Case Title: Judy Nield v. Pocatello Health Services

Citation: 

Docket Number: 38823

State: idaho

Court: Idaho Supreme Court (civil)

Date: 2014-02-18T00:00:00Z

Document:
IN THE SUPREME COURT OF THE STATE OF IDAHO

   

Docket No. 38823-2011
JUDY NIELD, Idaho Falls, November 2012
Term
Plaintiff-Appelta
2014 Opinion No. 20

 

Filed: February 18, 2014
POCATELLO HEALTH SERVICES, INC,

Nevada corporation, d/b/a Pocatello Care and
Rehabilitation Center,

Stephen W. Kenyon, Clerk

AMENDED.

Defendant-Respondent. SUBSTITUTE OPINION

Appeal from the District Court of the Sixth Judicial District of the State of Idaho,
Bannock County. The Hon, Robert C. Naftz, District Judge

The judgment ofthe district court is vacated andthe case is remanded,
Cooper & Larsen, Chartered, Pocatello, for appellant. Javier L. Gabiola argued

Duke Scanlan & Hall, PLLC, Boise, for respondent. Keely E. Duke argued,

BURDICK, Chief Justice.

‘This is an appeal from a judgment dismissing an action wherein the plaintiff sought
damages for injuries sustained as a result of contracting certain infections. The district court
‘employed a differential diagnosis analysis and held that plaintiff's medical experts were required to
rule out possible sources of the infections, other than the defendant's care. The district court
‘determined that plaintf?'s medical experts’ opinions were inadmissible because they did not
address the other possible sources of the infections that were suggested by defendant's medical
expert, We vacate the judgment and remand for further proceedings

1 FACTUAL BACKGROUND

‘This action was filed by Judy Nield to recover damages from Pocatello Health Services,

Inc,, dba Pocatello Care and Rehabilitation Center (PCRC), due to its alleged negligence in
providing her with wound cae, which allegedly caused her to become infected with methicilin-
resistant staphylococcus aureus (MRSA) and pseudomonas aeruginosa (pseudomons), ultimately
necessitating the amputation of her lower eft leg and surgery to repair her right hip implant.

On August 21, 2007, sixty-five-year-old Niekd was taken to the emergency room at
Porteuf Medical Center PMC) for pain and swelling in her left leg and pain inher right hip. She
had hada bilateral hip replacement in 1994, and since then she had a lack of feling inher left eg,
below the knee, In 2005, she dislocated her left hip in a fal, but it went undiagnosed and she
continued ambulating by using a cane ot walker. In Apeil 2007, her pain increased tothe pont that
she began using a wheelchair. Se developed open sores on her lower left leg and a nurse visited
her home to assist with dressing changes. By August 21, Nild’s pain was so severe that she could
not get out of bed, resulting in her trip tothe emergency room. It was noted that she presented
“with worsening oozing and redness of her left lower extremity.” Upon admission, she was “placed
con contact isolation in case she had MRSA.” She was administered intravenous antibiotics and
‘wound and blood samples were collected, A laboratory report ofa sample collected on August
2007, from “WOUND, LEFT LEG" didnot reveal ether MRSA or pseudomonas.

On August 23, 2007, a physician was consulted regarding Niels cellulitis and right hip
pain, He noted that “[she as 2 fair amount of cellulitis and open blistering of her left lower
extremity” and “{s}he has much less cellulitis and open areas on the right leg but has fair amount of|
pain both laterally and anteriorly with range of motion of her hip.” The physician ondered an
aspiration of her right hip to check for infection, but noted: “Unfortunately the results of this
aspiration are going to be compromised because of starting the antibiotics. However, if we obtain a

 

considerable amount of white blood cells we can assume thatthe hip is infected.” An aspiration of
her right hip was done on August 23, 2007. The laboratory report stated that no organisms were
seen after 48 hours. Nield was discharged from the hospital on August 25, and the discharge
‘summary stated that “an aspiration ofthe ight hip showed only white blood cells but did not grow
‘any bacteria” The discharge summary ends with a handwritten note by Dr. Ryan
‘Zisnmerman—"MRSA sereen negative.”

‘That same day, Nicld was admitted to PCRC for the purpose of healing the sores on her left
Jeg so that she could undergo surgery to repair er hip implants, She hal four open wounds on her
Jower left leg that were to be treated. The wounds were on her left ankle, her let shin, the top of
her left foot, and the back of her left ealf: Upon her admission, she was not sereened for either

 

 

2
MRSA or pseudomonas.

A laboratory report of a sample collected on November 9, 2007, from “WOUND, LEFT
LEG" revealed both moderate MRSA and moderate pseudomonas. She was placed on intravenous
‘antibiotics and completed that treatment on November 25, 2007. A laboratory report of a sample
‘collected on November 27, 2007, from “WOUND, LEFT LEG” revealed light MRSA and did not
reveal pseudomonas. She was then placed on another antibiotic. On December 3, 2007, she left
PCRC because her Medicare coverage was expiring.

\ield retumed ome where she remained until March 20, 2008, when she was admitted to
PMC because of a MRSA infection in her IeR foot that had spread to her ankle bone. She was
transferred toa hospital in Utah. On April 2, 2008, Nield’s left leg was amputated below the knee
due tothe infection.

Nield filed suit against PCRC on October 1, 2009, claiming that negligent wound care and
Uunsanitary conditions at is facility violated its duty of care, resulting inthe amputation of her lez,
impairment of her mobility, and attendant physical pain and suffering. On October 8, 2010, PCRC
moved for summary judgment on the ground that Nield could not prove that the MRSA and
pseucomonas infections she contracted were caused by its negligence. PCRC supported this
‘motion with the affidavit of Dr. Thomas Coffman, a physician who was board certified in both
{intemal medicine and infectious disease.

Among other things, Dr. Coffman stated:

(@) MRSA isnot more virulent than other strains of staphylococcus.

(b) Apperson may be colonized with MRSA but not show signs or symptoms of
infection.

