Nursing Home Litigation and Admissibility of Evidence: Proving or - - PowerPoint PPT Presentation

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Nursing Home Litigation and Admissibility

• f Evidence: Proving or Challenging

Authentication, Relevance and Hearsay

Today’s faculty features:

1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific THURSDAY, JULY 20, 2017

Mark A. Cox, Founder, Mark A. Cox, Edmond, Okla. Ahsan A. Jafry, Esq., Burns White, Cherry Hill, N.J.

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Nursing Home Litigation and Admissibility of Evidence

Mark A. Cox Law Office of Mark A. Cox, PLLC 15401 N. May Ave. Suite 400 Edmond, OK 73012 405.285.544 Mark@MarkCoxLaw.com www.MarkCoxLaw.com

Types of critical evidence in nursing home injury cases

Former Employee Testimony

• I think one of the most important types of evidence in a nursing home

case comes from former employee testimony. I’ve developed a systematic way to discover and secure former nursing home employee testimony which is the subject of another seminar. However, as far as getting such testimony admitted at trial, it comes down the relevance. There are different arguments used to admit nursing home employee testimony based on their case-specific knowledge base. If the nursing home employee took care of the resident at issue, then there is a strong probability such will be admissible at trial. It would be very hard for the nursing home to argue otherwise.

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Types of critical evidence in nursing home injury cases

Former Employee Testimony

• It’s a little more difficult if the former nursing home employee did not

take care of the resident at issue. However, as long as the former employee worked at the nursing home during the resident’s admission, and was in a position to observe the type of care given at the facility, then such testimony will likely be admitted at trial over any relevancy argument by the defense.

• Former nursing home employees that worked at the facility close in time,

either before or after your resident’s admission still may be able to testify about the conditions they witnessed and were actively involved in at the nursing home. It’s a little tougher argument but it is certainly possible.

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Types of critical evidence in nursing home injury cases

Nurse Expert’s Opinions as to Standard of Care Related to Federal and State Regulations

• Your nurse in his or her deposition should be able to explain why such

regulations are part of the standard of care for nursing homes. You can use such that deposition testimony to fight off any motion in limine or partial summary judgment motion on this issue. Assuming you win these motions, be sure and educate the judge, again, shortly before trial using a trial brief.

• If you are unable to convince the judge that the federal and state regulations

should be considered as subjects of negligence per se instructions, then at the very least, you should be able to get such regulations admitted at trial as evidence of negligence.

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Types of critical evidence in nursing home injury cases

Nurse Expert’s Opinions as to Standard of Care Related to Federal and State Regulations

• Because federal and state nursing home regulations are relatively plaintiff

friendly, plaintiff’s attorneys should work very diligently in order to get such regulatory evidence admitted at trial as the standard of care for nursing homes as well as the subjects of negligence per se instructions. The first step in getting such regulations admitted begins with depositions of nursing home personnel.

• Routinely, staff and supervisory LPNs and RNs will admit during their

depositions that regulations, both federal and state are part of the standard of care for nursing homes. Once they’ve admitted that, you should not have a difficult time getting such evidence to the jury. If, however, nursing home employees have been woodshedded properly by defense counsel, they may not admit as much. At that point, you must rely on your expert nurse.

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Types of critical evidence in nursing home injury cases

Owners’ Culpability

• In order to reach as many couple defendants as possible, I routinely sue all
• wners of the operating entity no matter what percentage of ownership

they hold. These individual owners desperately try to get dismissed from the lawsuit claiming that only the operating entity that holds the license and possibly the management company for the nursing home should be

• defendants. They argue such individual owners are simply shareholders in

a corporation and therefore protected by corporate law. However, if the

• wners participate, in any meaningful way in the operation of the nursing

home, then the court will usually allow me to pursue them in the lawsuit. If, however, an individual owner has never stepped foot in the nursing home and has never participated meaningfully in the operation of the nursing home, then the defense has a good argument that they should be dismissed from the lawsuit.

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Types of critical evidence in nursing home injury cases

Key Exhibits

• Below is a list of exhibits that I typically use as part of my preliminary and

final exhibit lists in nursing home cases. The list encompasses the types of evidence, critical to support your claims against the nursing home and its

• perators/owners. The list will naturally be longer depending on the

specific defendants I’m suing.

