Laurie Willson, RN
MS. ISAACSON: THE DEFENSE CALLS LAURIE WILLSON
STEVENSON.
THE COURT: MS. WILLSON, IF YOU'LL STEP UP, PLEASE.
IF YOU'LL COME RIGHT UP HERE. MS. WILLSON, WILL YOU RAISE
YOUR RIGHT HAND PLEASE AND FACE THE CLERK. SHE'LL PLACE YOU
UNDER OATH.
LAURIE ELLEN STEVENSON,
HAVING BEEN DULY SWORN, WAS EXAMINED AND
TESTIFIED AS FOLLOWS:
THE COURT: IF YOU'LL HAVE A SEAT UP HERE, PLEASE.
STATE YOUR FULL NAME, AND PLEASE SPELL YOUR LAST NAME.
THE WITNESS: LAURIE ELLEN STEVENSON, STEVENSON IS
S-T-E-V-E-N-S-O-N.
THE COURT: YOU MAY BE SEATED. THANK YOU.
DIRECT EXAMINATION
BY MS. ISAACSON:
Q. MS. STEVENSON, DURING DECEMBER OF 1995 AND JANUARY OF
1996, DID YOU BY ANOTHER NAME?
A. LAURIE WILLSON.
Q. AND ARE YOU PRESENTLY EMPLOYED?
A. YES, I AM.
Q. WHERE DO YOU WORK?
A. I WORK AT THE BANGOR COMMUNITY BASE CLINIC OUT OF THE
TOGUS VA IN MAINE.
Q. DID YOU SAY MAINE?
A. MAINE.
Q. YOU'LL HAVE TO KEEP YOUR VOICE UP BECAUSE YOU HAVE A
LITTLE BIT OF A SOFT VOICE.
A. I'M TRYING TO FIND THE RIGHT ANGLE ON THE MICROPHONE. IS
THAT BETTER?
Q. THAT'S GOOD.
AND WHAT DO YOU DO THERE? WHAT IS YOUR POSITION THERE?
A. I'M A NURSE PRACTITIONER.
Q. WHAT IS A NURSE PRACTITIONER?
A. NURSE PRACTITIONER IS A MID LEVEL PROVIDER, A NURSE WITH A
MASTERS DEGREE WHO CAN PROVIDE PRIMARY CARE FOR PATIENTS.
Q. AND HOW IS A NURSE PRACTITIONER DIFFERENT FROM A
REGISTERED NURSE?
A. A NURSE PRACTITIONER HAS AN ADVANCED DEGREE WITH A
SPECIALTY AREA OF PRACTICE. MY PARTICULAR AREA OF SPECIALTY
PRACTICE IS ADULT MEDICINE AND GERIATRIC MEDICINE.
Q. AT THE TIME THAT YOU WERE WORKING ON THE GEROPSYCHIATRIC
UNIT IN 1995 AND 1996, HAD YOU FINISH YOUR -- HAD YOU
ACTUALLY BECOME A CERTIFIED NURSE PRACTITIONER?
A. I WAS I THINK IN THE PROCESS OF WAITING FOR THE RESULTS
OF THE EXAM. I HAD FINISHED THE MASTER LEVEL COURSE WORK AND
FINISHING UP ON PRESENTING A THESIS. SO I THINK THE DIPLOMA
WAS ACTUALLY GIVEN TO ME IN AUGUST OF THAT YEAR.
Q. PRIOR TO YOUR WORKING ON THE UNIT, HOW LONG HAD YOU BEEN
A NURSE?
A. THAT WAS '95 GRADUATED -- SINCE 1985 SO THAT WOULD BE 10
YEARS.
Q. AND SO AT THAT TIME YOU WERE ACTUALLY A REGISTERED NURSE?
A. THAT'S RIGHT.
Q. WHEN DID YOU START WORKING AT THE DAVIS HOSPITAL?
A. SOMEWHERE IN '94, '95, SOMETHING LIKE THAT.
Q. AND DURING THIS TIME FRAME, DECEMBER, JANUARY OF 1996,
WHAT WAS YOUR USUAL SHIFT?
A. MOST OFTEN 11 TO 7, SOMETIMES 3 TO 11. I WORKED LATE
SHIFTS BECAUSE I WAS STILL DOING SCHOOL FULL TIME.
Q. SO USUALLY LATE AFTERNOON OR EVENING SHIFTS?
A. NIGHT SHIFT, MIDDLE OF THE NIGHT STUFF.
Q. WERE YOUR RESPONSIBILITIES DIFFERENT THAN THOSE WHO
WORKED DAY SHIFT?
A. DAY SHIFT PEOPLE DID A LOT OF GROUP TIME, A LOT OF
ONE-TO-ONE TIME WITH PATIENTS. AND THE RUNNING OF THE FLOOR,
MY RESPONSIBILITY WAS TO KEEP PATIENTS SAFE AND AS HEALTHY AS
POSSIBLE THROUGH THE NIGHT.
Q. DURING THIS TIME FRAME OR PRIOR TO THIS TIME FRAME, HAD
YOU HAD ANY SPECIALIZED TRAINING IN DETECTING PAIN IN A
NONVERBAL PATIENT?
A. THAT WOULD BE PART OF THE MASTER'S LEVEL TRAINING IN THE
GERIATRIC COURSES THAT I TOOK, YES.
Q. WHAT KIND OF THINGS HAD YOU BEEN TAUGHT WERE CUES OR
CLUES THAT THERE WAS PAIN IN A NONVERBAL PATIENT?
A. MOST COMMON IN TERMS OF DESCRIBING PAIN FOR OUR ELDERLY
PATIENTS WOULD BE THINGS LIKE GRIMACING, WRITHING, TENSING
AND RESISTING TOUCH, MOANING, CRYING, RESTLESSNESS,
AGITATION.
Q. WITH REGARD TO THE FIVE PATIENTS INVOLVED IN THIS CASE,
DO YOU HAVE ANY SPECIFIC RECOLLECTION OF ANY OF THE FIVE
PATIENTS INVOLVED?
A. NOTHING VERY CLEAR. I HAVE SOME MEMORY OF LYDIA SMITH AS
SOMEONE WHO I KNEW PREVIOUSLY.
Q. I'M SORRY. YOU'LL HAVE TO SPEAK UP A LITTLE BIT.
A. I KNEW LYDIA SMITH PREVIOUSLY IN A PREVIOUS EMPLOYMENT.
Q. SO YOU HAD ACTUALLY BEEN INVOLVED IN NURSING CARE FOR
LYDIA SMITH PREVIOUSLY?
A. YES.
Q. AND WHEN YOU SAW HER IN DECEMBER OF 1995, DID YOU NOTICE
ANY CHANGE IN HER CONDITION COMPARED TO HOW SHE HAD BEEN
BEFORE?
A. I BARELY RECOGNIZED HER.
Q. HOW WAS SHE DIFFERENT?
A. SHE DIDN'T RECOGNIZE ME AT ALL. SHE COULDN'T MAKE EYE
CONTACT OR COMMUNICATE WITH ME AS SHE HAD BEEN ABLE TO
PREVIOUSLY WITHIN A YEAR BEFORE THAT.
Q. NOW, YOU CARED FOR ALL FIVE OF THESE PATIENTS WHILE THEY
WERE ON THE GEROPSYCHIATRIC UNIT; IS THAT RIGHT?
A. ACCORDING TO THE RECORDS THAT I'VE SEEN, YES.
Q. AND OBVIOUSLY IT'S BEEN A NUMBER OF YEARS SINCE THE
EVENTS THAT WE'RE TALKING ABOUT TODAY SO -- WE'LL GO THROUGH
THE RECORDS AND USE THAT TO REFRESH YOUR RECOLLECTION; IS
THAT OKAY?
A. UH-HUH.
Q. WHY DON'T WE START WITH ELLEN ANDERSON. WHAT IS A
NURSING ASSESSMENT, A COMPREHENSIVE NURSING ASSESSMENT ON
THIS UNIT?
A. WE USE THE COMPREHENSIVE NURSING ASSESSMENT TO TAKE A
HISTORY OF WHAT WAS GOING ON FROM A NURSING PERSPECTIVE WITH THE
PATIENTS THAT WE'RE ADMITTING. IT'S SORT OF A BASELINE FROM
WHICH WE WOULD START CARE.
Q. AND HOW WOULD YOU PERFORM THE NURSING ASSESSMENT? HOW
WOULD YOU DO IT?
A. INFORMATION WOULD BE TAKEN FROM AS MANY SOURCES AS
POSSIBLE. THE PATIENT AS MUCH AS THEY WERE ABLE TO GIVE US
INFORMATION, FAMILY MEMBERS, IF THEY WERE PRESENT AND
RECORDS, IF RECEIVED ANYTHING FROM THE REFERRING FACILITY.
Q. WITH REGARD TO ELLEN ANDERSON, LET'S GO AHEAD AND LOOK AT
PART OF THAT NURSING ASSESS.
MS. ISAACSON: IT WOULD HAVE BEEN MARKED STATE'S
EXHIBIT 2-C AND THIS IS MED 180, COUNSEL.
Q. (BY MS. ISAACSON) IS THIS YOUR HANDWRITING HERE ON THE
DOCUMENT?
A. LOOKS LIKE.
Q. WHY DON'T WE GO TO A BLOWUP OF THIS PAGE, AND AGAIN, THIS
IS MED 180.
CAN YOU SEE THAT ALL RIGHT FROM WHERE YOU'RE SITTING?
A. LOOKS LIKE I CAN SEE IT PRETTY GOOD. AS LONG AS YOU CAN
STILL HEAR ME WHEN I TURN MY HEAD, WE SHOULD BE ALL RIGHT.
Q. SURE. SO DURING HER ADMISSION PROCESS, YOU PERFORMED
THIS NURSING ASSESSMENT AND YOU TAKE SOME NOTES HERE ABOUT
HER PREVIOUS CONDITIONS. AND, AGAIN, WHERE WOULD YOU HAVE
OBTAINED THIS INFORMATION ABOUT HIP FRACTURES, WRIST
FRACTURES ANGLE FRACTURES, SEVERE OSTEOPOROSIS AND
COMPRESSION FRACTURES?
A. THAT WOULD BE TALKING TO THE FAMILY AND LOOKING AT
PREVIOUS RECORDS MOST LIKELY.
Q. NOW, THE NURSING ASSESSMENT IS PRETTY COMPREHENSIVE, IT'S
A 12-PAGE DOCUMENT; DOES THAT SOUND RIGHT?
A. THAT'S CORRECT.
Q. LET'S GO TO THE SAME EXHIBIT, P2-C, ANOTHER PAGE OF
THIS -- PAGE 12 ACTUALLY, THE FINAL PAGE, IS THAT YOUR
SIGNATURE THERE AT THE BOTTOM?
A. YES.
Q. ONE OF THE THINGS YOU IDENTIFIED ON ADMISSION THERE'S A
PART THERE THAT SAYS EDUCATION, IS THAT RIGHT? NEEDS
IDENTIFIED FROM ASSESSMENT, EDUCATION, AT THE BOTTOM THERE.
CAN YOU SEE THAT?
A. YES.
Q. AND HERE YOU'VE INDICATED WITH REGARD TO ELLEN ANDERSON
THAT ONE NEED THAT'S IDENTIFIED IS TO TEACH PAIN MANAGEMENT
INTERVENTIONS.
A. YES.
Q. WHAT'S THE SIGNIFICANCE OF THAT NOTE?
A. VERY COMMONLY MANAGEMENT OF PAIN IS NOT ONLY THE
ADMINISTRATION OF MEDICATION BUT IT'S HELPING THE PATIENT
LEARN HOW TO MAKE THEMSELVES MORE COMFORTABLE IF THEY'RE
ABLE, TO TEACH FAMILY MEMBERS HOW TO HELP THEIR LOVED ONE BE
MORE COMFORTABLE IF THEY'RE ABLE.
Q. SO AT LEAST DURING YOUR INITIAL MEETING WITH THE PATIENT,
THE FAMILY AND LOOKING THROUGH THE RECORDS, YOU SAW A NEED TO
TEACH PAIN MANAGEMENT INTERVENTIONS?
A. THAT'S RIGHT.
Q. LET'S GO TO -- THIS IS STILL STATE'S 2-C MED 170. I SEE
HERE AN ADMIT NOTE THAT APPEARS TO BE IN YOUR HANDWRITING.
DOES THAT LOOK RIGHT?
A. THAT'S I THINK ADMISSION NURSE.
Q. SO AT THE TOP THERE IT SAYS ADMIT TO GEROPSYCHIATRY AND
I'LL BLOW UP THE TOP PART. YOU'VE INDICATED HER CONDITION ON
ADMIT IS POOR. WHAT DID YOU MEAN BY THAT OR WHAT DID YOU
MEAN BY THAT?