(© MRSA can be found in health care facilities and outside of health care

‘and long term

 

(MRSA can be transmitted in many ways, including contact with someone
‘who has an active infection, contact with Someone who is MRSA colonized
Dut not infected, contact with an object that has been contaminated with
MRSA, or breathing in droplets expelled by a MRSA carrier or infected
‘person expelled during breathing, coughing or sneezing.

(©) A resident ata skilled nursing facility such as [PCRC] can become MRSA

 

‘colonized or infected despite strict adherence to an appropriate infection
control policy.

(Wound and fluid cultures are one way to determine if a person is infected
with MRSA or pseudomonas.

(@) People may also be screened for MRSA to identify individuals who are
MRSA colonized. ... Thave not seen any records of MRSA screening for

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Ms. Nield prio to er admission to [CRC]. I note thatthe August 25, 2007
discharge summary from [PMC] includes a handwritten note that a MRSA
sereen was negative, .... However, there are no records of any MRSA
screen. ... Based upon the records, it appears Dr. Zimmerman’s reference
to a negative MRSA screen is referring to the culture taken of Ms, Nield’s
‘wound on August 21, 2007, and not an actual MRSA screening. Based on
the lack of any MRSA sereen repo, itis fair to assume that a MRSA sereen
‘was not performed. If Ms. Nicld was not screened for MRSA, it is not
possible to determine if she was MRSA colonized at the time she was
‘admitted to Pocatello Care and Rehab on August 25, 2007,

(h) Like MRSA, people may be carriers of pseudomonas aeruginosa without
showing any signs or symptoms of infection.

(Based on the records available, it is not possible to determine with a
reasonable degree of medical certainty, whether or not Ms. Nield was
MRSA or pscudomonas colonized as of the date she was admitted to

 

[PCRC}.
The August 21, 2007 wound culture does not rule out the possibility Ms.
\Nield was colonized or infected with MRSA or pseudomonas. . .. It is

possible Ms. Nield had MRSA and/or pseudomonas in her swabbed leg
‘wound, but that the culture did not grow out and identify these bacteria,
resulting ina false negative.
(&) Based upon the records available, my knowledge experience and traning, it
is not possible to determine whether or not Ms. Nicld was MRSA or
ppseudomonas colonized as of the time she was admitted to [PCRC] on
‘August 25, 2007. As such, it is not possible to determine when, where or
hhow Ms. Nield became infected with MRSA or pseudomonss.
Dr. Coffinan offered no opinion a to whether the amputation of Nicks leg was necessitated by
(MRSA or pseudomonas infections.
Nield moved to strike portions of Dr. Coffiman’s affidavit on a number of grounds,
particularly asserting that critical opinions were based on speculation. In her memorandum.
submitted in support of the motion to strike, Nield stated:

Dr. Coffiman again asserts supposition in concluding . . . “it appears” that Dr.
Zimmerman’ s reference in his discharge summary... to a negative MRSA sereen
refers to the culture taken, “and not an actual MRSA screening based on the lack
fof any MRSA sereen report.” Dr. Coffman goes on to speculate, “itis fair to
assume that a MRSA screen was not performed.” Again, Dr. Coffman speculates,
‘and does not endeavor to produce any facts to ascertain whether a screen and
cculture were done,

Dr. Coffiman goes on to conclude: “If Ms. Nield was not sereened for MRSA, itis
rot possible to determine if she was MRSA colonized at the time she was
admitted to [PCRC] on August 25, 2007.” This is again supposition and
conclusory speculation. Dr. Coffinan’s specul ‘evident by his use of "If"
indicative of his conclusory speculations.

 

  

 

4
Nid also responded to PCRC’s summary judgment motion with the affidavits of three exper
Sidney Gerber, a nursing facility expert; Suzanne Frederick, a nursing care expert; and Dr. Hugh
‘Selznick, a medical expert. Each of Nield’s experts attributed her infections to poor infection
‘control measures by the staf of PCRC.

ber submitted an a
report, In his report, he stated that nursing home operators must:

      

it, which attached and incorporated @ more comprehensive

Establish and maintain an infection control program designed to provide a system
that monitors, investigates, controls, and prevents the development and spread of
disease and infection in the facility, and for a resident to live in a safe, sanitary,

‘and comfortable environment.

Based on his review of PCRC records, as well as survey findings by the Idaho Department of

Health & Welfare (IDHW) regarding complaints against PCRC, Gerber opined that PCRC did

not comply with applicable safety and hygienic standards. Among other things, he stated:

‘According to the [IDHW] survey conducted on January 24, 2008, [PCRC] failed

to implement its own policies and procedures regarding proper wound care

technique according to accepted standards of practice to prevent the spread of

infection, Repeatedly, surveyors observed nurses failing to use proper wound

care, ie, using basic universal precautions of washing or sanitizing their hands

while providing treatment to two facility residents, one of which was admitted to

the facility with MRSA (Methicillinsesistant Staphylococcus aureus)...

Although Ms, Nield was not one of the residents surveyed, she was discharged

home on 12/3/07 with MRSA -

Frederick, the nursing care expert, submitted both an affidavit and a more comprehensive
report. The report does not appear inthe record as an attachment to her affidavit but, rather, as an
attachment to the affidavit of Nield's counsel, The report cited to PCRC’s “substandard nursing
practices regarding infeetion control,” based upon her review of PCRC’s records and the IDHW

survey, She recites:

 

 

During the inspections, surveyors observed nurses during wound care that failed
to follow professional practice standards and facility policies and procedure to
prevent infections. The facility was cited for failing to ensure residents received
proper wound care according fo accepted standard of practice in order to prevent
the possible spread of infection. According to the survey documents, nurses
repeatedly failed to wash their hands at appropriate times during the wound care
procedures and failed to follow proper precautions, including with a resident that
had MRSA, . . .The surveyor's description of the nursing staf’s actions and
breaches of the standard of care demonstrated the facility’s failure to adequately
train and supervise the nursing stafT in order to prevent the spread of infection
such as MRSA. The nurse’s failure to wash hands and failure to remove soiled
‘and contaminated gloves prior to touching items and equipment showed that the

 

 

