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Christensen v. Good Shepherd, Inc.

Court of Appeals of Iowa

June 6, 2018

KRISTINE CHRISTENSEN, Individually and as Executor of the Estate of MARIA O'BRIEN, STEPHANIE PROHASKI, Individually, ANTHONY SAVAS, Individually, and THEODORE SAVAS, Individually, Plaintiffs-Appellees,

          Appeal from the Iowa District Court for Cerro Gordo County, Christopher C. Foy, Judge.

         Good Shepherd, Inc. appeals a district court order upholding a jury award in favor of the plaintiffs. AFFIRMED.

          Mark McCormick of Belin McCormick, P.C., Des Moines, and David E. Schrock and Skylar J. Limkemann of Scheldrup Blades Schrock Smith P.C., Cedar Rapids, for appellant.

          Benjamin P. Long and Pressley W. Henningsen of RSH Legal, P.C., Cedar Rapids, for plaintiffs-appellees.

          Thomas J. Miller, Attorney General, and Richard E. Mull, Assistant Attorney General, for intervenor-appellee State.

          Heard by Danilson, C.J., and Potterfield and Mullins, JJ.

          MULLINS, Judge.

         Good Shepherd, Inc. appeals a district court order upholding a jury award in favor of the plaintiffs[1] in a nursing-home-negligence case. Good Shepherd contends the district court: (1) erred in overruling its objections to four specifications of negligence in the jury instructions; (2) abused its discretion in allowing irrelevant or prejudicial testimony concerning its receipt of prior regulatory citations; (3) erred in overruling its motion for a directed verdict on the plaintiffs' claim for punitive damages; and (4) abused its discretion in declining to remit the punitive-damages award to an amount equal to the compensatory-damages award.

         I. Background Facts and Proceedings

         Based on the evidence presented at trial, a reasonable jury could make the following factual findings. In 2011, Maria O'Brien moved into an assisted-living facility. Sometime thereafter, O'Brien was diagnosed with dementia. While residing in the assisted-living facility, O'Brien suffered a fall and injured her pelvis. Thereafter, in September 2012, O'Brien became a resident at Good Shepherd, a skilled-care nursing-home facility subject to state and federal regulations. Before the commencement of her residence at Good Shepherd, O'Brien had a history of falling down, a history of vertebral compression fractures, severe osteoporosis, mild dementia, and a preexisting shoulder affliction that limited the use of her right arm. Good Shepherd classified O'Brien as a high-fall-risk resident.

         O'Brien was initially placed on Good Shepherd's second floor. O'Brien's two daughters took issue with the adequacy of care their mother was receiving on the second floor, and lodged a number of complaints with staff. The sisters' frequent complaints to staff earned them the nickname of "the O'Brien bitch sisters." When the issues were not resolved, the sisters brought their concerns to the attention of Good Shepherd's director of nursing, who ultimately agreed to move O'Brien to the first floor.

         During her two-and-a-half-year residency at Good Shepherd, O'Brien experienced a number of falls. On December 6, 2012, O'Brien suffered a fall from her recliner, which was unwitnessed by staff. At this point in time, Good Shepherd had not implemented a care-plan strategy to lessen O'Brien's risk of falling, despite its previous assessment of O'Brien as a high-fall-risk resident. Ten days later, on December 16, O'Brien suffered two more falls, both of which were also unwitnessed by staff. The first fall was, again, from the recliner, but the circumstances of the second fall went undocumented. According to one expert witness, "The fall interventions in place before those two falls were none." On June 11, 2013, O'Brien suffered another unwitnessed fall, this time from her wheelchair while she was in her bathroom. As a result of this fall, O'Brien's care plan directed that she not be left alone in her wheelchair. On October 22, O'Brien experienced a fifth unwitnessed fall from her recliner. The next fall occurred about two weeks later on November 8, when O'Brien fell attempting to answer a phone located across the room; she was found lying on her floor, face down.

         O'Brien suffered two unwitnessed falls from her bed on November 15. No fall interventions were in place at the time of the first fall. A floor mat intended to absorb a fall was applied to her floor before the second fall on this date, but one expert testified the mat was misapplied. After the November 15 falls, Good Shepherd determined it would temporarily start checking on O'Brien every fifteen minutes, but staff members were inconsistent in following this plan. The fifteen-minute checks ceased altogether on November 24. The next, and final, fall occurred on March 12, 2014. As noted, by this point in time, O'Brien's care plan directed that she not be left alone in her wheelchair. Also, a document was previously posted in O'Brien's bathroom stating, "Resident not to be left unattended in the bathroom." Despite these directives, O'Brien was left alone in her bathroom in her wheelchair, from which she ultimately fell. She was assessed after the fall and reported she was not in pain; however, that evening she complained of back pain. The day after the fall, one of O'Brien's children, Stephanie Prohaski, went to visit O'Brien. After being advised by another resident that her mother suffered a fall the prior day, Prohaski went to O'Brien's room, where she found her seated in her wheelchair, alone.