• You should be able to lay the proper foundation for authenticating most of

the nursing home documents listed below by taking a corporate

• deposition. Whoever the nursing home produces should be able to

properly identify and verify the accuracy of such exhibits. It is up to you to develop the necessary evidence to convince the court that such evidence is relevant and therefore admissible.

• You should also have your nurse expert testify in his/her deposition about

all of the below evidence you want admitted at trial. If the expert identifies such evidence as the kind experts in his/her field rely on and in fact relied on to form his/her opinions, you should have no problem getting such evidence admitted at trial.

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Types of critical evidence in nursing home injury cases

Key Exhibits

• Advertising
• Anatomical charts, graphs, drawings and demonstrative

aids

• Business/Admin. file of Resident
• Census records
• Charts of relevant times and events
• Complaints
• Consultant Reports
• Daily Time Sheets
• Defendants’ Corporate Financial Information
• Deficiency Reports
• Government investigations of Defendant Nursing Home
• Documents, records and things concerning Defendant

Nursing Home employees including criminal investigation records and personnel material

• Employment records of personnel at Defendant Nursing

Home

• Floor Plan
• In-Service documents
• Medical bills-Relevant
• Medical/Nursing Home records- Relevant
• Nurse Aide licensure information
• Nurse Licensure information
• Oklahoma DHS/DOH material concerning any nursing

home owned, operated or administered by any of the

• wners of Defendant Nursing Home
• Policies and procedures
• Records concerning other nursing homes owned by

Defendants

• Staffing Documents
• Training/performance records
• Owner information
• Financial documents of the nursing home and its
• wners/operators
• Medicare Cost Reports
• Medicaid/Oklahoma Healthcare Authority Cost Reports
• DHS investigations/inspections
• Okla. DOH investigations/surveys/inspections
• Death Certificate
• Personnel files
• Administrative File
• Brochure
• Website
• Direct Care Hours Sheets
• Employee Manual
• Grievance Log
• Handwritten schedules
• Incident Log
• Incident reports
• Medical Director contract
• Monthly Staffing hours
• Quality of Care documents
• Timecard alternative report
• Regulatory investigation documents of Defendants’

employees

• Electronic communications

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Nursing Home Litigation and Admissibility of Evidence PART 1 - RELEVANCE

Nursing Home Litigation and Admissibility of Evidence PART 1 – RELEVANCE

Ahsan A. Jafry, Esq Burns White LLC aajafry@burnswhite.com

Nursing Home Litigation and Admissibility of Evidence PART 1 - RELEVANCE

F.R.E. 401. T est for Relevant Evidence Evidence is relevant if: (a) it has any tendency to make a fact more or less probable than it would be without the evidence; and (b) the fact is of consequence in determining the action.

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Nursing Home Litigation and Admissibility of Evidence PART 1 – RELEVANCE

What is “of consequence” in a Nursing Home Malpractice case

• DUTY – the nursing home has a duty to provide the

medical care that meets the standard of care

• BREACH – Did the nursing home breach that duty?
• CAUSATION – Did this breach cause the Plaintiff’s

damages? (was the damage caused by underlying medical issues)

• DAMAGES – What damages were caused by the breach
• f duty (i.e. pain and suffering, wrongful death, punitive

damages)

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Nursing Home Litigation and Admissibility of Evidence PART 1 - RELEVANCE

F.R.E. 403. Excluding Relevant Evidence for Prejudice, Confusion, Waste of Time, or Other Reasons The court may exclude relevant evidence if its probative value is substantially outweighed by a danger of one or more of the following: unfair prejudice, confusing the issues, misleading the jury, undue delay, wasting time, or needlessly presenting cumulative evidence.

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Nursing Home Litigation and Admissibility of Evidence PART 1 - RELEVANCE

ADMISSIBILITY AT TRIAL DIFFERENT THAN THE STANDARD FOR SCOPE OF DISCOVERY

• Fed. R. Civ. P. 26(b)(1): Parties may obtain discovery regarding any

non-privileged matter that is relevant to any party’s claim or defense and proportional to the needs of the case, considering the importance of the issues at stake in the action, the amount in controversy, the parties’ relative access to relevant information, the parties’ resources, the importance of the discovery in resolving the issues, and whether the burden or expense of the proposed discovery outweighs its likely benefit. Information within this scope

• f discovery need not be admissible in evidence to be discoverable
• Most states apply the “reasonably calculated to lead to

admissible evidence”