5
nurse did not understand basic infection control principles. .. ‘The nursing staff
failed to properly communicate the condition of Mrs. Nield’s wounds to her
physician and the healtheare team. The nurses failed to document Mrs. Nield’s
‘wounds completely and accurately... The written record is an extremely
important part of communication and the failure to maintain a complete and
‘accurate record prevents the healtheare team from properly evaluating a resident's
‘needs and response to treatment.
Dr. Selznick submitted an affidavit, which attached and incorporated a more lengthy report,
dated September 11, 2009. Among other things, he stated in the report

(@) MRSA js not « community acquired staph but rather a bacteria often
‘acquired nosacomially or asa result of hospitalization. Methicillin
resistant staph is rather virulent microbe resistant to many antibiotics,
including penicilin-related met al staph present, per
08/21/07 wound cultures (cougulase negative) was a much less virulent
and more susceptible organism

(©) There is no evidence, in my opinion, to a reasonable degree of medical
certainty, that Ms. Nield had MRSA infection prior to entering [PCRC}
Objective evidence for same exists, based on her 08/21/07 left lower
extremity wound cultures which confirmed coagulase negative staph, not
MRSA, whereas subsequent cultures following. her hospitalization at
[PCRC} did grow out MRSA (11/09/07, 01/18/08, 03/13/08)

(©) The provided medical records confirmed initiation of wound care at the
Portneuf Wound Care & Hyperbaric clinic on 11/09/07 with treatment
notes in evidence through 03/2008. No wound cultures were done at
[PCRC] from 08/25/07 until a wound culture was performed at Portneut
Wound Care & Hyperbaric Clinic on 11/09/07 inital evaluation. This
wound culture grew coagulase positive staph, which was different from
the prior coagulase negative staph. Sensitivity patterns confirmed this was
4. methcilin resistant Staphylococcus aureus. Addltionally, the
11/09/07 wound culture grew moderate Pseudomonas aeruginosa,

(My detailed review of the (IDHW] Summary Statement of Deficiencies,

confirmed patient being treated in August of 2007 atthe [PCRC} for
‘wound care and “pseudomonas cults of both knees.” It is my opinion
the objectively confirmed pseudomonas infection of left lower extremity
wounds per 11/09/07 culture was indeed contracted at {PCRC]. In
audition, allegations outlined in a 02/19/08 letter to the administrator of
[PCRC}. . . confirmed, “There were four or five other residents in rooms
near the identified resident with methicillin resistant staphylococcus
‘aureus infections The findings of the investigation confirmed and
substantiated poor infection control measures by the staff.

(© I is highly unlikely, in my opinion, that Ms. Nield contacted
ppscudomonas from any other source other than trom her (PCRC]
hospitalization given aforementioned positive 11/09/07 culture results,

 

 

 

6
‘This is a very rare onganism to cause total joint infection in general, and
‘given the positive 11/09/07 wound culture for pseudomonas, it is more
Tikely than not, colonization occurred while hospitalized at [PCRC] and
ultimately led to her right hip demise. It should be noted that right hip
aspiration atthe time of her 08/21/07 admission was negative.

Prior to the hearing on is summary judgment motion, PCRC moved to strike portions of
Nicld’s affidavits. With regard to Dr. Selznick’s affidavit, PCRC sought to strike as speculative
andlor without foundation one fall paragraph, one sentence in another paragraph, and two
sentences in a third paragraph, In addition, a statement contained in 2 fourth paragraph was
sought to be stricken on the grounds of being conclusory. PCRC did not seek to strike any
portion of two medical reports Dr, Selznick had attached and incorporated into his affidavit,
consisting of approximately fifty-two pages and containing further medical opinions. PCRC
sought to strike the entirety of Frederick's affidavit as being speculative and without foundation
and one paragraph of Gerber’s affidavit on grounds of speculation and lack of foundation. PCRC
did not sock to stvike the eight-page report that Gerber attached and incorporated into his
affidavit, detailing standards applicable to nursing care facilities for controling and preventing
the spread of infectious diseases, including MRSA, and explaining how PCRC had filed to
comply with those standards. PCRC did not seek to strike any portion of Fredrick’s report ether,
‘which was submitted as an incorporated attachment to the affidavit of Nild's counsel

‘The district court, rather than dealing dircetly with the evidentiary deficiencies asserted
‘by PCRC, determined that Dr, Selznick’s entre affidavit was inadmissible under LR.E. 702
because it did “not contain the reasoning or methodology required to asist the trier of fact in
{determining whether [PCRC’s] actions were a substantial facor in [Nicld] contracting MRSA
and pseudomonas.” The court noted, however, that it did “not mean to suggest that Dr. Selznick
does not possess the knowledge, skills or qualifications to address the question of causation.”
‘Although the dstriet court mentioned the affidavits of Frederick and Girber in is memorandum
ranting summary judgment, it did not analyze either of the affidavits or rule on their
admissibility. However, in its memorandum ruling on Nield’s motion for reconsideration, the
district court erroneously stated it had conducted an analysis of those affidavits and “found
[them] to be similarly insufficient in establishing where and how [Nield] contracted MRSA and
ppscudomonas.” The district court made no mention of the reports prepared by Frederick and
Gerber.
‘The distrit court quoted LR.
to the trier of fact and is inadmissible if itis speculative, conclusory or unsubstantiated by facts
in the record. On the other hand, the court noted that if an expert's reasoning and methodology
are scientifically sound and based on a reasonable degree of medical probability, the testimony
will be of assistance tothe trier of fet and admissible.

Because Dr. Selanick’s and Dr. Coffman's opinions differed as to when and where Nield
hhad likely contracted MRSA, the district court concluded that it was dealing with a “differential
diagnosis” case, citing Weeks v. Eastern Idaho Health Services:

Differential diagnosis involved an analysis of all hypotheses that might explain
the patient's symptoms or mortality. After identif¥ing all of the potential causes
‘of symptoms, the expert then engages in a process of eliminating hypotheses in
‘order to reach a conclusion as to the most likely cause. When using differential
 CRC never offered any evidence below contradicting Ms. Niels testimony that she was
housed next, and exposed to residents with MRSA and PA.

6s
rule out PCRC’s conduct as a cause of Ms. Nield’s infections. Its patently clear
that the Distriet Court improperly granted summary judgment.