A. POOR GENERALLY MEANS THAT THE PATIENT IS NOT DOING VERY
WELL. IT'S A RELATIVE SCALE AND I PROBABLY WOULD HAVE
ARRIVED AT THAT IN DISCUSSING THE CASE WITH THE PHYSICIAN
WHEN I GOT THE ORDERS.
Q. LET'S GO TO THIS IS THE SAME EXHIBIT, PAGE 190. IT LOOKS
LIKE THIS IS 12/29 OF '95 AND I'LL BLOW THIS UP IN A SECOND,
BUT THIS WHOLE NOTE -- HAVE I GOT IT RIGHT, IS IN YOUR
HANDWRITING?
A. YES.
Q. AND I SEE THAT YOU'VE WRITTEN 1600 SO MAYBE 23:30?
A. THAT LOOKS RIGHT.
Q. SO DOES -- WHEN WOULD THIS HAVE BEEN WRITTEN?
A. MOST LIKELY AT THE END OF THE SHIFT. I SPENT USUALLY THE
LAST HOUR OF MY SHIFT WRITING NOTES ON THE PATIENT.
Q. AND SO WOULD THIS BE A SUMMARY OF EVERYTHING THAT HAD
HAPPENED ON THIS SHIFT?
A. PRETTY CLOSE, YEAH.
Q. THAT WOULD BE THE IDEA?
A. YEAH.
Q. AGAIN, THIS IS ON THE DAY OF ADMISSION DECEMBER 29, WE'LL
BLOW THAT UP FOR A MINUTE. YOU'VE INDICATED THAT SHE HAD BEEN
DETERIORATING OVER THE PAST THREE WEEKS?
A. THAT'S RIGHT.
Q. THAT'S WHAT HAD BEEN REPORTED TO YOU?
A. YES.
Q. AND FURTHER DOWN IS A MED NOTE AND -- LET'S GO BACK JUST
SO WHERE WE SEE WHERE THAT FITS IN THE WHOLE BIG PICTURE. I
SEE HALFWAY DOWN IT SAYS MED NOTE OVER HERE.
A. UH-HUH, THAT'S RIGHT.
Q. THEN THERE'S A SECTION HERE. WHAT IS THE SIGNIFICANCE
MED NOTE? WHAT DOES THAT MEAN?
A. WE WOULD WRITE THINGS IN THE MARGIN OF NOTES, MED NOTE
PATIENT TEACHING, THAT SORT OF THING TO DRAW ATTENTION TO
THAT PARTICULAR ITEM THAT WE THOUGHT WAS IMPORTANT TO MAKE
MENTION OF TO OTHER PEOPLE READING THE CHART TO MAKE CERTAIN
THINGS EASIER TO FIND; MEDICATIONS EXTRA THAT WERE GIVEN;
PATIENT TEACHING THAT WAS DONE THAT WAS PARTICULARLY
IMPORTANT.
Q. OKAY. AND SO ON THE NIGHT OF ADMISSION YOU MAKE A MED
NOTE AND WHAT HAVE YOU WRITTEN HERE -- DO YOU SEE THAT OKAY?
A. IT LOOKS LIKE MORPHINE 10 MILLIGRAMS I.M. AT 2000 FOR
SEVERE PAIN.
Q. WHAT'S THIS LITTLE BRACKETED AREA?
A. HARD FOR ME TO READ FROM HERE UPSIDE DOWN.
THE COURT: YOU CAN STEP OVER IF YOU NEED TO.
MS. ISAACSON: YOU'RE WELCOME TO STEP DOWN.
THE WITNESS: PATIENT BECOMES RIGID AND SCREAMS WHEN
TOUCHED.
Q. (BY MS. ISAACSON) AND THEN THE NOTE GOES ON TO SAY?
A. RELATED TO PROFOUND OSTEOPOROSIS. MS GIVEN TO PATIENT PER
ORDER DR. WEITZEL.
Q. SO THE NOTE INDICATES -- WHAT DID YOU THINK THAT THE
SIGNIFICANCE WAS OF YOU -- OF THE PATIENT BECOMING RIGID AND
SCREAMING WHEN TOUCHED? HOW DID YOU INTERPRET THAT?
A. ACTUALLY, IT'S OBVIOUSLY SOMETHING I ADDED INTO THAT LINE
OF THE NOTE TRYING TO MAKE MORE CLEAR OF WHAT MY DEFINITION
OF SEVERE PAIN FOR THAT PATIENT WAS.
Q. SO WHEN WOULD YOU HAVE WRITTEN THAT SMALLER WRITING?
A. BEFORE I SIGN ANY NOTE I READ IT OVER TO MAKE SURE I
AGREE WITH WHAT I WROTE, AND IF I NEEDED TO PUT ANY MORE IN
THERE. WE ONLY HAD DEFINED SPACE AND I TEND TO WRITE A LOT
AS YOU SEE, SO I FIT IT IN WHERE IT BELONGED.
Q. SO YOU WERE TRYING TO EXPLAIN WHAT YOU MEANT BY SEVERE
PAIN?
A. RIGHT.
Q. AND THEN FURTHER DOWN ON THIS SAME NOTE I SEE AN R, WHAT
DOES THE R MEAN?
A. GENERALLY THE FORMAT FOR THOSE NOTES R WAS RESPONSE AS IT
RESPONSE TO TREATMENT, RESPONSE TO INTERVENTIONS.
Q. AND WHAT WAS THE RESPONSE TO THE MEDICAL INTERVENTION?
A. PATIENT CALMER TWO HOURS AFTER MORPHINE INJECTION.
Q. AND THEN VERY NEEDY OF STAFF ATTENTION, SCREAMS WHEN LEFT
ALONE?
A. RIGHT. IF AWAKE.
Q. FURTHER DOWN ON THE NOTE, YOU MAKE REFERENCE TO MASTER
TREATMENT PLAN?
A. THAT'S RIGHT.
Q. PLEASE SEE MASTER TREATMENT PLAN. WHAT IS A MASTER
TREATMENT PLAN?
A. IT -- THE MASTER TREATMENT PLAN HAD INFORMATION FROM ALL
OF THE DISCIPLINES CARING FOR THE PATIENT, THE PHYSICIAN, THE
SOCIAL WORKERS, THE NURSING HAD A LARGE INPUT IN TERMS OF THE
NURSING TREATMENT PLAN FOR THE PATIENT AND THAT'S WHAT I
WOULD BE PREFERRING TO.
Q. LET'S GO FOR THE MASTER TREATMENT PLAN FOR ELLEN ANDERSON
STATE'S 2-C MED 197. SO THIS IS IN A DIFFERENT PART OF THE
MEDICAL RECORD, BUT YOU WOULD NOTE THIS IN A SEPARATE
SECTION; IS THAT RIGHT?
A. THAT'S RIGHT.
Q. AND, AGAIN, IS THIS ALL IN YOUR WRITING?
A. YES. IT APPEARS TO BE.
Q. AND AT THE TOP THERE'S A PROBLEM STATEMENT AND YOU'VE
INDICATED THAT YOU SEE ANXIETY?
A. UH-HUH.
Q. -- EXTREME AGITATION AND INCONSOLABLE CRYING AND
SCREAMING?
A. RIGHT.
Q. AND YOU ALSO NOTE THAT WEAKNESSES AFFECTING THE PROBLEM
ARE SEVERE DISABILITY OR DEBILITY?
A. THAT IS CORRECT.
Q. WHAT DOES SEVERE PHYSICAL DEBILITY MEAN?
A. SEVERE PHYSICAL CONDITION THAT LIMITS THE PATIENT'S
ABILITY TO FUNCTION.
Q. WHAT WERE THE -- I GUESS IN THIS MASTER TREATMENT
PLAN, LONG TERM GOALS WERE IDENTIFIED. AND THE GOAL WITH
THIS PATIENT WERE TO BE ABLE TO DISCHARGE HER TO A LONG TERM
CARE FACILITY, RIGHT?
A. THAT'S RIGHT.
Q. ONE OF THE SHORT TERM GOALS WAS TO DEMONSTRATE A DECREASE
IN FREQUENCY AND INTENSITY OF CRYING AND SCREAMING?
A. THAT'S RIGHT.
Q. AND THEN WE CAN KIND OF GO BACK. BUT THERE'S A SECTION
THAT'S CALLED INTERVENTIONS ON THIS SAME PAGE, RIGHT?
A. RIGHT.
Q. AND ARE THESE BASICALLY INSTRUCTIONS FOR WHAT THE NURSES
NEED TO DO OR WHAT THE STAFF NEEDS TO DO?
A. IT'S SORT OF THE MEAT OF THE TREATMENT PLAN. YOU KNOW,
YOU HAVE A PROBLEM AND YOU HAVE GOALS FOR WHERE YOU WANT TO
GO, AND THE INTERVENTIONS ARE HOW YOU'RE GOING TO GET THERE,
THE STEPS THAT YOU'LL TAKE TO HELP THAT PERSON GET TO THE
GOAL.
Q. AND SO THE INTERVENTIONS THAT YOU'VE IDENTIFIED AND THEY GO
ON BUT AT LEAST THE FIRST ONE IS TO MONITOR AND DOCUMENT
BEHAVIOR?
A. YES.
Q. AND THEN NUMBER TWO, CAN YOU READ THAT FOR THE JURY?
A. ADMINISTER MEDICATION FOR PAIN AND ANXIETY AS ORDERED AND
MONITOR EFFECTS.
Q. LET'S TALK ABOUT JUDITH LARSEN. LET'S GO TO STATE'S 3-B
MED 530. THIS IS ANOTHER PATIENT -- EXCUSE ME -- THAT YOU
WERE INVOLVED WITH ON DECEMBER 8TH, 1995 AND WITH REGARD TO
THIS PATIENT IS THIS NOTE, THE ENTIRE NOTE IN YOUR
HANDWRITING?
A. YES.
Q. AND THIS IS A SIMILAR TYPE NOTE THAT WE SAW WITH ELLEN
ANDERSON; IS THAT RIGHT?
A. MOST OF THEM FOLLOW A VERY SIMILAR FORMAT YES.
Q. SO BASICALLY A SUMMARY FOR YOUR SHIFT THAT NIGHT?
A. YES.
Q. LET'S BLOWUP PART OF THAT. WITH REGARD TO JUDITH LARSEN
ON DECEMBER 8TH, YOU'VE CHARTED ALT. THOUGHT PROCESS, WHAT
DOES THAT MEAN?
A. ALTERATION IN THOUGHT PROCESS.
Q. HOW DO YOU TRANSLATE THAT INTO LAYMAN'S TERMS?
A. THAT IT WOULD BE OUTSIDE OF WHAT WOULD BE CONSIDERED
NORMAL THOUGHT PROCESS FOR US.
Q. AND SHE IS NOT INTERACTIVE WITH HER ENVIRONMENT?
A. THAT'S CORRECT.
Q. WHAT DOES THAT MEAN?
A. AN EXAMPLE WOULD BE IF I AS THE NURSE WALKED INTO THE
ROOM, SHE WOULD NOT BE RESPONDING TO ME, NOT MAKING EYE
CONTACT, NOT TALKING TO ME, NOT RESPONDING TO THINGS THAT ARE
GOING ON AROUND HER.
Q. AND WHAT BEHAVIORS WERE YOU SEEING ON DECEMBER 8TH IN
THIS PATIENT?
A. THE NOTE DESCRIBES SELF-STIMULATION BEHAVIORS LIKE
ROCKING AND REPETITIVE SPEECH, ECHOLALIA, MOANING, CRYING.
Q. AND ITS DOES SAY THAT FREQUENTLY.
A. FREQUENTLY, YES. I CAN'T TELL IF YOU CAN HEAR ME.
Q. SO FAR YOU'RE FINE.
NOW, IN RESPONSE TO THAT -- DOES THAT SAY I?
A. YES.
Q. WITH A CIRCLE?
A. INTERVENTION.
Q. SO THE INTERVENTION YOUR RESPONSE TO THE SYMPTOMS THAT
YOU WERE SEEING IS THAT RISPERDAL AND KLONOPIN WERE ORDERED?
A. RIGHT.
Q. SO THOSE WERE MEDICATIONS -- WHAT WAS THE PURPOSE OF
THOSE MEDICATIONS?
A. THOSE MEDICATIONS HAD ALREADY BEEN ORDERED AS PART OF HER
TREATMENT, SO THEY WOULD HAVE BEEN GIVEN AS SCHEDULED. ONE
IS ANTIANXIETY MEDICATION AND THE OTHER IS ANTIPSYCHOTIC
MEDICATION.
Q. YOU ALSO NOTED IN THE SAME CHART PROVIDE A SAFE
ENVIRONMENT. WHAT'S THE IDEA BEHIND THAT?
