicate to Imperial with respect to the need for or the concern about making an extra run?
A. In the normal course of events, we probably do 30 to 40 stat deliveries a day depending on the time of month and the needs of my customers. There is no extra charge for these, and we encourage the nursing homes to call us if they need anything.
Q. Now, sir, in addition to the actual order form that you told us that there would be - somebody would type in or process the request into your daily activity report?
A. Well, the daily activity report is generated off of the same database that produces the labels that we utilize all day long.
So at the end of the day, we merely give the computer a command to aggregate all of the orders that were processed that day, and it produces what we call a shipping list for what we delivered that day.
Q. After you do the shipping list - Let me back up.
Obviously you bill for the drugs that you ship to the various patients at Imperial Hazelcrest?
A. Yes.
Q. That's how you stay in, business, right?
A. That's right.
Q. Between the daily activity report and the billing pertaining to Paul Carter, did you ever find any evidence for an order for insulin at any time during the February admission to Imperial?
A. I did not.
Q. Did you review the records for that purpose?
A. The one record I did not review was my bills that I sent, but I think I reviewed those at my deposition.
Q. Let me ask you a different way. It wouldn't make the bill if it didn't make the daily activity report?
A. I'm sorry?
Q. It wouldn't make the bill if it didn't make the daily activity report, correct?
A. That is correct.
Q. There was no evidence on the daily activity report that the insulin was ever ordered; is that fair?
A. Not on the daily activity report there wasn't. I'm seeing an insulin order on the bill however.
Q. On what date is that?
A. February • 13th.
Q. Can you tell me on the bill on February 13th when it indicates that the insulin was ordered?
A. I'm sorry?
Q. Can you tell me on February 13th - the request for insulin - can you tell me what date it was ordered from the bill?
A. The 13th.
Q. Is that the date it was actually ordered from the nursing home - Maybe I could help you out.
Is that the insulin that was ordered on January 13, 1995?
A. January 13th. Excuse me. That's January 13th. My mistake.
Q. No problem.
A. We're talking about February.
Q. Yes, sir.
A. Yes, we are. That's why I couldn't understand what was going on there.
In February, there is no Humulin ordered in February - no insulin ordered in February or billed.
Q. So you're familiar with the Jacobs Healthcare Systems physicians order sheet form?
A. Yes.
Q. I believe it's Page 22 in your Plaintiff's Exhibit 6. The Jacobs Healthcare physicians order sheet is a preprinted sheet that is supplied to your nursing homes by you?
A. Yes, sir.
Q. Is it a multipart form?
A. Yes, it is.
Q. Can you tell me what the parts are to the form?
A. There are two - we call it a physician order sheet. The first two pages, one of which is a NCR paper or a carbonized paper and that is sent back to the pharmacy once a month for editing.
The top copy is the copy that is retained by the nursing home, and the last part of the form is something called a medication administration record.
On the first of the month that is separated from the physician order sheet and used as a separate document.
Q. If I may, is the pharmacy copy of the physician's order sheet the yellow copy or the bottom copy of that document?
A. Yes.
Q. And the white copy is the copy that stays in the chart?
A. Yes.
Q. Now, if I understand you correctly, you said that these are kept in the nursing home until some predetermined time and then they're picked up by pharmacy?
A. Yes. Once a month we pick this form up so that we can edit it and print a new form for use on the following month.
Q. Then the following month all the things that would be handwritten in would come back typed?
A. That is correct.
Q. Sir, in November - in February of 1995, do you know when Imperial's pharmacy order sheets would have been picked up in the month?
A. Yes. It's generally towards the end of the month that we did their sheets. My guess would be it would probably be someplace after maybe the 25th or the 26th of the month.
Q. Based on the documentation that is noted on this sheet - and I'm looking at Page 22 of Plaintiff's Exhibit 6 - is there any evidence that Jacobs Pharmacy picked up the pharmacy order sheet, No. 22, before February 20, 1995 from Imperial of Hazelcrest?
A. Is there evidence that we picked it up before the 20th?
Q. Yes, sir.
A. I couldn't say that we did. The last entry on these sheets is on the 16th of February - a handwritten entry is on the 16th. So it would have to have been after the 16th that we picked it up.
Q. Which page number are you referring to when you say that?
A. Page 23, the last handwritten entry by the RN is dated 2/16/95.
Q. Now, sir, based on your receipt of the documents from Imperial of Hazelcrest for orders that were initially given and then discontinued, what did your documentation usually contain when there was an order given and then later discontinued?