B. THE DISTRICT COURT MISAPPLIED THE SUMMARY
JUDGMENT STANDARD IN CONCLUDING MS. NIELD WAS
REQUIRED TO ESTABLISH SHE WAS NOT INFECTED AT THE
‘TIME OF HER ADMISSION; THAT HER WOUND CULTUI
DID NOT PRODUCE A FALSE NEGATIVE; AND THAT SHE
ONLY COULD HAVE CONTRACTED MRSA AND PA AT PCRC.

 

 

 

‘The District Court required Ms. Nield to establish proximate cause, by
cstablishing that she may have been a carrier of MRSA and PA but was not
infected at the time of her admission; requiring Ms. Nield to show why the wound
culture would not have produced a false negative; and requiring Ms. Nield to
show she could only have contracted MRSA and PA while admitted at PCRC’s
facility. R.,p. 1235. The District Court committed reversible error, as it failed to
follow the substantial factor test.

It is well-settled that the “question of proximate cause is one of fact and
‘almost always for the jury.” Cramer v, Slater, 146 Idaho 868, 875, 208 P.3d 508,
515 (2009). ‘The District Court misapplied Ms. Nield’s burden to establish that
jury question. Ms. Nield was not required to establish proximate cause by
showing that she only contracted MRSA and PA from PCRC; rather, Ms. Nield
‘need only establish proximate cause, through a chain of circumstances, that
PCRC’s actions and omissions were a substantial factor in bringing about her
injuries. Coombs ¥. Curnow, 148 Idaho 129, 140, 219 P3d 453, 464 (2009)
[Emphasis added]; Weeks v, BIRMC, 143 Idaho 834, 839, 153 P.3d 1180, 1185
(2007). Proximate cause “ean be shown by a ‘chain of circumstances from
which the ultimate fact required to be established is reasonably and naturally
inferable.”” Weeks, supra, 143 Idaho at 839, 153 P.3d 1185, citing, Sheridan,
supra, 135 Idaho at 785, 25 P.3d at 98 [Emphasis added}

‘Additionally, the District Court ignored the substantial factor test when it,
improperly, concluded that Ms. Nield may have been a carrier and not infected
when she was admitted to PCRC and the testing done by PMC may have
produced a false negative. Apparently, the District Court accepted Dr. Coffinan’s
speculation Ms. Nield may have been a carrer, based on the lack of screening.
What is patently erroneous is that the District Court accepted this from Dr.
Coffman, despite the fact that he admitted it was not the standard of care to do
any sereening. R., p. 212; Tr, p. 29, L. 14 to p. 30, L. 3. The District Court
further accepted Dr. Coffman's unfounded conclusion that not all of the wounds
were cultured and that Ms, Nield may have gotten MRSA or PA from visitors
Again, those are inferences to which PCRC, as the movant, was not allowed under
the summary judgment standard. Additionally, the record does not support those
inferences, since Dr. Coffman did not do the testing, and speculated about the test
results, The record is appropriately silent on the testing done by PMC. ‘There
no dispute PMC tested Ms, Nield for MRSA and PA, that it was proper and that
she was negative for both MRSA and PA.

 

 

 

 

 

 

o
THE DISTRICT COURT COMMITTED ERROR IN
MISAPPLYING THE SUBSTANTIAL FACTOR TEST BY
CONCLUDING MS. NIELD'S EXPERTS DID NOT ADDRESS
WHEN, WHERE OR HOW SHE GOT MRSA AND PA AND BY
REQUIRING MS NIELD'S EXPERTS TO RULE OUT OTHER
FACTORS THAT COULD HAVE BEEN A SUBSTANTIAL
FACTOR IN CAUSING HER TO CONTRACT MRSA AND PA.

‘The District Court erroneously decided, after weighing Dr. Selznick’s, Mr
Gerber’s and Ms. Frederick's affidavits, that Ms. Nield did not establish a genuine
issue of material fact, The District Court not only improperly weighed those
affidavits and assessed their credibility, it also misapplied the substantial factor
test. The record shows that Ms. Nield established a chain of circumstances and
‘met the substantial factor test.

1, Standard for expert testimony.

Idaho Rules of Evidence 702 and 703 govern the admissibility of expert
testimony, Rule 702 provides as follows:

 

If scientific, technical, or other specialized knowledge will assist
the trie of fact to understand the evidence or to determine a fact in
issue, a witness qualified as an expert by knowledge, skill,
‘experience, training, or education, may testify thereto in the form
of an opinion or otherwise.

Rule 703 provides, in pertinent part, as follows:

‘The facts or data in the particular case upon which an expert bases
tan opinion o inference may be those perceived by or made known
to the expert at or before the hearing. If ofa type reasonably relied
upon by experts in the particular field in forming opinions or
inferences upon the subject, the facts or data need not be
admissible in evidence in order for the opinion or inference to be
admitted.

Expert testimony in medical malpractice eases is admissible when:

*[T]he expert is qualified expert in the field, the evidence will be
of assistance to the trier of fact, experts in the particular field
‘would reasonably rely upon the same type of facts relied upon by
the expert in forming his opinion, and the probative value of the
‘opinion testimony is not substantially outweighed by its prejudicial
effect.”

 

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Coombs, supra, 148 Idaho at 140, 219 P.3d at 464 (quoting, Ryan v. Beisner, 123
Idaho 42, 47, 844 P.2d 24, 29 (CL App. 1992)). Admissibility of an expert's
pinion “depends on the validity of the expert’s reasoning and methodology,
rather than his or her ultimate conclusion.” ld. Moreover, where an expert's
reasoning or methodology is scientifically sound and “based upon a “reasonable
‘degree of medical probability” and not a mere possibility, such testimony will
assist the trier of fact. See, Bloching v. Albertson's, Inc., 129 Idaho 844, 846-47,
934 P.2d 17, 19-20 (1997) (quoting, Roberts v. Kit Mfg, Co. 124 Idaho 946, 98,
1866 P2d 969, 971 (1993 )).