A. IF A PATIENT IS NOT VERY RESPONSIVE TO THEIR ENVIRONMENT
THEN THEY CAN'T TRULY PROTECT THEMSELVES FROM BEING INJURED
IN SOME WAY, SO THAT IS THE RESPONSIBILITY OF THE NURSE TO
MAKE SURE THERE'S NOT SOMETHING HURTFUL THAT CAN HAPPEN LIKE
FALLING OUT OF BED OR, YOU KNOW, TWISTING THEIR ARM OR
SCREAMING AND CRYING AND BEING MASSIVELY UPSET AND NOBODY
KNOWS. IT MEANS KEEPING A CLOSE WATCH ON SOMEONE WHO IS NOT
IN A POSITION TO PROTECT THEMSELVES.
Q. IT LOOKS LIKE AFTER THE ADMINISTRATION -- ALTHOUGH
MEDICATIONS WERE ADMINISTERED THERE'S NOW AN R. THE R AGAIN,
IS THAT RESPONSE?
A. RESPONSE TO INTERVENTION, YES.
Q. SO ON THIS DATE SHE STILL REMAINS ACUTELY DISTRESSED,
THAT'S WHAT YOU'VE CHARTED?
A. THAT'S RIGHT.
Q. CRYING INCONSOLABLY IN BED?
A. YES.
Q. AND THEN WHAT DID YOU DO IN RESPONSE TO THAT?
A. IT SAYS I GAVE HER A BACK RUB FOR 20 MINUTES.
Q. AND SO YOU OBVIOUSLY -- WHAT WERE YOU TRYING TO DO WITH
THAT?
A. IT'S THOSE NONMEDICATIONS TYPES OF NURSING INTERVENTIONS
THAT I CAN DO INDEPENDENTLY TO TRY AND HELP SOMEBODY FEEL
BETTER.
Q. HOW DID SHE RESPONDS TO THE BACK RUB?
A. IT TOOK A WHILE BUT IT LOOKS LIKE AFTER AN HOUR SHE WAS
QUIETER.
Q. DID SHE STAY QUIET AND CALM ACCORDING TO YOUR NOTED?
A. ACCORDING TO THE NOTE, AFTER AN HOUR SHE WAS AWAKE AGAIN
AND CRYING.
Q. DID YOU DESCRIBE THE CRYING FURTHER THERE ON THE NEXT
LINE?
A. I BELIEVE THAT SAYS UNCONTROLLABLY.
Q. AND THEN IN RESPONSE TO THAT, WHAT DID YOU CHART? WHAT
DID YOU DO?
A. IT SAYS THAT I GAVE HER A MILLIGRAM OF ATIVAN
INTRAMUSCULARLY.
Q. SO WOULD THAT HAVE BEEN A P.R.N. SORT OF THING?
A. YES, MOST LIKELY -- DEFINITELY. I WOULDN'T GIVE ROUTINE
I.M. ATIVAN MEDICATIONS TO PATIENTS.
Q. WHAT WAS THE IDEA, WHY DID YOU GIVE HER THE ATIVAN?
A. THAT WOULD BE A NURSING ASSESSMENT AND USING MEDICATIONS
THAT WERE AVAILABLE TO US THROUGH THE DOCTOR'S ORDER TO
PROVIDE TREATMENT FOR THE PROBLEM THAT YOU SAW.
Q. HOW DID SHE RESPOND TO THE ATIVAN ACCORDING TO YOUR NOTE?
A. THAT AFTER A HALF HOUR SHE WAS MUCH CALMER.
Q. AND THEN YOU'VE MADE A NOTE THAT SHE WAS NOT ROUSED
BY SOMETHING.
A. UH-HUH. ONE HOUR LATER PATIENT IS RESTING QUIETLY, NOT
ROUSED BY 15 MINUTE NURSING CHECKS.
Q. IS THAT A GOOD THING?
A. THAT'S THE GOAL IS TO HELP HER SLEEP QUIETLY THROUGH THE
NIGHT AND NOT TO BE EASILY ABLE TO AROUSE HER AFTER WORKING
VERY HARD TO HELP HER CALM DOWN.
Q. LET'S GO TO -- THIS IS THE SAME EXHIBIT, MED 533.1 --
OKAY. THIS IS TWO DAYS LATER ON DECEMBER 10TH. AGAIN, IS
THIS ENTIRE PAGE YOUR NOTE?
A. YES. IT APPEARS TO BE.
Q. LET'S BLOW IT UP SO YOU CAN SEE IT BETTER. JUDITH LARSEN
TWO DAYS LATER, AGAIN, WE SEE THE THING YOU CHARTED BEFORE,
AN ALTERATION IN THOUGHT PROCESS.
A. THAT'S RIGHT.
Q. THEN YOU SAY PATIENT WAS SOMNOLENT MOST OF THE SHIFT,
DOES THAT MEAN SLEEPING?
A. SLEEPING.
Q. AND ON DECEMBER 10TH, IT LOOKS LIKE THE FAMILY VISITED
AND SOMETHING LENGTHY TEACHING SESSION. WHAT IS A TEACHING
SESSION WITH FAMILY? CAN YOU READ --
A. LENGTHY TEACHING SESSION WITH THIS R.N. REGARDING
PATIENT'S CURRENT MEDICATIONS.
THE COURT: SLOW DOWN, PLEASE.
THE WITNESS: I'M SORRY.
Q. (BY MS. ISAACSON) START OVER AGAIN. SO WITH THIS R.N.
A. LENGTHY TEACHING SESSION WITH THIS R.N. REGARDING
PATIENT'S CURRENT MEDICATION AND EXPECTED COURSE OF TREATMENT
DURING THIS HOSPITAL STAY.
Q. AND THEN WHAT DID THE FAMILY REPORT TO YOU ACCORDING TO
YOUR NOTE?
A. FAMILY REPORTED THEY REQUEST THAT PATIENT BE MADE
COMFORTABLE AND REQUEST THAT SHE BE MADE A D.N.R.
Q. WHY WOULD YOU HAVE UNDERLINED THAT IN THE MEMO?
A. THAT'S ONE OF THOSE VERY IMPORTANT THINGS THAT YOU WANT
TO DRAW ATTENTION TO SO THAT OTHER PEOPLE CAN FIND IT EASILY
IN THE CHART. AND THAT A WISH FOR A D.N.R. WHETHER IT'S
REPORTED TO THE NURSE OR THE PHYSICIAN IS IF IT'S DOCUMENTED
IN THE CHART, THEN THAT'S A WISH OF THE FAMILY THAT SHOULD BE
PAID ATTENTION TO.
Q. AND WHAT DID YOU -- IN THIS FAMILY TEACHING SESSION, YOU
TALK ABOUT THE MEDICATIONS THAT ARE BEING GIVE AND BASICALLY
WHAT THE PLAN IS?
A. YEAH. WE GO OVER THE MASTER TREATMENT PLAN.
Q. NOW, IT LOOKS LIKE LATER ON IN YOUR CHART YOU NOTE THAT
AT 8 O'CLOCK SHE WAS ROUSED AND BEGAN TO MOAN AND CRY.
A. YES, I SEE THAT.
Q. SO ALTHOUGH SHE WAS SLEEPING EARLIER IN THE SHIFT, AT 8
O'CLOCK SHE WAS MOANING AND CRYING?
A. THAT'S CORRECT.
Q. WHAT DID YOU MEAN WHEN YOU WROTE DOWN BE MADE
COMFORTABLE? WHAT DOES THAT PHRASE MEAN?
A. COMFORT MEASURES GENERALLY REFER TO THE RELIEF OF PAIN
AND DISCOMFORT.
Q. AND IF I UNDERSTAND CORRECTLY, THERE ARE THINGS THAT CAN
BE DONE MEDICALLY AND THERE ARE OTHER THINGS NURSES CAN DO TO
MAKE PATIENTS MORE COMFORTABLE WITHOUT MEDICATIONS?
A. THAT'S CORRECT.
Q. WE SAW AN EXAMPLE OF YOU GIVING A BACK RUB?
A. YES.
Q. WELL, SAY, FOR EXAMPLE, THAT A PATIENT WASN'T DRINKING OR
SOMETHING LIKE THAT AND HAD A VERY DRY MOUTH, ARE THERE
THINGS THAT NURSES COULD DO OTHER THAN GIVING THAT PATIENT
SIPS OF WATER TO MAKE THAT PATIENT MORE COMFORTABLE TO
MOISTEN THE MOUTH?
A. YES.
Q. WHAT KIND OF THINGS CAN A NURSE DO?
A. THERE ARE STANDARD MOUTH CARE KITS THAT ARE IN EVERY
HOSPITAL THAT I KNOW OF, THEY INCLUDE THINGS LIKE VERY LARGE
COTTON SWABS, THEY HAVE A LEMON GLYCERINE SOLUTION IN THEM,
YOU USE IT TO CLEAN OUT THE MOUTH AND SOOTH TISSUES. YOU CAN
USE JUST GAUZE SPONGES AND SOME WATER AND WIPE OUT THE DRY
MUCOUSY STUFF THAT'S VERY UNCOMFORTABLE.
Q. AND ARE THERE REASONS THAT THE PATIENT BECOMES
UNRESPONSIVE TO NOT GIVE THEM SIPS OF WATER OTHER THAN THE
REASONS FOR ADVANCED DIRECTIVES?
A. WATER IS A VERY THIN LIQUID, IT TENDS TO TRAVEL DOWN THE
AIRWAY AS EASILY AS IT TRAVELS INTO THE STOMACH. THAT CAN
CAUSE COUGHING, EXCESS PRODUCTION OF MUCOUS, DIFFICULTY
BREATHING AND A GREAT DEAL OF DISCOMFORT.
Q. THERE HAS BEEN TESTIMONY SUGGESTING THAT DR. WEITZEL TOLD
A NURSE NOT TO TAKE MEASURES -- OR NOT TO GIVE A PATIENT SIPS
OF WATER. DID DR. WEITZEL EVER TELL YOU NOT TO MAKE A
PATIENT'S MOUTH MOIST OR TO MAKE A PATIENT'S MOUTH
COMFORTABLE?
A. NO.
Q. LET'S CONTINUE ON WITH JUDITH LARSEN, STATE'S 3-B MED
582. ON DECEMBER 31ST SOME TIME HAS PASSED WITH REGARD TO
MS. LARSEN, MRS -- LARSEN FROM THE LAST NOTE.
ON DECEMBER 31ST IT LOOKS LIKE JUST THE FIRST PORTION OF
THE NOTE IS IN YOUR HANDWRITING; IS THAT RIGHT?
A. THE TOP HALF OF THE PAGE IT LOOKS LIKE.
Q. THIS IS A LITTLE BIT LIGHTER WRITING BUT YOU'VE NOTED
HERE AT THIS TIME FRAME THAT PATIENT IS GAZING AT LIGHT FROM
BATHROOM WHEN SHE'S AWAKE. WHAT WAS THE SIGNIFICANCE OF THAT
NOTE FROM YOU?
A. IT'S A BEHAVIOR THAT I COMMONLY CHART IN PATIENTS WHO ARE
DYING. IT'S PART OF THE LITERATURE WITH KUBLER-ROSS THAT
PATIENTS THAT ARE DYING WILL GAZE AT A LIGHT AND IT'S VERY
STANDARD NURSING CARE TO LEAVE A SMALL LIGHT ON IN A ROOM SO
THAT A PATIENT THAT IS DYING IS NOT LEFT ENTIRELY ALONE IN
THE DARK.
Q. NOW, ON THIS SHIFT YOU ALSO MAKE A NOTE THAT YOU GAVE TWO
SHOTS OF MORPHINE AT TWO DIFFERENT TIMES AND YOU'VE INDICATED
THAT THAT WAS FOR PAIN RELIEF?
A. THAT'S CORRECT.
Q. YOU ALSO NOTE THAT PATIENT WAS MOANING PRIOR TO THE 2:30
DOSE?
A. THAT'S CORRECT.
Q. WHEN YOU'RE ADMINISTERING MEDICATIONS, WHAT ARE YOUR
RESPONSIBILITIES AS FAR AS MONITORING A PATIENT'S RESPONSE?
A. THE IMPORTANCE IS TO MONITOR WHETHER OR NOT THE
MEDICATION WAS EFFECTIVE IN THE NURSING ASSESSMENT OF THAT
PATIENT AND TO DOCUMENT POSITIVE OR NEGATIVELY IN TERMS OF
THAT EFFECTIVENESS.
Q. SO YOU WANT TO SEE IF THE MEDICATION IS WORKING?
A. THAT'S RIGHT.
Q. LET'S GO TO JANUARY 2ND WITH REGARD TO THIS PATIENT, A
COUPLE DAYS LATER. THIS IS STATE'S 3-B MED 586 WE'LL DO A
BLOWUP OF THIS. ON THIS EVENING YOU NOTED SOME GROANING
SEVERAL MINUTES PRIOR TO THE 3:30 MORPHINE DOSE; IS THAT
RIGHT?
