Title: HARDER v. F.C. CLINTON, INC.

State: oklahoma

Issuer: Oklahoma Supreme Court

Document:

HARDER v. F.C. CLINTON, INC.  HARDER v. F.C. CLINTON, INC. 1997 OK 137 948 P.2d 298 68 OBJ 3603 Case Number: 86426 Decided: 11/04/1997 Modified: 04/03/1998 Mandate Issued: 12/03/1997 Supreme Court of Oklahoma MINNIE HARDER, as Administrator of the Estate of Ethel Kayser, Plaintiff-Appellant, v. F. C. CLINTON, INC. d/b/aHERITAGE CARE CENTER, Defendant-Appellee. ON CERTIORARI TO THE COURT OF CIVIL APPEALS, DIV. 4 ¶0 In a tort action for harm sustained by a resident of the Heritage Care Center, a nursing home, the District Court, Custer County, Alan D. Markum, Judge, directed a verdict for the Center at the close of the plaintiff's evidence that followed a res ipsa loquitur pattern of proof. The Court of Civil Appeals affirmed. On certiorari granted upon the plaintiff's petition, THE COURT OF CIVIL APPEALS' OPINION IS VACATED, THE TRIAL COURT'S JUDGMENT (ON DIRECTED VERDICT) IS REVERSED AND THE CAUSE IS REMANDED FOR FURTHER PROCEEDINGS TO BE CONSISTENT WITH TODAY'S PRONOUNCEMENT Rick Bisher, Boettcher, Ryan & Martin, Oklahoma City, Oklahoma for Appellant James M. Kaufman, Michael S. McMillin, Fenton, Fenton, Smith, Reneau & Moon, Oklahoma City, Oklahoma for Appellee OPALA, J. ¶1 The dispositive question before this court is whether the trial court erred by directing a verdict for the defendant at the close of the plaintiff's evidence that followed a res ipsa loquitur pattern of proof. We answer in the affirmative. I THE ANATOMY OF LITIGATION ¶2 Ethel Kayser [Kayser] was admitted on July 14, 1992 to the Heritage Care Center [Heritage, Center, or nursing home]. On the evening of September 30, 1992 she was transferred to the Clinton Regional Hospital after ingesting an overdose of Tolbutamide, a diabetic medication. There she was diagnosed as having a hypoglycemic coma caused by the lowering of her blood sugar from ingestion of the medication. An intravenous device was inserted in the dorsum area of her right foot to treat the coma. Gangrene later developed in the same foot, which eventually required an above-the-knee amputation. ¶3 Minnie Harder [Harder], Kayser's sister, brought a suit against the nursing home, as Kayser's guardian, 1 for harm caused to Kayser by an overdose of the wrong prescription administered to her while she was in the Center's care and custody. 2 At the close of Harder's case, which followed a res ipsa loquitur pattern of proof, the trial court, on Heritage's demurrer to the evidence, directed a verdict for the nursing home. The trial court ruled that Harder's evidence fell short of establishing a negligence claim because her proof failed to show all the requisite foundational elements for res ipsa loquitur. The Court of Civil Appeals affirmed. II STANDARD OF REVIEW FOR TESTING A DIRECTED VERDICT ¶5 Because the record contains some evidence adduced (without objection) by the defendant before the plaintiff had rested, and the order in the record treats the ruling as a "directed verdict," 3 we will review the dispositive ruling as a judgment on directed verdict. ¶6 The legal standard that governs motions for directed verdict and those for summary judgment is very similar, if not [948 P.2d 302] indeed identical. 4 Neither may be sustained unless there is an entire absence of proof on a material issue. Both should be denied when there are questions of material fact or reasonable persons could differ as to the choice of inferences to be drawn from the facts in evidence. 5 In determining whether a plaintiff's evidence is sufficient to withstand a motion for directed verdict, the trial court must consider as true all evidence favorable to the plaintiff together with all reasonable inferences to be drawn from it, and disregard all conflicting evidence favorable to the movant.6 Only if all the inferences to be drawn from the evidence are in favor of the moving party will a directed verdict withstand appellate scrutiny. III THE RES IPSA LOQUITUR PATTERN OF PROOF ¶7 Harder urges that the trial court erred when it directed a verdict for Heritage based on its ruling that she had not satisfied the requirements for a res ipsa loquitur submission. According to Harder, a directed verdict was inappropriate because she adduced reasonably supportive evidence to establish the foundation facts for application of the res ipsa loquitur pattern of proof. Heritage counters that Harder cannot invoke the res ipsa loquitur evidentiary process because she failed to establish two foundation facts 7 - (a) the thing causing the injury (the Tolbutamide) was under its exclusive control and (b) but for the negligence in administering an overdose of the wrong medication, the harm of which plaintiff complains would not have occurred. ¶8 Res ipsa loquitur ¶9 Whether a case is fit for the application of res ipsa loquitur presents a question of law ¶10 The effect of the res ipsa loquitur evidentiary rule is merely to raise a [948 P.2d 304] rebuttable inference which allows a plaintiff to take the case to the jury and thus avoid a directed verdict for the defendant. 18 Where the proof is conflicting or subject to different inferences, some of which are in favor of and others against the applicability of res ipsa loquitur, the question must be left to the jury. 19 It is only when one of the foundation facts is irrefutably negated20 that the necessary prop may be deemed knocked out from under the sine qua non predicate for application of the res ipsa proof pattern.Application Of Res Ipsa Loquitur In The Context Of Health-Care Litigation ¶11 A hospital has the duty to provide for the care and protection of its patients, and in the performance of this duty the hospital is required to exercise such reasonable care as the patient's known condition requires. 