‘In Weeks, supra, a medical malpractice case, this Court held that a district
court erred in granting summary judgment, when the district court excluded
‘expert testimony. This Court reasoned that where the expert based his opinions
on his experience and research, and made inferences from facts known to him, it
‘was reversible error to grant summary judgment. Weeks, supra, 143 Idaho at 839-
40, 153 P.3d at 1185-86. Also in Weeks, this Court followed the well-settled
principle that to survive summary judgment, the plaintiff does not need to rule out
all factors, but only needs to establish proximate cause by showing, through a
chain of circumstances, the defendant's actions and omissions were a substantial
factor in bringing about the injuries. Id, 143 Idaho 834, 839, 153 P.3d 1180,
1185 (2007). the [sic] District Cour, like the one in Weeks, committed reversible
error in weighing and assessing the credibility of Dr. Selznick’s, Mr, Gerber's and.
‘Ms. Frederick's opinions and ignoring other admissible facts

 

 

2. Ms. Nield submitted admissible expert opinions and other
evidence, thereby satisfying the substantial factor test.

‘The District Court acknowledged that Dr. Selznick was qualified to
provide expert testimony. Despite making that finding, the District Court stated
Dr. Selznick could not offer opinions that will assist the jury. R., p. 1236. To the
‘contrary, the record shows Dr. Selznick’s opinions are admissible under Coombs
and Weeks, such that Ms. Nield met the substantial factor test. First, Dr. Selznick
relied upon facts that other experts rely upon; that is, he reviewed Ms. Nield’s
‘medical records, including her negative test results in August of 2007, and the
positive results taken after her admission in November, 2007; he reviewed the
DHW records establishing PCRC’s failure to follow infection prevention
protocols; he reviewed PCRC's records of its treatment, or lack thereof, of Ms.
Nield: and he reviewed the DHW records to find that PCRC was housing MRSA.
and PA infected residents. R., pp. 1047-1089. Based on his experience and
research, like the expert witness in Weeks, Dr. Selznick properly concluded Ms.
\Nield contracted MRSA and PA due to PCRC’s actions and omissions. Again,
Ms. Nield does not have to establish she only could have contracted MRSA or PA

 

 

 

 

 

 

 

“In Bloching, this Cour disallowed a physician's testimony that was “possible” and not based
upon a reasonable degree of medical probability.” I, 129 Idaho at $46, 94 P24 a 19. Dr.
‘Schack based his opis ona resonable degree of medial certainty (Rp. 1043; p, 1061-68).
Further, Ms. Fredrick based her opinions toa reasonable degree of nursing certainty (Rp. 649).
Finely, Mr. Gerber based his opinions ona reasonable degree of certainty (Rp. 1106),

1
from PCRC, only that PCRC’s conduct was a substantial factor in causing her
injuries. Dr. Selznick’s opinions establish Ms. Nield’s (sic) met that test, and, at
the very least, raised genuine issues of material fact.

“Additionally, the District Court misconstrued its role in deciding the
motion for summary judgment. The District Court mistakenly determined it was
acting as a “gate keeper” a role associated with Daubert, It is well-established
that Idaho has not adopted Daubert. Weeks, supra, 143 Idaho at 838, 153 P-3d at
11845 See also, Swallow v. Emergency Med. of Idaho, 138 Idaho 589, 595 m1, 67
3d 68,74 (2003); State v. Merwin, 131 Kdabo 642, 646, 962 P.2d 1026, 1030
(1998), LE, 702 and 703 are the standards by which a court isto determine the
‘admissibility of an experts opinions. The District Court misapplied LR.E. 702
and 703 by trading the “methodology” or “reasoning” element a physician would
use, ie review medical records, performing research and basing an opinion on
experience with the unfounded speculations of Dr. Coffman, that Ms. Nield may
have been a carrier but was not infected, and that her wound culture may have
been a false negative. LR.E. 702 and 703 only required Dr. Selznick, Mr. Gerber
‘and Ms, Frederick to apply theit experience and review of records to satisfy the
‘methodology element of the rule, which they all did.

‘Also, the District Court misconstrued the substantial factor test in
requiring Ms. Nield to show she could only have contracted MRSA and PA from,
PCRC. Presumably, the District Court got this from this Court's decision
Weeks, where the Court stated the following dicta in relation to a differenti
diagnosis case:

 

   

‘The Ninth Circuit allowed for the use of differential diagnosis
‘under Daubert 1 establish reliability of an expert’s opinion,
(Clausen, 339 F.3d at 1057-58. Differential diagnosis involves an
analysis of all hypotheses that might explain the patient's
symptoms or mortality. Id, After identifying all of the potential
‘causes of symptoms, the expert then engages in a process of
climinating hypotheses in onder to reach a conclusion as to the
‘most likely cause. cd. When using differential diagnosis a district
‘court is justified in excluding the experts testimony if the expert
fails to offer an explanation why an alternative cause is ruled out,
Md,

   

Weeks, supra, 143 Wdaho at 849, 153 P.3d 1185. This is not a differential
diagnosis ease, and Ms, Nild was not required to eliminate any other causes and

* As this Cou in Weeks, supra, 143 Kaho at 838,153 Pd at 1184, tated,

“The Court has not apie the Dauber standard for admissibility ofan expert's testimony but has
ted some of Danber' standards in assessing whether the basis of an expers opinion is
Scientifically vali. See Swallow v- Emergency Med. of ldcho, 138 Idaho S89, 595 nl, 67 P34 68,
74 (2005) (his Court has not adopted the Davbert tet for admissbii”), The Daubert
‘Handards of wheter the theory canbe tested and wheter it has been subjected to peer-review and
publication have been applied, bu the Court has not adopted the standard that a theory must be
‘Sommonly agreed ypon or gencraly accepted.”

n
show that she could only have gotten MRSA and PA from PCRC. Instead, as this
Court stated, Ms. Nield only needed to show proximate cause, “[bly a ‘chain of
circumstances from which the ultimate fact required 10 be established is
reasonably and naturally inferable.” Weeks, supra, 143 Idaho at 849, 153 P.3d
1185, (quoting, Sheridan v. St Luke's Reg'l Med. Ctr., 138 Wdabo 775, 785, 25
P.3d 88, 98 (2001)).