A. THAT LOOKS RIGHT.
Q. WE'VE TALKED ABOUT -- HOW IS GROANING DIFFERENT THAN
MOANING? IS IT DIFFERENT?
A. IN MY EXPERIENCE GROANING IS A MUCH DEEPER MORE
DISTRESSING KIND OF A SOUND.
Q. TO YOU WHAT IS THE SIGNIFICANCE OF GROANING IN THIS
CIRCUMSTANCES?
A. GROANING IS ONE OF SEVERAL NONVERBAL EXPRESSIONS OF PAIN
IN PROFOUNDLY UNRESPONSIVE PATIENTS.
Q. ON A NUMBER OF OCCASIONS, YOU GAVE -- YOU ADMINISTERED
MORPHINE TO JUDITH LARSEN, DID YOU BELIEVE IN GIVING THOSE
DOSES OF MEDICATIONS UNDER THOSE CIRCUMSTANCES THAT YOU WERE
CAUSING OR CONTRIBUTING TO THE DEATH OF JUDITH LARSEN?
A. NO.
Q. LET'S GO TO MED 477, STATE'S 3-B. AND I SEE -- THIS IS
UNDER PROGRESS NOTES. AND THE TITLE OF THIS NOTE SAYS WEEKLY
R.N. ADVOCATE NOTE, WHAT DOES THAT MEAN?
A. ALL OF US WHO ARE R.N. STAFF ON THE UNIT AT THE TIME WERE
ASSIGNED A GROUP OF PATIENTS FOR WHICH WE WERE RESPONSIBLE IN
TERMS OF THEIR TREATMENT PLAN AND COMMUNICATING TO OTHERS
ABOUT THEIR PROGRESS. THAT'S WHY THIS PARTICULAR NOTE IS IN
THE COMMON AREA OF THE CHART AND NOT ALONE IN THE NURSING
NOTES AREA OF THE CHART.
Q. SO WHO ELSE DO YOU EXPECT WILL LOOK AT THIS NOTE?
A. THE EXPECTATION IS THAT ALL OF THE OTHER MEMBERS OF THE
TREATMENT TEAM WILL LOOK AT THAT, THE PHYSICIAN, THE SOCIAL
WORKER, ANYBODY ELSE INVOLVED WITH THE CARE OF THAT PATIENT.
Q. SO ON JANUARY 2ND IN YOUR NOTE REGARDING THIS PATIENT
WHAT DO YOU SAY HERE ABOUT HER MEDICAL STATUS?
A. HER MEDICAL STATUS HAS RAPIDLY AND PROFOUNDLY
DETERIORATED THIS WEEK.
Q. AND YOU NOTE SEIZURE AND MULTIPLE EPISODES OF VOMITING
COFFEE-GROUND MATERIAL?
A. THAT'S CORRECT.
Q. AT THIS TIME SHE'S NO LONGER VERBALLY RESPONSIVE?
A. THAT'S CORRECT.
Q. AND THEN YOU SAY THE CARE PLAN HAS BEEN ALTERED TO
REFLECT THE NEED OF PATIENT AND FAMILY THROUGH A POSSIBLE
DYING PROCESS?
A. YES.
Q. SO THERE HAD BEEN A CARE PLAN IN PLACE AND NOW THAT HAS
BEEN ALTERED BASED UPON HER MEDICAL CONDITION?
A. YES.
Q. AND THEN PATIENT IS CURRENTLY RECEIVING MORPHINE I.M.,
WHAT DOES THIS MEAN, Q3?
A. EVERY THREE HOURS FOR COMFORT.
Q. LET'S SEE NOW. LET'S GO TO MED 596, STATE'S 3-B I GUESS
THIS IS THE NURSING CARE PROGRAM. THAT'S KIND REFERENCED IN
THE OTHER NOTE; IS THAT RIGHT?
A. THAT'S RIGHT.
Q. SO JANUARY 2ND, AGAIN, THE NEW PROBLEM IS COPING PATIENT
FAMILY DEATH AND DYING ISSUES?
A. YES.
Q. BLOWUP OF THIS. ON EXPECTED OUTCOMES, ON JANUARY 2ND
WHAT IS THE EXPECT THE OUTCOME FOR JUDITH LARSEN? I DON'T
KNOW HOW WELL YOU CAN READ THAT.
A. I'M GOING TO HAVE TO STEP DOWN, IS THAT ALL RIGHT?
Q. WELL, DOES IT -- YEAH, COME ON UP.
SO THE EXPECTED OUTCOME YOU'VE OUTLINED AS WHAT?
A. PATIENT WILL EXPERIENCE A PEACEFUL --
THE COURT: COULD YOU PLEASE SPEAK UP?
THE WITNESS: I'M SORRY.
THE COURT: THANK YOU.
THE WITNESS: PATIENT WILL EXPERIENCE A PEACEFUL
DEATH FREE FROM DISCOMFORT IS WHAT IT SAYS.
Q. (BY MS. ISAACSON) AND THEN THERE'S A SECTION FOR NURSING
INTERVENTIONS. WHAT DOES NURSE INTERVENTIONS MEAN?
A. THOSE MEASURES THAT WE TAKE TO HELP MEET THE GOAL.
Q. AND SO NUMBER ONE, YOU'RE GOING TO MONITOR HER?
A. YES.
Q. AND NUMBER TWO, PROVIDE COMFORT CARE OR COMFORT MEASURES
YOU INDICATE --
A. TURNING EVERY TWO HOURS.
Q. THE MOUTH CARE LIKE WE'VE TALKED ABOUT EARLIER?
A. YES. TALK WITH PATIENT WHILE PROVIDING CARE.
Q. WHAT'S THE PURPOSE OF THAT?
A. IN DYING PATIENTS IT'S A MISTAKE TO ASSUME THAT THEY CANNOT
SEE OR HEAR YOU. I THINK ONE OF THE MOST UNKIND THINGS A
PERSON CAN DO AS A NURSE IS TO SPEAK ILL OR IRRESPONSIBLY OR
IN A WAY OF IGNORING THE PATIENT WHEN YOU'RE TAKING CARE OF
THEM.
Q. THEN THERE'S SOME OTHER THINGS KIND OF ALONG THE SAME
LINES, VISITING THE ROOM FREQUENTLY, SOFT LIGHTING, THEN
THERE'S ALSO A NOTE THAT MORPHINE WILL BE ADMINISTERED FOR
PAIN?
A. THAT'S CORRECT.
Q. THEN FINALLY YOU'RE GOING TO NOTIFY THE FAMILY THAT DEATH
IS IMMINENT?
A. THAT'S RIGHT. IF THEY'RE NOT PRESENT AT THE TIME.
Q. LET'S TALK ABOUT MARY CRANE. AS WITH ELLEN ANDERSON YOU
ALSO --
THE COURT: LET'S TAKE A BREAK AT THIS TIME,
MS. ISAACSON. YOU MAY STEP DOWN, MS. STEVENSON. LADIES AND
GENTLEMEN, WE'LL BE ON BREAK UNTIL 3:20. I'LL REMIND YOU OF
MY PRIOR CAUTION.
(THE JURY EXITS THE COURTROOM.)
(A RECESS WAS TAKEN.)
THE COURT: PARTIES AND COUNSEL ARE PRESENT. THE
JURY IS IN THE JURY BOX. MS. STEVENSON IS ON THE STAND. I
REMIND YOU THAT YOU'RE STILL UNDER OATH AND YOU MAY CONTINUE
WITH YOUR EXAMINATION.
MS. ISAACSON: THANK YOU, YOUR HONOR.
Q. (BY MS. ISAACSON) LET'S TURN NOW TO MARY CRANE. YOU
ALSO PERFORMED THE NURSING ADMISSION ASSESSMENT ON THIS
PATIENT AS WELL; IS THAT RIGHT?
A. THAT APPEARS TO BE MY HANDWRITING, YES.
Q. AGAIN, THIS IS A 12-PAGE DETAILED ASSESSMENT?
A. YES.
Q. LET'S GO TO STATE'S 4B, MED 298. IT APPEARS TO BE PAGE 5
OF THAT NURSING ASSESSMENT. I'M GOING TO BLOWUP A SECTION.
AND DURING YOUR ASSESSMENT YOU'VE NOTED A FEW THINGS
THAT -- YOU HAD CIRCLED A COUPLE OF THESE ITEMS, BACK PAIN,
HISTORY OF FALLS, HIP FRACTURE, AND IS THIS FREQUENT?
A. FREQUENT FALLS, YES.
Q. AND THEN WHAT ABOUT THIS PAIN SCALE? WOULD YOU ASK THE
PATIENT TO RATE THEIR PAIN?
A. YES. IF THEY WERE ABLE TO VERBALLY RESPOND TO ME AND
MAKE SOME ESTIMATE OF THEIR PAIN. THE QUESTION IS GENERALLY
ONE BEING THE LEAST AMOUNT OF PAIN THAT YOU'VE SORT OF EVER
EXPERIENCED AND FIVE BEING THE WORSE PAIN YOU'VE EVER HAD IN
YOUR LIFE, WHERE ARE YOU RIGHT NOW.
Q. AND SO BY YOUR NOTE IT APPEARS THAT MARY CRANE RATED HER
PAIN AS A FIVE?
A. THAT'S WHAT IT SAYS, YES.
Q. TURN TO SOME OF YOUR NURSING NOTES WITH REGARD TO MARY
CRANE, THIS IS STATE'S 3-B MED 311. THIS IS A NOTE IF I CAN
READ IT FROM DECEMBER 31ST OF 1995. IT LOOKS LIKE JUST A
PORTION OF THAT NOTE IS IN YOUR HANDWRITING?
A. THAT'S MY NOTE AT THE TOP OF THE PAGE, YES.
Q. SO WITH REGARD TO MARY CRANE THERE'S A NOTE OF TRAZODONE
BEING GIVEN P.R.N., WHAT'S THE PURPOSE OF TRAZODONE? WHY
WOULD YOU HAVE GIVEN TRAZODONE?
A. TRAZODONE IS COMMONLY USED TO HELP WITH SLEEP IN ELDERLY
PATIENTS.
Q. IT LOOKS LIKE SHE HAD BEEN AWAKE MOST OF THE SHIFT?
A. THAT'S CORRECT.
Q. AND THIS IS 11 TO 7 SO THE BULK OF THE NIGHT?
A. UH-HUH.
Q. AND AT 2 A.M. YOU GAVE HER TRAZODONE?
A. YES.
Q. AND WHAT WAS HER RESPONSE TO THE TRAZODONE AND IT LOOKS
LIKE AND TYLENOL YOU GAVE HER?
A. THE PATIENT WAS ABLE TO REST QUIETLY UNTIL 6 O'CLOCK.
Q. ON THE TRAZODONE THAT WAS A P.R.N. ORDER SO SOMETHING
THAT YOU DECIDED TO GIVE IN RESPONSE TO SYMPTOMS?
A. THAT'S CORRECT.
Q. AND YOU DID NOT ADMINISTER ANY MORPHINE TO THIS
PARTICULAR PATIENT, DID YOU?
A. NOT AT THIS PARTICULAR TIME ACCORDING TO THIS NOTE, NO.
Q. DO YOU RECALL IF YOU EVER GAVE ANY MORPHINE TO MARY
CRANE?
A. I HAVE NO SPECIFIC RECOLLECTIONS WITHOUT REFERRING TO THE
RECORDS AND THE CHART.
Q. LET'S MOVE ON TO LYDIA SMITH, STATE'S 5-B AND THIS IS MED
800. IT LOOKS LIKE THIS IS JANUARY 7TH NOTE. AGAIN, JUST A
PORTION OF THE NOTE IS IN YOUR HANDWRITING, WE'LL BLOW THAT
UP SO EVERYONE CAN SEE IT.
DO YOU RECALL AT THIS TIME INDEPENDENTLY -- YOU'VE
ALREADY INDICATED WHAT YOU CAN RECALL. STRIKE THAT.
LET'S GO TO JANUARY 7TH. AT THIS TIME -- WELL, I
THINK -- I THINK WHAT I'D LIKE TO DO IS HAVE THE JURY SEE THE
DATES OF THE -- DATES OF HER STAY SO WE CAN LOOK AT WHAT
MEDICATION SHE WAS ON. SO LET'S PUT UP HER CHART AND I'LL
HAVE YOU COME DOWN. IS IT OKAY IF YOU STEP DOWN?
A. YES.
Q. WHY DON'T YOU COME DOWN.
THE COURT: 5-E? I ASK YOU MS. STEVENSON TO SPEAK
UP WHILE YOU'RE OVER THERE, IF YOU WOULD, PLEASE.