         Prior to the fall in March, O'Brien was able to walk with assistance and was able to feed herself. Following the fall in March, O'Brien's condition began to decline-she was no longer able to feed or hydrate herself, she could no longer walk, and she required additional assistance from staff in performing other ambulatory tasks. One expert witness testified "the fall brought about multiple factors that triggered this cascade." Upon examination following the March fall, a neurosurgeon discovered some complications in O'Brien's vertebral area and opined the fall exacerbated some underlying conditions. In April, O'Brien developed a small pressure ulcer on her right buttock. Although this ulcer healed in a couple weeks, another one reappeared in the same area in August, which also healed in a couple weeks. In November, O'Brien developed several superficial pressure ulcers on her right buttock. In December, O'Brien developed several more pressure ulcers.

         Throughout her residence at Good Shepherd, O'Brien also experienced a significant loss in weight. When she moved in in September 2012, she weighed 127 pounds. In November, O'Brien lost 5.4 pounds. At this time, O'Brien was supposed to be receiving dietary supplements three times per day. However, her supplement was not given to her on thirty-five occasions in November. By February 2013, O'Brien weighed 118 pounds. Good Shepherd's own expert testified that, per Good Shepherd's policies and procedures, O'Brien should have been started on a restorative dining plan at this time. O'Brien did not receive any nutritional supplements in February, despite the fact that the supplements were not ordered to be discontinued until late in the month. By June, O'Brien weighed 114 pounds, but O'Brien was still not placed on a restorative dining plan. By February 2014, O'Brien weighed 108 pounds; placement on the restorative dining plan was still yet to be had. O'Brien was finally placed on a restorative dining plan in the summer of 2014. By September 2014, O'Brien weighed less than 98 pounds; by December, 90.8 pounds; and by March 2015, she weighed only 84 pounds. One expert testified there was a "[p]retty substantial connection" between O'Brien's weight loss and her decreased overall strength which accordingly increased her risk of falling. Good Shepherd's expert testified O'Brien's weight loss played a role in her declining health. When O'Brien's children visited her, they were often required to feed and hydrate O'Brien (and other residents who also needed assistance) themselves, because there was insufficient staff to adequately feed or hydrate all of the residents at meal time.

         In late March 2015, Prohaski received a call from Good Shepherd in which she was advised O'Brien "wasn't doing well" and "wasn't very responsive." Good Shepherd asked for permission to admit O'Brien to the hospital. O'Brien was admitted to the hospital on March 28, 2015 due to dehydration. Prior to this, no one at Good Shepherd informed O'Brien's family that O'Brien was struggling with hydration or nutrition, although the nursing notes reveal these concerns were known to staff. While visiting their mother in the hospital, O'Brien's children discovered another pressure ulcer on O'Brien's backside. Hospital personnel tried to administer an IV to provide O'Brien with fluid but were unable to do so due to O'Brien's deteriorated condition. O'Brien was transferred to hospice care after spending less than a day in the hospital and ultimately passed away on April 1, 2015. O'Brien's certificate of death identified dehydration as the underlying cause of death.

         In February 2015, prior to O'Brien's death, she and her children filed suit against Good Shepherd and a number of its employees. An amended petition was filed after O'Brien's death. The plaintiffs subsequently dismissed the action as to the individually-named defendants. Following a nine-day trial in September 2016, a jury found Good Shepherd was negligent in its care of O'Brien. The jury awarded plaintiffs $150, 000 in compensatory damages attributable to O'Brien's past physical and mental pain and suffering. The jury also concluded Good Shepherd's conduct was willful and wanton and awarded plaintiffs punitive damages in the amount of $750, 000. The district court subsequently denied Good Shepherd's motion for a directed verdict on the issue of punitive damages.[2] Good Shepherd moved for a new trial, judgment notwithstanding the verdict, or a remittitur of damages. The district court denied the post-trial motions and Good Shepherd appealed. Additional facts will be set forth below as are relevant to the issues raised on appeal.

         II. Jury Instructions

         Good Shepherd contends the district court erred in overruling its objections to the following four specifications of negligence in the jury instructions:

To recover damages on their claim in this case that Good Shepherd was negligent in its care of Maria O'Brien, Plaintiffs must prove . . .:
1. Good Shepherd was negligent in one or more of the following ways:
(A) Failing to assure Mrs. O'Brien urgent access to hospital and medical care as needed and failure to transfer her to an appropriate level of care in a timely manner; or
(G) Failing to abide by all applicable state and federal regulations, administrative codes, and laws in its care ...

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