The District Court improperly weighed the evidence when it discounted
the opinions of Mr. Gerber and Ms. Fredericks, as well as Ms. Nield’s own
‘observations establishing the “chain of circumstances” sufficient to defeat
summary judgment. Mr, Gerber and Ms. Frederick concluded, from their review
of all of the medical records, state and federal regulations, PCRC” s own records
and the reports from DHW, that Ms, Nield contracted MRSA and PA due to
PCRC’s failure to follow infection control. R., pp. 640-653; pp. 1096-1106. Mr.
Gerber and Ms. Frederick also concluded PCRC failed 10 adequately train its
medical care providers, and failed to provide an adequate number of staf, which
resulted in Ms. Nield contracting MRSA and PA from PCRC.

It must be remembered that Ms, Nicld’s doctors required PCRC to
perform daily wound assessments. PCRC did not comply. PCRC did them
‘weekly and also ineompetently as they failed to properly document the size of the
‘wound, what the wound looked like, and any other identification of the wound
the skin assessments/uleer sore sheets. PCRC completely stopped documentation
‘of two of the wounds on September 18, 2007, and the largest wound on October
22, 2007, a few weeks prior to Ms. Nield testing positive for MRSA and PA. R.,
1p. 603-639; pp. 648.653; p. 678; pp. 1027-1029; pp. 1095-1097; pp. 1098-1106.
Furthermore, PCRC was found to be in violation of state and federal standards by
DHW on January 24, 2008, DHW found that the staff at PCRC could not
demonstrate proper infection control policies and procedures when handling
patients that had MRSA. R., pp. 671-673; p. 750; pp. 923-927; p.931. All of Ms.
Nield’s experts — Dr. Selznick, Ms. Frederick and Mr. Gerber considered these
facts in reaching their respective opinions.

‘Additionally, there was undisputed evidence Ms. Nield was housed in a
room next to a resident that had MRSA and that another resident was infected
with PA. R., p. 9215 p. 9315 p. 973. Ms. Nield also testified that she witnessed
nurses exiting the MRSA patient's room without any gloves on or washing their
hands. R., pp. 971-72. These facts are sufficient to preclude summary judgment,
1s they establish the chain of circumstances that may lead a jury to conelude Ms.
Nield was infected with MRSA and PA due to PCRC’s conduct and omissions.
The reconds estab
resolve, not the

 

 

 

 

  

D, MS. NIELD IS ENTITLED TO ATTORNEY'S FEES AND COSTS:
ON APPEAL.

Ms. Nield is entitled to attomey’s fees and costs under Idaho Code §12-

121 and Idaho Appellate Rules 40 and 41. Idaho Code § 12-121 and LAR. 41
allow for the award of attorney's fees and costs in a civil action where a matter

B
‘was defended frivolously, unreasonably and without foundation, TLA.R. 40 allows.
for the award of costs to the prevailing party on appeal. Ms. Nield submits that
PCRC was clearly not entitled to summary judgment, and that the District Court’s
‘grant of summary judgment was unreasonable and without foundation. This ease
is, unequivocally, the epitome of a case that should have been presented to the
jury for resolution, not the District Court. For these reasons, Ms. Nieldis entitled
‘to an award of attorney's fees and costs on appeal.

CONCLUSION
Based on the foregoing, Ms. Nield respectfully requests that the Court

reverse the District Court's grant of summary judgment, and remand the ease 10
the District Court for further proceedings.

”
HORTON, J, dissenting,

| entirely concur with the legal reasoning contained in Justice Fismann’s dissent. I write
separately because I am unable-perhaps itis more accurate to say that 1am unwilling-to reach
Justice Bismann’s conclusion as to our colleagues’ motives, Le. that the majority’s decision is
“based solely upon whom they want to win or lose” and that the majority’s description of our
holding in Weeks v. E. Idaho Health Servs, 143 Idaho 834, 153 P.3d 1180 (2007) is motivated
by a desire “to find @ way to reverse the distret court so that Ms. Nield can prevail in this
action.” Thus, I would characterize the majority's description of the perceived limitations of
Weeks as “mistaken” of “inaccurate,” rather than suggesting that the majority is deliberately
“untruthful.” In my view, the majority's error is not the product of a preference for one party
‘over the other; rather, the majority's error isa failure to observe the limitations upon an appellate
‘court when reviewing a tial court's discretionary decision.

The majority correctly states and applies our rule that the determination of the
admissibility of evidence offered “in support of or in opposition to « motion for summary
Jjudgment is a threshold question to be answered before applying the liberal construction and
reasonable inferences rule to determine whether the evidence is sufficient to create a genuine
issue for tral" JLU-B Engineers, Ine. v. Sec. Ins. Co. of Hariford, 146 Kdaho 311, 314-15, 193
P.3d 858, 861-62 (2008) (citing Gem State Ins. Co. v. Hutchison, 145 daho 10, 13, 175 P34
172, 175 (2007). However, although the majority correctly states the standard of review
governing this threshold question of the admissibility of evidence, I believe that it has failed to
apply that standard in deciding this case

[Before turning to the somewhat mechanical process of applying the standard of review of
discretionary decisions, I think that a few words about the nature of discretionary decisions are in
fonder, A discretionary decision is one where reasonable people may consider the facts and
applicable law and reach differing conclusions. Thus, in the context of sentencing—another
discretionary function exercised by trial courts—this Court has stated “where reasonable minds
‘might differ, the discretion vested in the trial court will be respected, and this Court will not
supplant the views of the trial court with its own.” State v. Windom, 150 Wdaho 873, 875, 253
P.3d 310, 312 Q2011) (quoting State ». Broadhead, 120 Idaho 141, 145, 814 P-2d 401, 405
(1991), overruled on other grounds by State v. Brown, 121 Idaho 385, 825 P.24 482 (1992))

15
 

‘This characterization of diseretionary deci
‘encyclopedia of American law explains, “[a] determination that atrial court abused its discretion
involves far more than a difference in judicial opinion.” 5 Am. Jur. 2d Appellate Review § 623
(2007) (citing Saffian v. Simmons, 727 N.W.2d 132, 135 (Mich. 2007)). The preeminent legal
dictionary provides a simil “Judicial and legal diseretion. These terms are applied
to the discretionary action of a judge or court, and mean discretion bounded by the rules and