THE WITNESS: I'LL TRY.
MS. ISAACSON: TRY TO PUT THIS NOTE HERE IN CONTEXT.
THIS HERE IS STATE'S EXHIBIT 5-E AND I THINK -- HAVE YOU SEEN
THIS CHART BEFORE?
THE COURT: THAT'S A NO?
THE WITNESS: THAT'S A NO.
THE COURT: YOU'RE SAYING NO? YOU CAN'T TAKE DOWN A
SHAKE OF YOUR HEAD.
THE WITNESS: I'M LOOKING AT THAT AND LOOKING AT
THAT AND YOU IN TRYING TO MAKE A DETERMINATION IF I'VE SEEN
IT. I'VE SEEN A SIMILAR REPRESENTATION. I DON'T KNOW IF IT
WAS THIS EXACT ONE, NO.
Q. (BY MS. ISAACSON) LET'S LOOK AT LYDIA SMITH'S CHART HERE
WITH REGARD TO MEDICATIONS AND HER STAY. SO SHE'S ADMITTED
ON DECEMBER 20TH AND PASSES AWAY ON JANUARY 8TH. DOES THAT
SOUND ABOUT RIGHT?
A. THAT WOULD BE IN THE CHART.
Q. OKAY. AND WE'RE TALKING FOR THIS NOTE AT LEAST JANUARY
7TH SO THE DAY BEFORE HER DEATH?
A. OKAY.
Q. DOES THAT SOUND RIGHT?
A. YEAH.
Q. WHY DON'T YOU GO AHEAD AND WE'LL LOOK AT THIS CHART NOW
TOGETHER NOW THAT WE'VE PUT IT INTO CONTEXT FOR HER STAY. SO
JANUARY 7TH, THE DAY BEFORE HER DEATH, PATIENT RESTED QUIETLY
THROUGHOUT SHIFT.
A. YES.
Q. MINIMALLY RESPONSIVE.
A. TO A.M. CARE.
Q. AND THEN YOU MAKE A NOTE, MOST OF THE TIME NO COMBATIVE
BEHAVIOR.
A. KEEPS EYES CLOSED MOST OF THE TIME, NO COMBATIVE
BEHAVIOR.
Q. AND THEN POSTURE IS RIGID AT THAT TIME?
A. YES.
Q. IS THERE A SIGNIFICANCE TO THE FACT THAT YOU'VE NOTED
THAT MOST OF THE TIME THERE'S NO COMBATIVE BEHAVIOR?
A. SHE HAS PROGRESSED IN HER ILLNESS TO A POINT WHERE SHE'S
NO LONGER FIGHTING THE STAFF.
Q. AND IS YOUR RECOLLECTION THAT PRIOR TO THIS DATE,
ACCORDING TO YOUR RECOLLECTION OR WHAT YOU SEE IN THE NOTES,
THAT SHE WAS EXTREMELY COMBATIVE DURING MOST OF HER STAY ON
THE UNIT?
A. I WOULD ONLY HAVE NOTED NO COMBATIVE BEHAVIOR IF IT HAD
BEEN A PROBLEM BEFORE.
Q. AND THEN ON JANUARY 8TH, THE NEXT DAY WE'RE LOOKING AT
AGAIN A WEEKLY R.N. ADVOCATE NOTE LIKE WE SAW BEFORE AND THIS
IS STATE'S 5-B MED 719 -- 719. SO THIS IS ON PER LAST DAY,
WHAT DOES YOUR NOTE INDICATE ABOUT HER PHYSICAL CONDITION?
A. PATIENT'S PHYSICAL CONDITION HAS MARKEDLY DETERIORATED.
SHE IS UNABLE TO SWALLOW FOOD, FLUID OR MEDICATION. SHE'S
NOT VERBALLY RESPONSIVE TO HER ENVIRONMENT. SHE DEMONSTRATES
SOME REGRESSED REFLECTIONS, REFLEXIVE GRASPING, SNAP REFLEX,
PUPILS ARE MINIMALLY REACTIVE TO LIGHT.
Q. IT SAYS SHE'S RECEIVING MORPHINE FOR COMFORT?
A. YES.
Q. AND THE CARE PLAN HAS BEEN CHANGED TO REFLECT
PATIENT/FAMILY NEEDS AROUND DEATH AND DYING ISSUES?
A. YES. THAT'S WHAT IT SAYS.
Q. AND THAT'S THE PURPOSE AGAIN OF THIS WEEKLY R.N. NOTE?
A. THAT'S --
Q. SORRY GO AHEAD.
A. THAT'S TO SHARE THE NURSING SUMMARY OF HOW THE PATIENT IS
FROM A NURSING PERSPECTIVE WITH THE OTHER DISCIPLINES.
Q. LET'S TALK ABOUT ENNIS ALLDREDGE. LET'S GO TO STATE'S
6-B MED 69. PART OF THIS AGAIN NOTE IS IN YOUR HANDWRITING
AND IT LOOKS LIKE IT'S JANUARY 12TH OF 1996 FOR
MR. ALLDREDGE. IS THIS IN PROGRESS NOTES?
A. I CAN'T TELL BY LOOKING AT THAT FROM HERE.
Q. SO IT'S IN PROGRESS NOTES, AGAIN IS THAT THE PLACE WHERE
YOU PUT IF SO THAT OTHER STAFF CAN SEE WHAT'S GOING ON WITH
THIS PATIENT?
A. YES.
Q. SO ON JANUARY 12TH YOU NOTE YOU MAKE NOTE OF AN M.R.I.
HERE?
A. YES.
Q. HOW WOULD YOU HAVE -- WELL WHAT DOES YOUR NOTE INDICATE
HOW YOU LEARNED ABOUT THAT?
A. IT INDICATES DR. CLINGER CALLED TO REPORT EVIDENCE OF
POSSIBLE INFARCT LEFT OCCIPITAL LOBE.
Q. AND THEN WHAT DO YOU NOTE ABOUT THE PATIENT'S CONDITION?
A. PATIENT REMAINS RESTLESS, MINIMALLY RESPONSIVE EXCEPT TO
DISCOMFORT.
Q. AND THEN DR. WEITZEL HAD BEEN NOTIFIED OF THE RESULTS?
A. YES.
Q. THEN THERE'S SOME MENTION OF THE PATIENT'S DIABETES AND
CONCERNS ABOUT DEHYDRATION?
A. YES.
Q. AND THEN THE NEXT -- WELL, LET'S GO TO STATE'S 6-B MED
13. AGAIN, STILL ON JANUARY 12TH IT LOOKS LIKE IN YOUR
HANDWRITING UNDER PHYSICIAN'S ORDERS I'LL BLOW THIS UP. YOU
MAKE A NOTE TO START AN I.V. FOR MR. ALLDREDGE?
A. YES.
Q. AND IS THAT IN RESPONSE TO THE CONCERNS ABOUT
DEHYDRATION?
A. YES. AND THAT THE PATIENT WAS DIABETIC SO THE I.V. WOULD
GIVE HIM SUGAR, A SOURCE OF CALORIES.
Q. AND IS THERE ALSO AN ORDER TO TEST THE HYDRATION OF THE
PATIENT?
A. THAT'S THE CHEM 7 IS A TEST FOR ELECTROLYTES AND FLUID
BALANCE.
Q. LET'S GO TO STATE'S 6-B MED 18. JANUARY 14TH, TWO DAYS
LATER, AGAIN IN PROGRESS NOTES YOU'VE MADE ANOTHER WEEKLY
R.N. ADVOCATE NOTE. NOW, IT'S ONLY TWO DAYS SINCE THE
PREVIOUS NOTE, WHY WOULD YOU HAVE MADE ANOTHER ONE?
A. ANOTHER NURSING WEEKLY ADVOCATE NOTE?
Q. RIGHT.
A. BECAUSE THERE HAD BEEN A PROFOUND CHANGE IN THE PATIENT.
THE STANDARD WAS TO WRITE A NOTE LIKE THAT ONCE A WEEK ON
EVERY PATIENT, AND THEN AGAIN IF THERE WAS A PROFOUND CHANGE
IN THE PATIENT'S CONDITION.
Q. AND THEN AT THIS TIME TWO DAYS LATER HAD THE CARE PLAN
BEEN AMENDED? HOW DID YOU INDICATE THAT?
A. THE NOTE STATES PATIENT'S CARE PLAN HAS BEEN AMENDED TO
REFLECT DEATH AND DYING ISSUES.
Q. OF COURSE, THERE'S A NOTE HERE ABOUT THAT DR. WEITZEL HAD
WRITTEN A NOTE REGARDING THE M.R.I. RESULTS?
A. THAT'S RIGHT.
Q. THE M.R.I. RESULTS WE WERE TALKING ABOUT FROM BEFORE?
A. RIGHT.
Q. WHAT'S THE GOAL NOW WITH MR. ALLDREDGE ON JANUARY 14TH?
A. PATIENT'S GOAL IS TO EXPERIENCE A PEACEFUL DEATH FREE OF
DISCOMFORT.
Q. AND THEN YOU GO ON TO TALK ABOUT WHAT'S -- WHAT DOES THIS
SAY?
A. IT'S MORPHINE AND ATIVAN --
Q. I.M.?
A. -- I.M. ARE BEING PROVIDED EVERY THREE HOURS IT LOOKS
LIKE.
Q. WHAT ELSE DOES DID SAY ABOUT THAT?
A. TO ASSURE PATIENT'S COMFORT.
Q. AND IT SAYS AROUND THE CLOCK?
A. YES.
Q. LET'S GO TO STATE'S 6-B MED 77. JANUARY 14TH, THE SAME
DAY, THE NOTE IS MOSTLY IN YOUR HANDWRITING. I'LL BLOWUP
PORTIONS AT A TIME SO WE CAN GO THROUGH THAT.
DURING THE NIGHT SHIFT YOU NOTE HIS LEVEL OF AWARENESS
HAS BEEN PROGRESSIVELY, QUOTE, SINKING. WHAT DOES THAT MEAN?
A. A MORE CLINICAL TERM WOULD BE DETERIORATING.
Q. AND ALL FAMILIES HAVE BEEN --
A. ALL FAMILY MEMBERS HAVE BEEN PRESENT INTERMITTENTLY.
Q. YOU MAKE A NOTE AT IT LOOKS LIKE 0500 THAT A DOSE OF
MORPHINE AND ATIVAN WERE GIVEN?
A. AT 4:30.
Q. SO THERE WAS A STANDING ORDER FOR AROUND THE CLOCK FOR
COMFORT CARE BUT YOU GAVE IT EARLY BECAUSE BECAUSE WHY?
A. BECAUSE I'M ASSUMING AND LABORED BREATHING INDICATING HIS
LEVEL OF STRESS.
Q. AGAIN, THE SAME NOTE JANUARY 14TH. ON THIS DATE THERE'S
CHEYNE-STOKES RESPIRATIONS, CONTINUED WITH PERIODS OF APNEA
LASTING UP TO 30 SECONDS.
A. THAT'S CORRECT.
Q. THEN THERE WAS SUCTIONING FOR COMFORT?
A. THAT'S CORRECT.
Q. AND THEN CONTINUES TO HAVE DEEP CHEST RATTLE AS OF 6
O'CLOCK?
A. YES.
Q. IT LOOKS LIKE AT 6 O'CLOCK IN THE SAME NOTE THAT THERE
WAS A TELEPHONE ORDER BY DR. WEITZEL OF MORPHINE?
A. YES.
Q. WHAT DOES THIS LAST PART HERE THESE LAST COUPLE OF LINES?
A. FAMILY REMAINS WITH PATIENT COMFORTING HIM AND TALKING
WITH HIM ASKING HIM TO LET GO.
Q. YOU ADMINISTER MORPHINE TO JUDITH LARSEN, LYDIA SMITH,
AND ENNIS ALLDREDGE WHILE YOU CARED FOR THEM; IS THAT RIGHT?
A. YES.
Q. WHEN YOU WERE ADMINISTERING MORPHINE TO ANY OF THESE
PATIENTS, DID YOU BELIEVE THAT YOU WERE CONTRIBUTING TO OR
CAUSING THE DEATH OF ANY OF THESE PATIENTS?
A. NO.
MS. ISAACSON: I HAVE NO MORE QUESTIONS.
THE COURT: CROSS-EXAMINE.
MS. BARLOW: GOOD AFTERNOON, MRS. STEVENSON.
THE WITNESS: HELLO.
CROSS-EXAMINATION
BY MS. BARLOW:
Q. YOU SAID YOU'RE CURRENTLY IN BANGOR, MAINE, AND I'M SORRY
I DIDN'T HEAR. ARE YOU AT THE V.A. HOSPITAL THERE?
A. I'M AT THE -- I GUESS THE COMMON TERM FOR IT WOULD BE A
SATELLITE CLINIC VA IN TOGUS, MAINE.