• This standard much lower than admissibility at trial

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Nursing Home Litigation and Admissibility of Evidence PART 1 - RELEVANCE

OWNERS AS DEFENDANTS

• Owners of a nursing home typically have never met the

resident and do not provide any hands on care

• Very difficult to argue that they have any relevant facts

for a nursing home malpractice claim

• Typically, owners are dismissed from the case before

trial

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Nursing Home Litigation and Admissibility of Evidence PART 1 - RELEVANCE

NURSING HOME FINANCIAL DATA

• Budgets
• Medicare and Medicaid Cost Reports
• Case Mix Index (CMI) – Medicare

Reimbursement rate

• This evidence is not relevant to Duty, Breach
• r Causation, or Damages and will get

excluded at trial

• Relevance as to punitive damages????

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Nursing Home Litigation and Admissibility of Evidence PART 1 - RELEVANCE

FEDERAL AND STATE REGULATIONS

• May be relevant to assist in defining the standard of

care

• An expert witness is not permitted to explain the law,

this is the function of the judge. Ptaszynski v. Atlantic Health Systems, 111 A.3d 111 (N.J.Super. App. Div. 2015)

• Likely to get excluded from trial under F.R.E 403

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Nursing Home Litigation and Admissibility of Evidence PART 2 – HABIT v. CHARACTER

Nursing Home Litigation and Admissibility of Evidence PART 2 – HABIT v. CHARACTER

Ahsan A. Jafry, Esq Burns White LLC aajafry@burnswhite.com

Nursing Home Litigation and Admissibility of Evidence PART 2 – HABIT v. CHARACTER

F.R.E. 406. Habit; Routine Practice Evidence of a person’s habit or an organization’s routine practice may be admitted to prove that on a particular

• ccasion the person or organization acted in accordance

with the habit or routine practice. The court may admit this evidence regardless of whether it is corroborated or whether there was an eyewitness.

• This is a regular response to a repeated specific situation
• The doing of the habitual acts may become semi-automatic
• Example 1: habit of going down a particular stairway two

stairs at a time

• Example 2: giving the hand-signal for a left turn

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Nursing Home Litigation and Admissibility of Evidence PART 2 – HABIT v. CHARACTER

F.R.E. 404. Character Evidence; Crimes or Other Acts

• Evidence of a person’s character or character trait

is not admissible to prove that on a particular

• ccasion the person acted in accordance with the

character or trait.

• Evidence of a crime, wrong, or other act is not

admissible to prove a person’s character in order to show that on a particular occasion the person acted in accordance with the character

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Nursing Home Litigation and Admissibility of Evidence PART 2 – HABIT v. CHARACTER

TYPES OF HABIT EVIDENCE IN NURSING HOME LITIGATION

• Turning and Repositioning
• Always an issue in Pressure Ulcer cases
• Not typically documented
• Done every two hours
• Done during rounds
• The positioning is checked by nursing staff
• Toileting
• Usually an issue in fall cases
• Not typically documented
• Performed before and after meals, during CNA rounds,

before putting a resident to bed

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Nursing Home Litigation and Admissibility of Evidence PART 2 – HABIT v. CHARACTER

TESTIMONY OF FORMER EMPLOYEES

• Is the testimony of Habit/Routine Practice or

Character/Prior Bad Acts?

• Testimony that the Nursing Home is a horrible place is

inadmissible character evidence

• General testimony that the Nursing Home has provided

negligent care to other residents is inadmissible character evidence

• Testimony that the nursing home has a habit and

routine practice of a specific act on a specific occasion may be admissible (probative value must exceed prejudice)

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Nursing Home Litigation and Admissibility of Evidence PART 2 – HABIT v. CHARACTER

STATE SURVEY RESULTS

• State Survey process involves an Annual State Survey

and Complaint surveys

• Citations are issued violations of Federal Regulations
• Citations in State Surveys are generally inadmissible

prior bad acts and inadmissible character evidence

• State Survey results showing a habit and routine

practice might be admissible (probative value must exceed prejudice)

• When the Plaintiff is the subject of a State Survey, the

results will likely be admissible as something relied upon by experts

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Nursing Home Litigation and Admissibility of Evidence