MR. SHAPIRO: Object.
THE COURT: Sustained.
BY MR. POWER:
Q. Was there a policy or procedure that your records followed with respect to how orders were completed and discontinued when it was received on behalf of Jacobs?
MR. SHAPIRO: Objection.
THE COURT: Sustained.
BY MR. POWER:
Q. Are you familiar with the custom and practice followed at Imperial with respect to orders that were received and later discontinued based upon the documentation of your business records?
A. Am I familiar with the procedures at Imperial?
Q. Yes.
A. for DCing an order?
Q. Yes, based upon the documents you received and are kept as part of your business records.
A. DCs are generally written on the physician order sheet. That's where they're documented.
Usually the order itself, the verbal order from the physician, will be handwritten on the right-hand side of the sheet, and the items which they are actually discontinuing will be crossed off and marked DC for discontinued on the left-hand side of the sheet. That's pretty much the practice at most nursing homes that I'm servicing.
MR. POWER: I have no more questions for you, sir.
THE COURT: Is there any cross-examination?
MR. SHAPIRO: Yes, sir.

CROSS-EXAMINATION

BY MR. SHAPIRO:
Q. Now, Mr. Skrabacz, am I correct that whether a physician's order was faxed in or called in, if it was either faxed in or called in without - I'm sorry - if there had been an order for insulin without a DC on it, then your pharmacy would have shipped insulin to the nursing home, correct?
A. Yes.
Q. But you never did ship any insulin to the nursing home, correct?
A. Not in February.
Q. So that would be consistent with no order for insulin having been given, correct?
A. Yes, it would.
MR. POWER: Objection on the word “given.”
THE COURT: Overruled.
THE WITNESS: Being - not being delivered. I can't vouch for whether it was given or not.
BY MR. SHAPIRO:
Q. You never saw anything on a physician order sheet for February ordering insulin, did you?
A. You mean in retrospect?
Q. Right.
A. Not as an order, no.
Q. Similarly if there had been an order for a blood glucose monitoring that had not been discontinued, you would have shipped blood glucose monitoring kits?
A. No, we would not have.
Q. So you don't get involved with blood glucose kits?
A. The blood glucose strips are what we call a house stock item. They come in bottles of multiple doses and the house generally buys those and uses them on multiple patients.
So when we ship them, we ship them as a bill to the house rather than to a patient. We don't know who they're going to be used for.
Q. Doctor, when you pick up the POS forms from the nursing home and you look at them after they've been picked up, is that in any way an audit to make sure that the orders that were on the POS form that you picked up were consistent with the orders that you had received and shipped?
A. Not when we pick it up. There's a different system in place to audit the chart against the actual orders that were shipped, and that would be done through my consultant pharmacists who visit the nursing homes. That's not done off-site.
Q. Now, Mr. Skrabacz, with respect to - and I believe you have your records that are marked Pages 21, 22 and 23 of Plaintiff's Group Exhibit No. 6 which are the Jacobs Healthcare records - do you have those in front of you?
A. Yes, I do.
Q. With respect to Page 21, that is the pharmacy copy?
A. The yellow copy that you have, yes. You have a copy of the yellow one, I believe.
Q. It says up in the right-hand corner, pharmacy copy, correct?
A. Yes.
Q. That form was picked up - according to the practice and procedure, was picked up by the pharmacy from the nursing home sometime before the physician signed it, correct?
A. Yes.
Q. So at the time that the form was filled out as a carbon copy before the physician signed it, it had this language already on it in the right-hand side, discontinue blood glucose monitoring, A, C and H's insulin as well as discontinue sliding scale insulin, correct?
A. That's correct.
Q. And there are some marks on there and on the medication orders. What do those marks indicate?
A. Are you talking about the red checkmarks?
Q. Right.
A. The red checkmarks were done - on my copy they're red. They were done by my editors at the pharmacy that indicate that they picked them up, if you will, and put them into the computer system. That there were changes from previous.
Q. So if there had not been a DC on the form and it just said sliding scale insulin, that would have been picked up as an order for insulin, correct?