21 Vis-a-vis its resident, a nursing home stands in a relationship similar to that which a hospital occupies opposite its patient. A resident is under the control and in the care of an entity to which his (or her) safety is entrusted. A nursing home has a duty to provide care at a reasonable standard, taking into consideration the resident's known mental and physical condition. 22 In the context of health-care litigation, res ipsa loquitur - which is applicable to actions against physicians and hospitals 23 - may, upon proof of the foundation elements, also be followed in lawsuits against nursing homes. 24 Negligence can never be presumed from showing no more than the happening of the harmful event. 25 ¶12 It is unnecessary to analyze this cause in terms of our medical-malpractice [948 P.2d 305] legislation, 76 O.S. 1991 §21 ,26 whose provisions raise "a presumption of negligence."27 Harder's proof clearly met the common-law parameters of the res ipsa rule. No more is required by statute than by the common law to bring a case within the purview of res ipsa loquitur rule. 28 IV DIRECTED VERDICT PROCESS ANALYZED AND ASSESSED IN THE CONTEXT OF THE INVOKED RES IPSA LOQUITUR PATTERN OF PROOF ¶13 To establish prima facie a case for res ipsa application, Harder was required to show that (1) an overdose of the wrong prescription medication is not usually ingested in the course of administering prescription drugs to residents; (2) the nursing home has exclusive control and management of the instrumentality (prescription drugs) that caused the injury; (3) evidence shedding light on the harmful event is more accessible to the nursing home than to the plaintiff; and (4) the administration of the injurious overdose is the sort of occurrence which, in the ordinary course of events, would not have happened if one having control of the instrumentality exercised due care. ¶14 The foundation facts can be established by expert testimony or by demonstrating that the defendant's substandard conduct falls within the realm of common knowledge. 29 If the showing of any foundation fact requires a degree of knowledge or skill not possessed by the average person, expert testimony must be adduced. 30 A. Foundation Fact I - The Injury Does Not Occur In The Ordinary Course of Operations ¶15 The first foundation fact requires a showing that the injury - an overdose of the wrong prescription - does not occur in the ordinary course of operations at the nursing home. 31 ¶16 Jackie Dixon, a licensed practising nurse (and a medication clerk at the Center), testified that residents' prescription drugs are stored at the nurse's station. She gave a detailed account of the method used for dispensing prescribed medication to the residents. Heritage residents have no access to prescription drugs except when they are administered to them by authorized personnel - a registered or licensed practising nurse or a certified medication aide. When medication is to be administered, the correct dosage is removed from the storage site and placed in a cart that is pushed down the halls. The nurse (or certified medication aide) removes the medication from its container, places it in a cup, and then serves it to the resident. The cart is kept locked [948 P.2d 306] while the nurse or aide is administering the medication. Dr. Hays - Kayser's family physician since 1973 (as well as Heritage's medical director) - testified that the administration of the wrong prescription drug in an amount that would cause harm is below the applicable standard of care. ¶17 The first res ipsa element is met by the evidence adduced because, under the applicable standard of care, the overdose of a wrong prescription drug would not occur in the ordinary course of operations at the defendant nursing home. B. Foundation Fact II - The Nursing Home Has Exclusive Control Of The Harm-Dealing Instrumentality ¶18 The second res ipsa element is satisfied by proof that the agency or instrumentality causing the injury was under the defendant's exclusive control or management at the time the negligence inferable from the type of accident occurred. 32 Exclusive control is a flexible concept 33 which denotes no more than elimination, within reason, of all explanations for the genesis of the injurious event other than the defendant's negligence 34 - a showing that defendant's negligence probably caused the accident. 35 The nature and degree of control must be such that the reasonable probabilities point to the nursing home and support an inference that it was the negligent party. 36 Prima facie satisfaction of the control element requires only reasonably supportive evidence. 