8 is scarcely unique to this state. As an

 

   

dseripti

 

principles of law, and not arbitrary, capricious, oF unrestrained. It is not the indulgence of a
judicial whim, but the exercise of judicial judgment....” Black's Law Dictionary 419 (Sth ed
1979),

‘Our recognition that there are categories of judicial decisions broadly falling under the
rubric of discretionary decisions for which there may be more than one “right answer” has led
this Court to focus on the process, rather than the result, when reviewing a trial court's decision
‘ona matter committed to its diseretion. Thus, this Court has state:

We have long held that the appellate court should not substitute is discretion for
that of the tial court. Implicit inthis principle is the truism that the appellate court
should not simply focus upon the results of a discretionary decision below, but
rather upon the process by which the trial court reached its discretionary decision.

Quick v. Crane, 111 Idaho 759, 772, 727 P.2d 1187, 1200 (1986).

As the intensity of Justice Eismann’s dissent suggests, whether evidence should or should
not be admitted can be the object of substantial disagreement between reasonable people
Perhaps ths isthe reason that this Court has frequently stated thatthe trial courts have “broad

discretion” in deciding whether oF not evidence is ad

 

ible. Sve, e.g, Warren v. Sharp, 139
[dlaho $99, 605, 83 P.3d 773, 779 (2003) (citing State v. Howard, 135 Kdaho 727, 731, 24 P3d
44, 48 (2001)). Given the extensive discussion of the decision by both the majority and Justice
Eismann, itis worth noting that Weeks explicitly recognized that this “broad diseretion” extends
to the determination of the admissibility of expert testimony. Weeks, 143 Idaho at $37, 153 P.3d
at 1183 (citing Warren, 139 Idaho at 605, 83 P.3d at 779),

It is against this backdrop that I turn to the standard of review which (I feel obligated to
reiterate) focuses on how the trial judge reached the decision, not what that decision was:

“A trial court does not abuse its discretion if it (1) recognizes the issue as one of
discretion, (2) acts within the boundaries of its discretion and applies the
applicable legal standards, and (3) reaches the decision through an exercise of
reason.” Johannsen v. Uiterbeck, 146 Idaho 423, 429, 196 P.3d 341, 347 (2008),

 

%6
Martin ». Smith, 154 Idaho 161, 163, 296 P-3d 367, 369 (2013).

This appeal from the grant of summary judgment tums upon the single issue!" of whether
the district court ered when, in the district judge's words, he “evaluated the affidavits submitted
by the Plaintiff's experts and determined the causation analyses offered were not based on val
and reliable principles or methodology, and, therefore, unhelpful to the trier of fact.” Ifthe final
clause were not clear enough, the district court expressly stated that this decision was predicated
‘upon its analysis under Rule 702 of the Idaho Rules of Evidence.

“The majority does not suggest that the district court failed to recognize this decision was,

 

‘one of discretion, Given the district court’s extensive discussion of Weeks, which as previously
noted identified the admissibility of exper opinion as committed to the broad discretion of the
trial court, and the extensive discussion of the reasons it concluded that Ms. Nield’s experts’
affidavits failed to meet the requirement of LR.E. 702,
recognized that this was a discretionary call.

evident that the district court

 

‘The second prong of the “three-part test” for abuse of disc

 

actually contains two
discrete inquiries: whether the trial court “acted within the outer boundaries of its diseretion” and
whether the trial court’s decision was consistent “with the legal standards applicable to the
specific choices availabe toi.” Magleby v. Garn, 154 Idaho 194, 197, 296 P34 400, 403 (2013)
(iting Bailey ¥. Bailey, 153 Idaho 526, 529, 284 P.3d 970, 973 (2012)). In the context of
summary judgment proceedings, the district court faced a binary choice, to admit or exclude the
opinions of causation proffered by Ms. Nield's experts.” Thus, the determination that the

proffered opinions would not assist the trier of fut was within the range of legitimate, available

 

options

“The second aspect of this second prong warrants more discussion, because this is where I
believe the majority has first gone astray. The district court determined that the nature of Ms.
Nield’s lawsuit was such that it “required the testimony of experts to establish proximate cause
of the injury suffered by the Plaintiff.” Although Ms. Nield has not challenged this threshold
legal determination by the trial court in her opening brief, the majority rejects the district court's
‘considered analysis with the conclusion that “expert testimony is not necessary in determining
1 Aitough the majority explains why it believes the district cour erred in relying on Dr. Cotman’ aiavt,
Justice Esmann is caret in his observation that Ms, Nild has not asd his as am isse on appeal and that iss is
ot propery before tis cour.

Tha jury trial the decision t9 admit evince may also result in a court exercising a thi option—to amit
evidence subject to limiing nsrocton.

 

n
how a particular person contracted the disease.” I do not believe this statement by the majority
accurately reflects the current state of jurisprudence in Idaho. Infact, in support of this threshold
determination that expert testimony was necessary to establish causation, the district court cited
‘our decision in Coombs v. Curnow, 148 Idaho 129, 219 P34 453 (2009), where we stated:

‘Although the Idaho Rules of Evidence do not require expert testimony to establish

‘causation in medical malpractice cases, such testimony is often necessary given

the nature of the cases. Expert testimony is generally required because “the

causative factors are not ordinarily within the knowledge or experience of laymen

composing the jury.”

148 Idaho at 140, 219 at 464 (quoting Flowerdew v. Warner, 90 Idaho 164, 170, 409 P.2d 110,
113 (1965)). Coombs is scarcely an outlier. Rather, it is consistent with other decisions from this
‘Court indicating that causation of medical conditions may require the presentation of expert
testimony, See Swallow v. Emergency Med. of Idaho, P.A., 138 Idaho 589, 597-98, 67 P.3d 68,
76-77 (2003); Cook v. Skyline Corp,, 135 Kdaho 26, 35, 13 P.34 857, 866 (2000); Evans v. Twin
Falls County, 118 Idaho 210, 214, 796 P.2d 87, 91 (1990). I cannot find error in the district
‘court's determination that the cause of nosocomial infections is a matter “not ordinarily within
the knowledge or experience of laymen.”