Q. AND YOU WORKED WITH THE V.A. HOSPITALS FOR HOW LONG?
A. IT'S BEEN ALMOST EIGHT YEARS NOW.
Q. A COUPLE OF YEARS AGO YOU WERE WORKING IN ONE IN
PENNSYLVANIA; IS THAT CORRECT?
A. THAT'S CORRECT.
Q. HAVE YOU RECENTLY REVIEWED THESE HOSPITAL RECORDS THAT
YOU TESTIFIED FROM TODAY?
A. YES.
Q. THEY WERE SENT TO YOU OR MAILED TO YOU OR YOU HAD THEM IN
SOME FASHION?
A. YES.
Q. AS YOU LOOK AT MRS. ANDERSON, I THINK WE'LL DO IT A
LITTLE DIFFERENTLY THAN THEY DID BECAUSE IT'S A LITTLE EASIER
PERHAPS TO READ IF YOU'VE GOT THE RECORDS THERE IN FRONT OF
YOU. NOW WITH MRS. ANDERSON --
THE COURT: DO YOU HAVE AN EXHIBIT NUMBER?
MS. BARLOW: OH, EXCUSE ME. THAT IS -- I THINK IT'S
2-C, YOUR HONOR.
THE COURT: THANK YOU.
Q. (BY MS. BARLOW) WITH MRS. ANDERSON, YOU WERE ON DUTY
WHEN SHE CAME IN AT 4 O'CLOCK THAT EVENING, DO YOU RECALL?
YOU'D HAVE TO JUST --
A. I WILL SAY YES BASED ON RECORDS.
Q. AND YOU DON'T RECALL WHETHER -- YOU DON'T RECALL THAT HER
DAUGHTERS OR AT LEAST HER ONE DAUGHTER WAS THERE UNTIL ABOUT
7 O'CLOCK THAT NIGHT?
A. I HAVE VERY FEW INDEPENDENT RECOLLECTIONS OF THOSE KINDS
OF DETAILS.
Q. SO IF YOU LOOK AT 2-C WHICH IS THE MEDICAL RECORDS,
THERE'S A PHONE INTAKE WHICH IS PAGE 166 IN THE MEDICAL
RECORDS RIGHT AFTER THE TAB THAT SAYS ADMIT. IT'S RIGHT
CLOSE TO THE FRONT THERE. DO YOU SEE THAT?
A. WHAT ARE YOU ASKING ME FOR? I'M SORRY.
Q. MED PAGE 166. DO YOU HAVE THAT PAGE IN FRONT OF YOU?
MR. BUGDEN: WHAT WAS IT, PLEASE?
MS. BARLOW: 166.
MR. BUGDEN: THANK YOU.
Q. (BY MS. BARLOW) THE NUMBER IS DOWN IN THE BOTTOM
RIGHT-HAND CORNER.
A. OKAY. YES.
Q. OKAY. THANK YOU.
AS YOU LOOK AT THE PRESENTING PROBLEM THERE, THERE'S
NOTHING THERE THAT SAYS SHE WAS COMING IN FOR PHYSICAL PAIN;
ISN'T THAT CORRECT?
A. THERE'S A HIP FRACTURE NOTED ON THIS PAGE.
Q. AND SHE'S HAD THAT AND IT'S BEEN REHABBED, THAT SHOWS
REHAB AS WELL, DOESN'T IT? WHERE IT SAYS PRESENTING PROBLEM
IN THE MIDDLE OF THE PAGE, DEMENTIA, DIAGNOSIS FOUR YEARS,
SEVERE ANXIETY, THAT'S WHAT SHE WAS COMING IN FOR; ISN'T THAT
CORRECT?
A. ALL PATIENTS ADMITTED TO THE PSYCHIATRIC UNIT ARE
REQUIRED TO HOLD A PRIMARY DIAGNOSIS OF PSYCHIATRY REGARDLESS
OF OTHER CONDITIONS.
Q. BUT WHAT SHE CAME IN FOR WAS SEVERE ANXIETY; IS THAT
CORRECT?
A. THAT WAS THE ADMITTING DIAGNOSIS, YES.
Q. IN FACT, SHE WAS HAVING ANXIETY ATTACKS FOR THE LAST
THREE WEEKS, SUFFERING SEVERELY FROM ANXIOUSNESS, NOT
CONSOLABLE BY FAMILY, REQUIRES FAMILY SUPPORT MOST OF THE DAY
AND THEN IT SAYS FRAIL AND OSTEOPOROSIS.
DO YOU RECALL FAMILY MEMBERS TELLING YOU EVER THAT SHE
CAME IN FOR TREATMENT OF PAIN OR FOR PAIN MANAGEMENT?
A. I RECALL I WAS ASKED TO HELP HER FEEL BETTER.
Q. AND, IN FACT, THEIR MAIN PROBLEM WAS THAT SHE WAS SO
INCONSOLABLE THAT EVEN WHEN THEY WERE PRESENT SHE COULD NOT
BE CONSOLED, WAS STILL WAILING OUT FOR BARBARA EVEN WHEN
BARBARA WAS WITH HER, DO YOU RECALL THAT?
A. THAT'S CORRECT.
Q. YOU DIDN'T HAVE THE NURSING HOME RECORDS THAT SHOWED THAT
EVEN THOUGH SHE HAD HAD HYDROCODONE, SPECIFICALLY LORTAB
ORDER P.R.N. THAT SHE HAD NOT RECEIVED -- I DON'T THINK SHE
HAD RECEIVED ANY HYDROCODONE OR LORTAB DURING THE MONTH OF
DECEMBER AND SHE'D ONLY RECEIVED ONE 10 GRAM -- GRAIN DOSE OF
TYLENOL --
THE COURT: COUNSEL, ARE YOU TESTIFYING OR ARE YOU
ASKING A QUESTION?
MS. BARLOW: I WAS ASKING IF SHE RECALLED THAT.
THE COURT: ALL RIGHT. GO AHEAD.
THE WITNESS: I HAVE NO SPECIFIC RECOLLECTION OF
READING PRIOR RECORDS ON THIS PATIENT OTHER THAN WHAT I MAY
HAVE WRITTEN MYSELF IN THE RECORD.
Q. (BY MS. BARLOW) YOU DIDN'T SEE DR. WEITZEL THAT EVENING
AFTER SHE WAS ADMITTED TO THE UNIT, DID YOU?
A. I HAVE VERY FEW SPECIFIC RECOLLECTIONS OF WHOLE DAYS OR
WHOLE SHIFTS FROM THAT LONG AGO, I'M SORRY.
Q. AND YOU DON'T RECALL WHAT YOU TOLD TRACY SCHOLL WHEN THEY
SAME ON AT 11 O'CLOCK?
A. I DON'T REMEMBER TRACY SCHOLL AT ALL. I'M SORRY.
Q. YOU WROTE ON THE MASTER PROBLEM LIST THAT THE PROBLEM
HERE WAS ANXIETY; ISN'T THAT CORRECT?
A. THAT'S CORRECT.
Q. THIS WAS NOT A PAIN MANAGEMENT CLINIC; IS THAT CORRECT?
A. THAT IS CORRECT.
MS. BARLOW: SORRY TO KEEP LOOKING THROUGH, YOUR
HONOR, BUT THERE ARE QUESTIONS I WON'T ASK BECAUSE SHE
DOESN'T HAVE RECOLLECTIONS.
Q. (BY MS. BARLOW) IF YOU WOULD TURN TO 190. I BELIEVE
COUNSEL PUT THAT UP ON THE BOARD FOR YOU. IT'S THE FIRST
NURSING NOTE THAT YOU WROTE WHEN MRS. ANDERSON CAME INTO THE
UNIT.
A. I HAVE THAT.
Q. AND IT SAYS ADMITTED IN THE COMPANY OF THE DAUGHTER FROM
CARE CENTER, DETERIORATING OVER THE LAST THREE WEEKS, NOT
SLEEPING, CRYING AND SCREAMING INCONSOLABLY EVEN WHEN FAMILY
IS PRESENT. AND THEN WE'VE TALKED ABOUT THE MED NOTE.
NOW, I DON'T RECALL EVER SEEING ANYWHERE ELSE IN THESE
RECORDS THAT YOU INSERTED ANY KIND OF INSERTION LIKE YOU DID
ON THIS; THE PATIENT RIGID AND SCREAMS WHEN TOUCHED. WAS IT
COMMON FOR YOU TO INSERT SOMETHING LIKE THAT AFTER THE FACT?
A. I GUESS IT DEPENDS ON WHAT YOU MEAN BY AFTER THE FACT.
MY COMMON PRACTICE IS TO READ THE NOTE AND IF IT DOES NOT
APPEAR SPECIFIC ENOUGH, I ATTEMPT TO MAKE IT MORE SPECIFIC,
YES.
Q. BECAUSE YOU HAD INDICATED -- DID YOU TELEPHONE
DR. WEITZEL AND SAY SHE'S SCREAMING, SHE'S RIGID TO TOUCH,
WHAT SHALL I DO?
A. YOU'LL HAVE TO EXCUSE ME WHILE I REFER TO MY NOTE.
Q. THAT'S FINE.
A. IT APPEARS THAT I CALLED HIM, YES, AND REPORTED HER
CONDITION.
Q. RIGID AND SCREAMS WHEN TOUCHED, COULD THAT BE SOMEONE
WHO'S ANXIOUS AND IN A NEW CIRCUMSTANCE AND HER FAMILY'S LEFT
AND SHE DOESN'T KNOW WHO YOU ARE?
A. RIGID AND SCREAMS WHEN TOUCHED IS ALSO A PRIMARY
INDICATOR OF NONVERBAL RESPONSE TO PAIN.
Q. WELL, IS THAT THE ONLY INDICATION IT COULD BE?
A. IT WAS THE INDICATION THAT I INTERPRETED AS THE NURSE.
IT IS NOT THE ONLY CIRCUMSTANCE IN WHICH PEOPLE DO THAT, NO.
Q. DO YOU RECALL THAT YOU PUT MRS. ANDERSON INTO A SECLUSION
ROOM PRIOR TO TRACY SCHOLL COMING ON AT 11 O'CLOCK?
A. I HAVE NO PARTICULAR RECOLLECTION, NO.
Q. NOW, YOU ADMINISTERED THE MORPHINE AT 8 P.M. AND AT
APPROXIMATELY FIVE HOURS LATER AT 1 O'CLOCK IN THE MORNING ON
PAGE 191. HER RESPIRATIONS ARE VERY ERRATIC, RANGING FROM
EIGHT TO 16 HER MINUTE, HER BLOOD PRESSURE IS 70 OVER 50, AS
A NURSE WOULD THAT CONCERN YOU?
A. THIS IS NOT MY NOTE AND I CAN'T VERIFY WHETHER OR NOT
THAT WAS TRUE.
Q. NO. I'M ASKING YOU: IF THIS IS TRUE, WOULD THAT CONCERN
YOU WITH THE LOW BLOOD PRESSURE AND ERRATIC BREATHING AND
EIGHT TO 16 BREATHES PER MINUTE?
A. EIGHT TO 16 BREATHS PER MINUTE IS WITHIN NORMAL RANGE OF
BREATHING.
Q. BLOOD PRESSURE IS LOW, THE BREATHING IS ERRATIC, ALL OF
THE THINGS TOGETHER, WOULD THAT CAUSE YOU CONCERN AS A NURSE?
A. THAT WOULD SAY THAT THE PATIENT'S CONDITION HAD CHANGED.
Q. NOW EVIDENTLY, YOU CALLED DR. WEITZEL AT 8 P.M. AND GOT
THE ORDER FOR THE MORPHINE. YOU WEREN'T THERE THE NEXT
MORNING WHEN HE WAS PAGED BY TRACY SCHOLL?
A. NO.
Q. AND YOU WERE NOT PRESENT WHEN MRS. ANDERSON PASSED AWAY
AT 8:55 THE NEXT MORNING?
A. NO.
Q. GIVE YOU JUDITH LARSEN WHICH IS I BELIEVE FOUR -- I CAN'T
READ IT UPSIDE DOWN. I'LL GET IT HERE JUST ONE SECOND --
3-B. IF YOU'LL TAKE THAT -- IF YOU'LL JUST SET THAT ONE
THERE FOR NOW, I'LL TAKE IT FROM YOU. IF YOU'D TURN AGAIN TO
THE TAB BEHIND ADMIT AND IT'S MED 443.
A. OKAY.
Q. IF YOU WOULD JUST READ THROUGH THE PRESENTING PROBLEM?
A. ARE YOU ASKING ME TO READ THAT OUT LOUD?
Q. NO. JUST TO YOURSELF IF YOU WOULD, PLEASE.
A. OKAY.
Q. DO YOU SEE ANYTHING IN THERE INDICATING THAT SHE WAS
BROUGHT IN SPECIFICALLY FOR PAIN MANAGEMENT?