PART 2 – HABIT v. CHARACTER

PERSONNEL FILES OF EMPLOYEES

• Disciplinary records of employees are generally

considered inadmissible evidence of prior bad acts

• Factual data pertaining to the discipline of a particular

incident at issue in a case will likely be admissible

• The conclusions in the disciplinary documents of a

particular incident at issue in a case will likely inadmissible as subsequent remedial measure

• The results of disciplinary decisions of a particular

incident at issue in a case may be inadmissible as prejudicial as it would not have probative value

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Nursing Home Litigation and Admissibility of Evidence

PART 2 – HABIT v. CHARACTER

INCIDENT REPORTS

• Incident Reports of other incidents are generally

considered inadmissible evidence of prior bad acts

• The factual data in an incident report is typically

admissible

• The conclusions in Incident reports are likely

inadmissible as subsequent remedial measure but this information is typically in an updated care plan

QUALITY CONTROL DATA

• Nursing Homes are required to keep quality control data

(i.e. number of falls, facility acquired pressure ulcers). This data is generally considered inadmissible evidence

• f prior bad acts

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Nursing Home Litigation and Admissibility of Evidence PART 3 – HEARSAY

Nursing Home Litigation and Admissibility of Evidence PART 3 – HEARSAY

Ahsan A. Jafry, Esq Burns White LLC aajafry@burnswhite.com

Nursing Home Litigation and Admissibility of Evidence PART 3 – HEARSAY

HEARSAY

• Out of court statement or document that is
• ffered for the truth of the matter asserted
• Most of the evidence in a Nursing Home

Malpractice case is derived from Hearsay

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Nursing Home Litigation and Admissibility of Evidence PART 3 – HEARSAY

HEARSAY EXCEPTIONS

• Records of a Regularly Conducted Activity

(Business records exception)

• Statement made for Medical Diagnosis or

Treatment

• Then-existing mental, emotional or physical

condition

• Public records
• Admission of a party opponent

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Nursing Home Litigation and Admissibility of Evidence PART 3 – HEARSAY

HEARSAY WITHIN HEARSAY

• This is when a hearsay statement is made within

another hearsay statement (or document)

• Each level of hearsay has to be evaluated
• The statements are admitted if each level of

hearsay conforms with an exception to the hearsay rule

• Known as the “food chain” or “telephone rule”

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Nursing Home Litigation and Admissibility of Evidence PART 3 – HEARSAY

HEARSAY ANALYSIS #1

• This is deposition testimony of a conversation between a

daughter and a nurse at a hospital

• Very common in a Nursing Home Malpractice case for family

members to claim that another medical provider commented about the nursing home’s actions

• The issue here is whether the resident was “lying flat” during a

tube feed.

• Clearly inadmissible hearsay

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Nursing Home Litigation and Admissibility of Evidence

PART 3 – HEARSAY

HEARSAY ANALYSIS #2

• This is a situation involving Hearsay within Hearsay
• First level of hearsay is from an unidentified CNA – may qualify as

admission of a party opponent

• Second level of hearsay from another unidentified individual
• Lack of personal knowledge and inability to identify the witnesses

makes this inadmissible

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Nursing Home Litigation and Admissibility of Evidence

PART 3 – HEARSAY

HEARSAY ANALYSIS #3

• This is another Hearsay Within Hearsay situation
• The first level is met because of the business records exception
• The second level “had been like this since 5am” and “had to go now”

could be met as an admission of a party opponent

• Because of the prejudicial nature it was excluded and the ambulance

personnel had to testify live at trial

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Nursing Home Litigation and Admissibility of Evidence PART 3 – HEARSAY

HEARSAY ANALYSIS #4

• This is another Hearsay Within Hearsay situation
• The first level is met because of the business records exception And

public records exception

• The second level statement from the CNA “it was an oversight” could

be met as an admission of a party opponent

• Depends on identifying the CNA and probative v. prejudicial nature

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Nursing Home Litigation and Admissibility of Evidence PART 3 – HEARSAY

OTHER COMMON HEARSAY ISSUES WITH MEDICAL RECORDS

• Competency of the declarant making statements for

purposes of diagnosis (i.e. may be a patient with dementia)

• Complex medical opinions contained within medical records

are not admissible (Nowacki v. Community Health Systems, 141 N.J. 95, 660 A.2D 1193 (1995)

• Experts will be able to talk about the contents of the medical

records as materials relied upon in the field of nursing home medicine

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