A. It would have been picked up as an order to be put oh the physician order sheet.
Q. But that wasn't done, correct?
A. No.
Q. Now, with respect to the second page, and you indicated that you didn't know when that was picked up because showing you 22 of the pharmacy's records, the pharmacy copy -
A. Yes.
Q. The last notation that's written on the carbon copy is an order on February 13, right?
A. Yes, it is.
Q. And that order for February 13 says that on February 26, ‘95, give 5 milligrams of Valium and on 3/27 give something about Valium for a 1:30 p.m. procedure; is that right?
A. That's right.
Q. Somebody wrote on there that it was noted on February 13th of ‘95, correct?
A. Yes.
Q. Then this section on the lower right-hand corner on your pharmacy carbon copy is completely blank, correct?
A. The big square at the bottom?
Q. Right.
A. It has the note in the corner. The rest of it is blank.
Q. Right, and the doctor has not yet signed it, correct?
A. Yes. It's part of the same form that we had just discussed.
Q. Now, do you have Defendant's Group Exhibit No. 1 in front of you which are physicians order sheets chart copies?
Let me give you an extra copy of this so you can follow along with me.
A. Okay.
Q. By the way, one more question about Page 22: This pharmacy copy also has pharmacy orders over on the left-hand side, correct?
A. Yes.
Q. For blood glucose monitoring and for Humulin R insulin?
A. Yes.
Q. And it's got a DC written on it, correct?
A. Yes.
Q. So the pharmacy carbon copy has got that DC language on it at a point in time before Dr. Azaran has signed it, correct?
A. Yes.
Q. Now, if you could just go back for a minute to the chart copy for the nursing home and it's specifically Page 147.
A. I don't have a 147.
Q. I'm sorry. Check Imperial records from 2120. Let me just show you my copy. That will make it a little bit quicker. I'll show the jury.
Do you see on the chart copy, Doctor -
THE COURT: What's being shown to the witness, Counsel?
MR. SHAPIRO: This is Page 147 of the Imperial Nursing Home records for February 1st.
THE WITNESS: Okay.
BY MR. SHAPIRO:
Q. Doctor, on this chart copy there has now been an order added to the chart copy, correct?
A. It looks like.
Q. And that's an order dated February 20th for blood glucose monitoring every six hours, correct?
A. Um-humn.
Q. Is that a “yes”?
A. Yes.
MR. POWER: Your Honor, could we have a sidebar?
(Whereupon, the following proceedings were held out of the hearing and presence of the jury.)
MR. POWER: This clearly goes beyond the scope of direct. He's now going to start comparing parts of the chart that never made it to the pharmacy so this wouldn't have been part of his business records.
He's now going to I guess attempt to start comparing when things were done as compared to signatures which has nothing to do with this witness nor was it ever disclosed under 213 nor is there any basis for this witness to start talking about when signatures were placed on the chart since it's not dated.
All of this is clearly beyond the scope of direct and clearly beyond this witness's foundational abilities as to what occurred in the nursing home since it didn't make the business record.
MR. SHAPIRO: Counsel, specifically asked him when they picked up these copies and that he couldn't tell from the document when it was picked up.
well, I have the pharmacy copy showing this language isn't on it. I've got the chart copy showing that there was a notation made on February 20th, okay, which would clearly show that the pharmacy copy was picked up before February 20th.
MR. POWER: It means it was torn apart. It could mean a million things. It doesn't mean it was picked up.
THE COURT: Well, for that limited purpose I would allow the examination of the witness. The jury can draw whatever inferences from that that they wish. But it goes to an issue that was brought up on the direct examination of the witness. So I would allow it for that purpose only.
MR. POWER: I'm sorry, Judge, while we were walking out, I asked you a question that wasn't on the record.
My concern is that with respect to when Dr. Azaran signed this clearly is beyond this witness's foundational capabilities to talk about that, number one. Number two, it has nothing to do with the limited purpose that you are asking about - with respect to when it was picked up.
THE COURT: The witness has already testified that Dr. Azaran has not signed the pharmacy copy so he has - he can't tell when the Doctor signed it.
The only purpose this examination would have was with regard to the picking up of the document, that is, he said he thought the regular procedures was around the 25th or the 26th and there was an entry that he had testified to that was made sometime and now there's a question that there is a copy made after that.
So the jury can infer that it may have been picked up prior to that last entry. That's all. That's the only purpose of the examination with this document with this witness.
(End of sidebar discussion.) (Whereupon, the following proceedings were held in open court.)