A. NO.
Q. AND THE MASTER PROBLEM LIST AGAIN WAS NOT ABOUT PAIN
MANAGEMENT; ISN'T THAT CORRECT?
A. I WOULD NEED TO LOOK AT IT.
Q. OKAY. IT'S 606, MED PAGE 606. IF YOU'LL LOOK BACK WHERE
IT SAYS MASTER TREATMENT PLAN THERE'S A TAB THERE, IT WILL BE
THE FIRST ONE AFTER THAT.
A. OKAY.
Q. AND THAT WAS -- SHE WAS NOT BROUGHT IN FOR PAIN. THAT
WAS NOT THE MASTER -- THAT WAS NOT THE PROBLEM THAT SHE CAME
TO THE PSYCH UNIT FOR?
A. IT'S NOT LISTED AS A PROBLEM ON THE PROBLEM LIST, NO.
Q. DID YOU LOOK AT HER NURSING HOME RECORDS THAT WERE SENT
TO THE HOSPITAL, DO YOU RECALL?
A. ALL I CAN SAY IS MY COMMON PRACTICE IS TO LOOK AT RECORDS
WHEN THEY COME. IF I HAVE THEM, I LOOK AT THEM; IF NOT, I
DON'T.
Q. DO YOU RECALL THAT WHILE AT THE NURSING HOME ANY
COMPLAINTS OF PAIN HAD BEEN TREATED WITH TYLENOL?
A. I DON'T RECALL ANY HISTORY OF ANY OF THESE PATIENTS PRIOR
TO THEIR COMING TO THE HOSPITAL WHERE I SAW THEM, NO.
Q. THEN LET'S TURN TO THE NURSE'S NOTES. NOW, 516. I
UNDERSTAND AND I RECOGNIZE THAT YOU HAD NOT DONE THE ADMIT
FOR MRS. LARSEN. IN FACT, IT APPEARS FROM 523 THAT IT WAS
LYNN LONG, DO YOU RECALL LYNN LONG ANOTHER R.N. ON THAT UNIT?
A. YES.
Q. YOU NOTICE THAT IN THE CENTER OF PAGE 516, SELF-CARE
ACTIVITY IT SAYS CIRCLE THOSE APPLICABLE AND THEN HAS PAIN
SCALE. THAT'S NOT FILLED IN?
A. I'M SORRY. I NEED TO CATCH UP TO YOU HERE.
Q. OKAY. 516 IN THE NURSING NOTES, NURSES NOTES.
A. MY NURSES' NOTES START WITH 524.
Q. I'M SORRY. THE ASSESSMENT IS IN THE NURSING NOTE -- IN
FRONT OF THE NURSING NOTES. IF YOU'D TURN TO 516. DO YOU
HAVE THAT PAGE?
A. YES.
Q. AND THE PAIN SCALE IS NOT FILLED IN. SHE DIDN'T RATE HER
PAIN, EITHER SHE OR HER FAMILY MEMBER; IS THAT CORRECT?
A. IT'S NOT FILLED IN.
Q. AND FIVE -- LET'S GO TO 523 OVER SOME OF THIS.
DISCHARGE PLANNING: HOW CAN THE STAFF HELP YOU WITH
THOSE NEEDS, PROBLEMS, EXPLAIN. SON WANTS PATIENT TO IMPROVE
AND HAVE THAT IMPROVEMENT LAST BEYOND DISCHARGE.
DO YOU UNDERSTAND THAT THAT WAS THE GOAL FOR THE FAMILY
PRIOR TO HER COMING TO THIS UNIT?
A. THAT'S WHAT IT SAYS, YES.
Q. AND IN FACT, THE GOAL OF THIS UNIT WAS TO IMPROVE
PEOPLE'S BEHAVIOR AND GET THEM BACK INTO WHATEVER THEIR
LONG-TERM CARE FACILITY WAS; IS THAT CORRECT?
A. IF THAT WAS POSSIBLE, YES.
Q. IF YOU WOULD TURN TO 533.1.
A. 533?
Q. YES. 533.1, WE HAD TO PUT ANOTHER PAGE IN THERE.
THIS IS A NOTE I BELIEVE THAT YOU WENT THROUGH WITH
COUNSEL AND I WON'T GO THROUGH IT AT LENGTH. BUT THIS IS ON
THE 10TH OF DECEMBER AND YOU WROTE THAT THE PATIENT WAS
SOMNOLENT MOST OF THE SHIFT.
A. YES.
Q. SO SHE WAS SLEEPING MOST -- AND OF THIS THE 3 TO 11
SHIFT; ISN'T THAT CORRECT?
A. THAT'S WHAT IT STATES, YES.
Q. SHE HAD BEEN RECEIVING ATIVAN FOR A COUPLE OF DAYS AND,
IN FACT, I BELIEVE WAS ATIVAN, SERZONE, RISPERDAL, TRAZODONE,
KLONOPIN, SHE HAD BEEN RECEIVING THOSE FOR SEVERAL DAYS
BEFORE THAT. DO YOU RECALL THAT?
A. I WOULD HAVE TO REFER TO THE MEDICATION RECORD, BUT IF
THAT'S WHAT THE MEDICATION RECORD STATES, YES.
Q. AND YOU AGREE THAT SERZONE, RISPERDAL, TRAZODONE,
KLONOPIN ARE ALL SEDATING MEDICATIONS?
A. THEY'RE PSYCHOACTIVE MEDICATIONS, YES.
Q. AND THEY DO HAVE A CENTRAL NERVOUS SYSTEM DEPRESSANT
EFFECT? CAN HAVE?
A. THEY CAN HAVE, YES.
Q. SO ON THE 10TH, YOU SEE HER SOMNOLENT. ON THE 11TH WHICH
IS PAGE 534 YOU WROTE, SHE'S RESTED QUIETLY THROUGHOUT THE
SHIFT -- THIS WAS THE 11 TO SEVEN YOU WOULD HOPE SHE WOULD BE
QUIET, IT'S DURING THE NIGHTTIME.
MS. ISAACSON: IS THAT A QUESTION? OBJECTION.
THE COURT: DON'T COMMENT ON THE RECORD.
MS. BARLOW: I WILL RESTRAIN MYSELF, YOUR HONOR.
Q. (BY MS. BARLOW) DO YOU RECALL THIS TIME PERIOD WITH
MRS. LARSEN THAT DURING THIS TIME PERIOD SHE WAS ON SEVERAL
MEDICATIONS, SHE BECAME SOMNOLENT, AS YOU WROTE, DO YOU
RECALL THAT?
A. I HAVE NO SPECIFIC TIME FRAME RECOLLECTIONS IN WHOLE
CASES OF PATIENTS. MY RECOLLECTION HAS TO DO WITH WHAT I'VE
WRITTEN IN THE CHART.
Q. DO YOU RECALL THAT SOME OF THESE SEDATING MEDICATIONS
WERE HELD ON THE 11TH AND 12TH OF DECEMBER?
A. IF THAT'S WHAT'S INDICATED IN THE MEDICAL RECORD, I WOULD
SAY THAT'S PROBABLY TRUE.
Q. DO YOU RECALL THAT SHE DID IMPROVE ON THE 14TH AND, IN
FACT, TO THE POINT THAT DR. WEITZEL WROTE THAT SHE HAD MADE A
MIRACULOUS RECOVERY?
A. I'M SORRY. I HAVE NO RECOLLECTION.
Q. THEN LET'S TURN TO 545 WHICH I BELIEVE IS A NOTE THAT YOU
WROTE. WOULD YOU READ -- THIS IS -- WHAT DAY THIS ON 545?
A. I'M GETTING THERE.
Q. OKAY.
A. 12/15/95 IT APPEARS.
Q. WHAT SHIFT?
A. THREE TO 11.
Q. AND WOULD YOU READ WHAT YOU WROTE THERE?
A. PATIENT IS CALM AND COOPERATIVE. SHE IS ALERT AND
ATTENTIVE TO HER ENVIRONMENT.
Q. THEN IF YOU'D GO AHEAD --
A. MAKES SOME EYE CONTACT WITH STAFF AND ATTEMPTS TO OFFER
APPROPRIATE VERBAL COMMENTS. FRUSTRATED BY EXPRESSIVE
APHASIA.
Q. AND YOUR INTERVENTION?
A. IS TO PROVIDE SAFE TREATMENT ENVIRONMENT, PROVIDE
MEDICATIONS AS ORDERED AND MONITOR EFFECTS.
Q. AND THEN IF YOU'D READ THE RESPONSE.
A. PATIENT IS MORE CALM, ATE WELL AT DINNER. ATTEMPTED TO
FEED HERSELF, COMPLIANT WITH ALL MEDICATIONS CRUSHED IN APPLE
SAUCE. INTERACTIONS WITH OTHERS ARE MORE MEANINGFUL.
Q. THEN IF YOU TURN TO 546.
A. I GO FROM 545 TO 548.
Q. I WILL HAND YOU MINE, THEN. WE'LL HAVE TO MAKE SURE THAT
THAT GETS COMPLETED.
NOW, THIS NOTE I RECOGNIZE IS NOT YOURS, BUT IF YOU WOULD
JUST WRITE -- OR WHAT DATE IS THAT?
A. IT LOOKS LIKE 12/16/95.
Q. AND WHAT TIME WAS THAT FIRST NOTE WRITTEN?
A. THAT'S 1500.
Q. AND IF YOU WOULD READ THE FIRST LINE AND THEN THE
QUOTATION FROM THE FAMILY JUST RIGHT UP HERE.
A. FAMILY: THE FAMILY STATES? OH, THAT'S A REFERENCE TO A
CONTINUED FROM A PREVIOUS PAGE?
Q. RIGHT.
A. FAMILY STATES PATIENT IS MUCH IMPROVED FROM LAST WEEK AND
HOPES THIS PROGRESS WILL CONTINUE.
Q. THANK YOU. I'LL WRITE MYSELF A NOTE SO WE CAN FIX IT.
NOW, IF YOU'D TURN TO 575.
A. OKAY.
Q. AND WHAT DATE WAS THIS?
A. IT LOOKS LIKE 12/29/95.
Q. THIS IS THE SAME TIME THAT MRS. ANDERSON CAME IN IS THAT
NOT CORRECT? YOU DON'T RECALL OKAY. THANK YOU.
THE 2200 NOTE IS NOT YOURS BUT IT SAYS PATIENT ATTENDED
GROUPS BUT SLEPT THROUGH THEM. AT 1600 PATIENT BEGAN A FIVE
HOUR CYCLE OF SEVERE EMESIS TIMES SEVEN AND DIS --
A. DIAPHORETIC.
Q. -- DIAPHORETIC -- THANK YOU -- SKIN TO TOUCH. AND THE
TEMPERATURE ROSE SLIGHTLY. DOWN AT 1900 YOU BEGAN WRITING.
WHAT DID YOU WRITE AT 1900?
A. IT SAYS PAGED DR. WEITZEL TO NOTIFY HIM OF PATIENT'S
PERSISTENT NAUSEA AND VOMITING, VITAL SIGNS STABLE,
PATIENT IS AWAKE. VOMITUS IS CLEAR TO YELLOW WITH FOOD
PARTICLES.
Q. YOU WROTE THAT. AND THEN IS THE NEXT 2000?
A. IT'S DIFFICULT TO READ WITH THE COPY AND ALL OF THAT.
IT'S SOMEWHERE BETWEEN 1900 AND 2130 WHICH IS THE FOLLOWING
NUMBER.
Q. WHAT DID YOU RIGHT AT LET'S SAY 2000 JUST FOR SAKE --
A. PAGED DR. WEITZEL AGAIN. PATIENT CONTINUES TO VOMIT.
Q. AND 2130?
A. PAGED DR. WEITZEL AGAIN. PATIENT CONTINUES TO VOMIT, HAS
BEEN N.P.O. SINCE 1730 AND THE REST I CAN'T READ.
Q. N.P.O. MEANING NOTHING PROVIDED BY MOUTH?
A. YES.
Q. YOU DIDN'T WRITE THAT DR. WEITZEL RESPONDED TO YOUR PAGE
DURING THAT TIME PERIOD DID YOU?
A. IT'S NOT ON THE NOTE, NO.
Q. DO YOU RECALL NOW WHETHER HE RESPONDED TO YOU THAT NIGHT?
A. I DON'T REMEMBER THIS INCIDENT.
Q. YOU'VE TALKED ABOUT MOANING AND GROANING AND WITH SOME OF
THESE PATIENTS THAT'S WHAT YOU SAW. NOW, IS THERE SOMETHING
OTHER THAN PAIN THAT CAN CAUSE MOANING AND GROANING?
A. THERE ARE MANY THINGS THAT CAN CAUSE MOANING AND
GROANING, YES.