[As I ean find no error in the district court's determination that causation in this ease
required the presentation of expert testimony, I tun to the ertical decision by the district court
that Ms. Nield's experts affidavits failed to meet the requirements of LR-E, 702,

‘The district court explained the standards that it applied in evaluating Ms. Nield’s
experts’ opinions. As these standards are those which this Court has applied, the district court's
articulation of the standards that it applied bears repeating:

Rule 702 of the Idaho Rules of Evidence permits the admission of expert

testimony only when

the expert is a qualified: expert in the field, the evidence will be

of assistance to the trier of fact, experts in the particular field
‘would reasonably rely upon the same type of facts relied upon

by the expert in forming his opinion, and the probative value of

the opinion testimony is not substantially outweighed by its
prejudicial effect.

Ryan v. Beisner, 123 Wdaho 42, 47, 844 P.2d 24, 29 (Idaho CLApp. 1992).

Expert opinion which is speculative, conclusory, or unsubstantiated by facts in

the record is of no assistance to the jury in rendering its verdict, and therefore

is inadmissible. Id. at 46-47, 844 P.2d at 28-29. The testimony of an expert is,

speculative when it “theorizfes] about a matter as to which evidence is not

sufficient for certain knowledge.” Karlson v, Harris, 140 Idaho 561, 565, 97

8
P3d 428, 432 (2004). On the other hand, if an expert’s reasoning or
methodology underiying the opinion is scientifically sound and “based upon @
“reasonable degree of medical probability” not a mere possibility, then the
testimony will assist the tier of fact. Bloching v. Albertson's, Inc., 129 Idaho
844, 846-47, 934 P-2d 17, 19-20 (1997) (quoting Roberts». Kit Mf. Co., 124
Maho 946, 948, 866 P.2d 969, 971 (1993).

In deciding whether to admit expert testimony, a court must evaluate
“the expert's ability to explain pertinent scientific principles and to apply
those principles to the formulation of his or her opinion.” Ryan, 123 Idaho at
46, 844 P 2d at 28, Admitting the expert’s testimony depends upon the validity
of the expert's reasoning and methodology, not his or her ultimate conclusion
Id, at 46-47, 844 P-2d at 28-29. As long as the principles and methodology
‘behind a theory are valid and reliable, the theory need not be commonly agreed
‘upon or generally accepted. Weeks, 143 Idaho at 838, 153 P.3d at 1184,

‘There is simply no error in the legal standards that the district court applied to its decision.
‘This brings me to the heart of my dissent: in my view, the majority simply does not agree
‘with the reasons that the district court art

 

lated for its decision that Ms. Nieid’s experts’
‘opinions failed to meet the requirements of LR.E. 702. In the memorandum opinion denying Ms.
\Nield’s motion for reconsideration, the district court quoted from its earlier opinion, explaining:

Dr. Selznick “failed to identify all of the potential causes of symptoms,
<liminating hypotheses in order to reach a conclusion as to the most likely cause.”
Instead, Dr. Selznick simply and improperly concluded
‘hat because the Plaintiff was negative for MRSA and
ppscudomonas at the time of her admission to PCRC, but then tested
positive for MRSA and pscudomonas prior to her discharge, then
she must have contracted MRSA and pseudomonas while at
PCRC. He docs not address the other factors that could have been
a substantial factor in causing the infections.
‘As such, this Court found “the validity of Dr. Selznick’s reasoning and
‘methodology regarding how the Plaintiff contract MRSA and pseudomonas [to
bbe] without merit.”

 

ct court ci

  

ions to earlier opinion omitted),

‘This statement clearly reflects the distriet court's application of the legal principle we
adopted in Weeks. Indced, the district courts or
holding: “After identifying all ofthe potential causes of symptoms, the expert then engages in a
process of eliminating hypotheses in order to reach a conclusion as to the most likely cause.”
Weeks, 143 Idaho at 839, 153 P-3d at 1185 (citing Clausen v. M/V New Carissa, 339 F.3d 1049,
1060 (9th Cir. 2003)). Significantly, the district court then further quoted Weeks: “When using

 

decision not only cited, but quoted, our

”
differential diagnosis, a district court is justified in excluding the expert's testimony ifthe expert
fails to offer an explanation why an altemative cause is ruled out.” Id. tis evident, a least to me,
tion where, in evaluating the
admissibility of expert opinions, Weeks provided guidance as to the applicable legal standard
‘governing the decision before him.

 

that the district judge viewed this case as presenting a

“Trial courts are not free to willfully disregard precedent from the appellate courts of
state.” State ». Hanson, 152 Kaho 314, 325 1.6, 271 P.3d 712, 723 n.6 (2012) (citing State v.
Guzman, 122 Wdaho 981, 986, 842 P.2d 660, 665 (1992)), Aside from the failure to anticipate that
this Court would overrule Weeks sub silentio (a decision, by the way, in which two-thirds of the
present majority concurred), I cannot imagine what more the district judge could have done.

‘This case presented what I view as being a very close call for the district judge. Indeed,

 

hhad I been in the position of the district judge, I likely would not have stricken Dr. Selznick’s

‘pinion. However, this Court should not reverse discretionary decisions when the trial court has

 

identified the applicable legal standards governing a discretionary decision and rationally
explained the manner in which those principles apply to the decision. To do so is to usurp the
rol of the trial cout in exercising considered legal judgment

Because reasonable minds can—and as is reflected in the sharply diverging views
‘expressed in the majority and Justice Eismann’s dissent, do in fact—disagree as to whether the
district court properly concluded that Ms. Nield's experts failed to adequately address other
potential causes of her MRSA and pseudomonas infections, this is an instance where the
standard of review should have dictated affirmance. The district judge recognized the issue as a
‘matter of discretion, the exclusion of the proffered opinions was within the boundaries of his
discretion, he recognized and applied the governing legal principles as articulated by this Court,
and he did so by an exercise of reason. For these reasons, I would affirm