THE COURT: The objection is overruled. BY MR. SHAPIRO:
Q. Showing you Page 147 - we've got an extra copy now so we can look at it together - this is the chart copy, right, from Imperial?
A. It appears to be, yes.
Q. Now, this document - I think you said that these forms are carbon copies, correct?
A. Mine is a carbon, yes. It's NCR copy.
Q. So what it is written on the one would be identical to what is written on the other, correct?
A. Yes.
Q. But this form - the chart copy has now- got - that we see in this has got a new order added to it, correct?
A. Yes, it does. It has an order that the yellow copy did not have.
Q. This order is dated February 20 for blood glucose monitoring every six hours, correct?
A. Yes.
Q. And this form is signed by Dr. Azaran, correct?
MR. POWER: Objection, foundation.
THE COURT: Sustained.
BY MR. SHAPIRO:
Q. So if the chart copy has got a February 20th order on it and your form - your carbon copy doesn't have that February 20th order on it yet but it's got the last order being February 13th, would it be fair to say that the pharmacy picked up the carbon copy of the order sometime between February 13th and February 20th?
A. It would be fair to say.
Q. And in the pharmacy copy, it's already got the DC on it, doesn't it?
A. It has - Yes. It has the DC in the left-hand on the same page up in the left-hand corner.
Q. It's got DC on both of these forms, correct?
A. Pardon?
Q. It's got DC on the chart copy as well as the pharmacy copy?
A. Yes, it does.
Q. You said that there was a 7:00 p.m. published cutoff for the 8:00 o'clock run?
A. Yes, sir.
Q. But isn't it a fact that if an order was processed by 7:30 or even on occasion a quarter to 8:00, you would go ahead and include it on the 8:00 o'clock run?
A. Depending on the situation, we might recognize the fact that we need to add that order, yes, and put it in.
Q. If there was some reason it couldn't be made by then, you would just send it over on a separate run, correct?
A. If we had indication that it was needed quickly, we would make a stat on it, yes.
Q. There would be no extra charge to the nursing home for that, correct?
A. There would not.
Q. Now, just hypothetically, Mr. Skrabacz - By the way, on the orders that were called in on February 1st, they ordered nine different medications?
A. Yes.
Q. And if for some reason they forgot to order one of the medications and then it came the next morning and they realized that they didn't have that medication in-house but they had an order to give that medication to the patient, based on your experience, what would be the practice and procedure?
MR. POWER: Objection, foundation.
THE COURT: Sustained.
BY MR. SHAPIRO:
Q. Well, was your pharmacy open the next day?
A. Yes, sir.
Q. So they could just order it the next day if for some reason somebody didn't order it the night before?
MR. POWER: Objection, foundation.
THE COURT: Sustained.
BY MR. SHAPIRO:
Q. You were available at all times for the nursing homes for medications?
A. Yes.
Q. And as a matter of fact, didn't you even provide medication, insulin medication, for nursing homes to keep on hand for emergencies?
A. Yes.
MR. SHAPIRO: That's all I have. Thank you.
THE COURT: Any redirect?
MR. POWER: Yes, your Honor.

REDIRECT-EXAMINATION

BY MR. POWER:
Q. You were just shown the two documents with the note on it on the 20th and the one without the note on it on the 20th.
Sir, based on your business records, can you tell me whether that form was separated on the 13th, 14th, 15th, 16th, 17th, 18th, 19th or 20th two minutes before that note was entered?
A. Can I tell you if it was? It could have been. It could have been separated on any of those dates.
Q. As late as a minute before she wrote that 2/20 order?
A. Yes, sir.
MR. POWER: No more questions.
THE COURT: Recross examination?
MR. SHAPIRO: No.
THE COURT: Thank you, sir.
THE WITNESS: Should I take the exhibits with me?
THE COURT: Yes.
(Witness excused.)
THE COURT: Defense, call your next witness.
MR. POWER: Yes, your Honor. fit this time we will call Dr. Abdol Azaran.
THE COURT: Be seated. Again, identify yourself for the record.
THE WITNESS: Abdol Azaran.
THE COURT: And you have been sworn in this cause; is that correct?
THE WITNESS: Yes, sir.
THE COURT: You realize, sir, that you are still under oath?
THE WITNESS: Yes, sir.
THE COURT: Again, can you please keep your voice up so all of the jurors, the court reporter and the attorneys and I can hear you?
THE WITNESS: Sure.
THE COURT: You may proceed.

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