Q. ON THE FIRST OF JANUARY THERE WERE NOTES THAT THERE WAS
CHEYNE-STOKES BREATHING AND APNEA AND REFLEXIVE MOTIONS. CAN
LACK OF OXYGEN CAUSE THAT KIND OF RESPONSE?
A. I REALLY COULDN'T TELL YOU AN HONEST ANSWER ABOUT THAT
RIGHT NOW.
Q. ON 587 --
THE COURT: MS. BARLOW, YOU NEED TO PICK THIS UP A
LITTLE BIT.
MS. BARLOW: I'M JUST ABOUT THROUGH WITH JUDITH
LARSEN, YOUR HONOR.
THE COURT: ALL RIGHT.
Q. (BY MS. BARLOW) AT 1530 THERE'S A NOTE --
A. I'M SORRY. DID YOU DIRECT ME TO ANOTHER PAGE?
Q. 587. OKAY. AT 1530 THERE'S A NOTE WRITTEN BY IT APPEARS
SHEILA HANSEN, MED ENTRY. CAN YOU READ THAT?
A. 1530 MED ENTRY MORPHINE I.M. WITHHELD RESPIRATION SIX PER
MINUTE, HEART RATE -- I CAN'T READ THAT -- IRREGULAR BLOOD
PRESSURE 138 OVER 72.
Q. AND AS A NURSE, A NURSE PRACTITIONER, DO YOU AGREE WITH
HOLDING MORPHINE IF RESPIRATIONS ARE DOWN SIX PER MINUTE?
A. GENERALLY IN TREATING PATIENTS WHO ARE DYING WE DON'T
COUNT RESPIRATIONS ANY LONGER.
Q. BECAUSE IF A PATIENT IS DYING, MORPHINE MAY KEEP THEM
COMFORTABLE; IS THAT CORRECT?
A. THAT'S CORRECT.
Q. IF YOU'LL TURN TO MARY CRANE WHICH IS 4-B I. BELIEVE YOU
TESTIFIED ON DIRECT THAT THERE WAS A SELF-REPORT OF PAIN YOU
KNOW SHE SAID HER PAIN WAS FIVE ON A SCALE OF ONE TO FIVE, DO
YOU RECALL THAT?
A. I RECALL THAT THAT'S WHAT'S IN THE RECORD.
Q. RIGHT, RIGHT. BUT YOU AGREE THAT SELF-REPORT BY DEMENTED
PEOPLE IS NOT ALWAYS ACCURATE; IS THAT CORRECT?
A. THE RESPONSIBILITY OF MYSELF AS THE NURSE IS TO BELIEVE A
PATIENT WHEN THEY TELL ME THAT THEY'RE IN PAIN. THE ACCURACY
OF THE REPORT CAN BE DETERMINED OVER TIME.
Q. NOW, THIS IS THE PATIENT WHO RECEIVED THE DURAGESIC
PATCH, DO YOU RECALL THAT? IT IF IT SAYS IT IN THE RECORDS;
IS THAT CORRECT?
A. THAT'S FINE.
Q. DID YOU HAVE THE NURSING HOME RECORDS TO SEE WHAT PAIN
MEDICATION SHE HAD RECEIVED PRIOR TO COMING TO THE HOSPITAL?
A. AS I SAID, I DON'T REMEMBER SPECIFIC NURSING HOME RECORDS
ON ANY PARTICULAR PATIENT.
Q. DO YOU AGREE THAT DURAGESIC IS A STRONG PAIN MEDICATION?
A. IT'S A MEDICATION USED FOR THE CHRONIC MANAGEMENT OF
PAIN, YES.
Q. DO YOU AGREE THAT IT'S A STRONG ONE?
A. THAT WOULD DEPEND ON THE DOSE.
Q. IN FACT, ISN'T IT TRUE THAT DURAGESIC IS USUALLY ORDERED
WHEN A PATIENT'S BEEN ON HIGH DOSES OF MORPHINE AND THE
MORPHINE IS NO LONGER CONTROLLING PAIN SO A DURAGESIC PATCH
IS APPLIED TO GET A CONSISTENT NONSHOT KIND PAIN?
MS. ISAACSON: OBJECTION, YOUR HONOR. THIS IS
BEYOND THE SCOPE OF THIS WITNESS'S --
THE COURT: SUSTAINED.
Q. (BY MS. BARLOW) LET'S TALK JUST BRIEFLY ABOUT LYDIA
SMITH.
MS. BARLOW: YOUR HONOR, THIS ONE IS 5-B.
Q. (BY MS. BARLOW) IF YOU WOULD TURN TO PAGE 800 WHICH IS
IN THE NURSING NOTES JUST RIGHT BEHIND THE TAB THAT SAYS
NURSES NOTES.
A. OKAY.
Q. NOT RIGHT BEHIND. IT'S A FEW PAGES --
A. DID YOU SAY 802? I'M SORRY.
Q. EIGHT HUNDRED.
A. THERE'S NO NUMBER. I THINK IT'S 800.
MS. BARLOW: MAY I APPROACH YOUR HONOR?
THE COURT: YOU MAY.
THE WITNESS: THERE IT IS, WAY OVER HERE.
Q. (BY MS. BARLOW) RIGHT IN THE CENTER. YES.
A. OKAY.
Q. YOU HAVE YOUR NOTE AT THE TOP THERE. AND IN THAT NOTE
YOU SAID RESTED QUIETLY OUT THE SHIFT THIS IS THE 11 TO 7
SHIFT, WHAT DID YOU MEAN BY POSTERIOR IS RIGID AT TIMES?
A. THAT SHE WAS TENSING ALL OF HER MUSCLES.
Q. AT THAT TIME YOU DIDN'T WRITE THAT THAT WAS PAIN, DID
YOU?
A. NO. I DESCRIBED HER BEHAVIOR.
Q. AND THEN ON 802 WHICH IS TWO PAGES OVER, THIS IS THE 8TH
OF JANUARY AND I'LL REPRESENT THAT SHE -- THAT THE NOTES
INDICATE SHE PASSED AWAY AT 12:45 IT LOOKS LIKE. AND YOU
HAVE WRITTEN A NOTE FOR THE 11 TO 7 SHIFT.
WOULD YOU READ YOUR NOTE FOR THE 11 TO 7 SHIFT ON THE 8HT
OF JANUARY, PLEASE?
A. BEGINNING ALL THE WAY THROUGH?
Q. NIGHT SHIFT, YES, PLEASE.
A. NIGHT SHIFT FREE TEXT NOTE PATIENT LYING IN BED WITH EYES
OPEN THROUGHOUT SHIFT --
THE COURT: SLOW DOWN.
THE WITNESS: SORRY -- DEMONSTRATES MUCH REFLEXIVE
GRASPING IN RESPONSE TO PHYSICAL STIMULI. UNABLE TO MAKE ANY
VERBAL RESPONSE. MORPHINE EVERY THREE HOURS I.M. AS
SCHEDULED FOR COMFORT. 2400 DOSE OMITTED DUE TO PATIENT
APPEARED IN NO ACUTE DISTRESS AT THE TIME AND NURSING STAFF
WAS ATTENDING ANOTHER DYING PATIENT AND HER FAMILY. 0300
DOSE GIVEN AT 0230, RESPIRATORY RATE 10 TO 12 APNEIC PERIODS
FROM 10 TO 20 SECONDS. LONG PERIODS OF CHEYNE-STOKES
RESPIRATIONS. AFTER 0500 RESPIRATIONS 12 TO -- OR 14 TO 16.
SLOW DEEP AND REGULAR WITHOUT WAXING AND WANING PATTERN.
Q. SO YOU HELD THE 2400 DOSE; IS THAT CORRECT --
A. YES.
Q. -- ACCORDING TO THIS RECORD? YOU HELD IT BECAUSE SHE
DIDN'T APPEAR TO BE IN ANY ACUTE DISTRESS AT THE TIME; IS
THAT CORRECT?
A. YES.
Q. AND YOU'RE ALSO CARING FOR MARY CRANE WHO WAS DYING AT
THAT TIME, DO YOU RECALL?
A. IT DOESN'T SAY WHICH PATIENT BUT IT WAS ANOTHER PATIENT
WHO WAS DYING, YES.
Q. BUT IF THE RECORDS SHOW THAT IT WAS MARY CRANE, YOU DON'T
DISPUTE THAT?
A. THAT'S CORRECT.
Q. FINALLY, MR. ALLDREDGE.
MS. BARLOW: AND THIS IS 6-B, YOUR HONOR.
Q. (BY MS. BARLOW) I WANT TO SPECIFICALLY TALK ABOUT THE
M.R.I. THAT YOU REFERENCED. IF YOU WOULD TURN TO PAGE LET ME
SEE IF I CAN GET -- I BELIEVE FROM THE RECORDS IT APPEARS THE
FIRST TIME YOU SAW HIM WAS ON THE 12TH WHICH IS PAGE 69 IN
THE NURSE'S NOTES.
A. PROGRESS NOTES?
Q. IN PROGRESS NOTES. THANK YOU. LOOKING AT THESE TOO
LONG.
YOU WROTE -- YOU INDICATED REPORT EVIDENCE OF A POSSIBLE
NEW INFARCT FROM DR. CLINGER IN THE LEFT OCCIPITAL LOBE.
A. YES.
Q. IF YOU'LL TURN BACK TO PAGE 68 AND YOU WOULD READ THE
FREE TEXT NOTE THAT STARTS ON THE BOTTOM OF PAGE 68 WHICH IS
THE 12TH OF JANUARY AT 1410. I RECOGNIZE THIS IS NOT YOUR
NOTE, BUT IF YOU COULD READ THAT FOR US.
A. THAT LAST LINE ON THE PAGE AND THEN OVER TO --
Q. LAST LINE AND THEN OVER TO THE NEXT PAGE.
A. PATIENT RETURNED FROM M.R.I. ROOM SOMETHING BY M.R.I.
PERSONNEL WHO REPORTED PATIENT REMAINS TOO AGITATED --
THE COURT: SLOW DOWN.
THE WITNESS: -- BY M.R.I. PERSONNEL WHO REPORT
PATIENT TOO AGITATED TO CONDUCT M.R.I. PATIENT'S RESTRAINT
RELEASED FOR RANGE OF JOINT MOTION PERICARE CIRCULATION
CHECK. OFFER OF H20 AND FOOD AND JUICE, PATIENT REFUSING
EVERYTHING BY MOUTH CLENCHING TEETH TRYING TO HIT STAFF
TRYING TO GET UP WITHOUT ASSIST. POSEY REAPPLIED FOR
PATIENT'S SAFETY.
Q. (BY MS. BARLOW) THEN I THINK ON DIRECT EXAMINATION YOU
TALKED ABOUT PAGE 77 WHICH WAS THE 14TH OF JANUARY IN WHICH
YOU INDICATED HE WAS SINKING, HAD LABORED BREATHING.
COULD THE GRIMACING AND LABORED BREATHING BE CAUSED BY
BREATHING PROBLEMS -- WELL, LACK OF OXYGEN?
A. IN MY EXPERIENCE I HAVE NOT SEEN BREATHING PROBLEMS CAUSE
GRIMACING IN PATIENTS.
Q. HOW ABOUT LACK OF OXYGEN? HAVE YOU SEEN THAT CAUSE
GRIMACING?
A. THAT'S NOT A SPECIFIC ENOUGH TERM I GUESS FOR ME TO
UNDERSTAND WHAT YOU MEAN.
MS. BARLOW: YOUR HONOR, I CAN SEE THAT'S ALL THAT I --
WELL, JUST ONE MORE -- NO I THINK THAT'S PROBABLY ALL.
THE COURT: THANK YOU. MS. ISAACSON REDIRECT?
REDIRECT EXAMINATION
BY MS. ISAACSON:
Q. MS. STEVENSON, WHETHER YOU WORK IN A GEROPSYCHIATRIC UNIT
OR YOU WORK IN A PAIN CLINIC, IF YOU SEE SYMPTOMS OF PAIN DO
YOU TREAT SYMPTOMS OF PAIN?
A. IF YOU'RE A NURSE TAKING CARE OF A PATIENT, NO MATTER
WHERE THEY ARE IT'S YOUR RESPONSIBILITY TO DO THE BEST YOU
CAN TO TAKE CARE OF THAT PATIENT.
MS. ISAACSON: THAT'S ALL I HAVE.
MS. BARLOW: NO FURTHER QUESTIONS, YOUR HONOR.
THE COURT: YOU MAY STEP DOWN MS. STEVE. THANK YOU
FOR TESTIFYING. MAY THIS WITNESS BE EXCUSED?
MS. ISAACSON: YES.
MS. BARLOW: NO OBJECTION.
THE COURT: YOU MAY BE EXCUSED. AGAIN, THANK YOU.