37 ¶19 Janis Raab, the nursing home administrator, testified that Kayser was at the nursing home on September 30, 1992, the day [948 P.2d 307] she ingested an overdose of Tolbutamide. She stated that Heritage was on that day responsible for Kayser's care. This includes the supervision and administration of prescribed medication. Dr. Hays gave testimony that the Mayo Clinic report indicates the drug Kayser ingested on September 30, 1992 was Tolbutamide (also known as Orinase), a prescription for diabetes. Although Dr. Hays had not ordered any diabetes medication for Kayser since her admittance to Heritage in July 1992, he had in 1987 given her a prescription for Tolinase, a different hypoglycemic medication for a mild, adult-onset diabetic condition. ¶20 The September 29, 1992 "nurses notes" indicate that when Kayser had complained of pain, she was given a placebo injection of sterile water. Later that day she received some Tylenol tablets. She was given another placebo injection for pain on September 30. That evening she was transferred to the Clinton Regional Hospital and admitted there while in an unconscious state. Dr. Hays, who attended her in the emergency room, diagnosed the condition as hypoglycemia. While she was hospitalized there, an intravenous device was inserted in the top of her right foot to treat the coma. She was later transferred to Presbyterian Hospital, where she showed signs of ecchymosis 38 on top of the right foot. This condition ultimately developed into gangrene and required an above-the-knee amputation of her right leg. Kayser's medical records at Heritage did not indicate that she had exhibited any hypoglycemia symptoms until the evening of September 30. According to Dr. Ellis' review of the medical records, Kayser ingested the medication while a resident at the home. Dr. Davis, the endocrinologist who treated Kayser at Presbyterian Hospital, opined that Kayser must have ingested a large dosage of Tolbutamide because 72 hours later it was still in her system.¶21 Harder argues she has established the element of exclusive control by showing that (a) Kayser's injury can be traced to the ingestion of an overdose of Tolbutamide, a diabetic medication, (b) Heritage was responsible for supervising and administering prescription drugs to its residents, and (c) Kayser was in the nursing home's care and control when she ingested Tolbutamide. ¶22 Heritage counters that there is no evidence of its exclusive control over Tolbutamide or over Kayser's ability to obtain (or ingest) that medication. Neither is there evidence, Heritage urges, as to the source of the Tolbutamide. The nursing home's computer records do not list the medication as one prescribed for any resident. According to Heritage, Kayser was mentally and physically capable of obtaining drugs from a source other than the Center. We are directed to testimony that (a) Kayser was ambulatory and could take care of routine day-to-day functions, (b) she was oriented as to time and place, (c) her comprehension was quick, (d) she was independent as far as her nutrition was concerned, (e) she had frequent visits from her sisters and a brother-in-law, (f) two weeks before the critical event, she stayed at her sister's (Harder's) house for three days, and (g) at the time of Kayser's visit, Harder was taking Micronase, a diabetic medication. Because Kayser had become addicted to prescription drugs and was a known drug seeker, Heritage argues, she could have gained access to hypoglycemia medication from her sister, a third party, or from one of her old prescription containers still stored at her sister's house. Heritage argues there is no evidence that one of its employees administered the diabetic drug. According to Heritage, Harder's evidence establishes no more than Kayser's presence at the nursing home at the time she ingested the medication. From this, Heritage urges, the jury would be left to speculate as to the source of the ingested Tolbutamide. An inference, Heritage argues, cannot supply the necessary foundation fact. 39 ¶23 Harder counters that the computer printout does not contain a complete list of all prescription medications then on the premises. There is proof, she urges, that the Center's computer database includes only those drugs which are in current and continuous [948 P.2d 308] patient use. It does not encompass drugs for short-term administration or any medication a resident may bring into the home when initially admitted there. According to Harder's proof, it is not until a physician directs the nursing home to refill the prescription that it is entered into the computer database. ¶24 On review of assigned error in the trial court's directed verdict for a defendant, our scrutiny is confined to the evidence favorable to the plaintiff together with all reasonable inferences that may be drawn from that proof. We must disregard conflicting proof or contrary inferences. 40 The plaintiff established that (l) the offending drug was prescribed medicine; (2) the administration of prescription drugs to the residents is within the control of the defendant, and (3) at the time of the harmful event, the decedent, a Heritage resident, was at the nursing home and subject to the policies that govern there the distribution and administration of prescribed medicine. This constitutes a legally sufficient showing to satisfy the control-element requirement for the res ipsa loquitur pattern of proof.41 ¶25 It was not fatal to the plaintiff's case that she failed to refute the defendant's proof of Tolbutamide's absence from the computer list of prescribed drugs present in the distribution pool on the critical day the drug was ingested. Nor was the plaintiff under a duty to show that the particular drug alleged to have been responsible for the decedent's harm was on any other resident's list of medication to be administered. The offending drug's absence from the drug bank list shown in the computer is the defendant's refutational evidence which the trial court was bound to leave out of its analysis when passing on the Center's challenge to the sufficiency of the evidence for submission of plaintiff's case to the jury. C. Foundation Fact III - True Explanation For The Harm's Occurrence Is More Accessible to the Nursing Home ¶26 The third res ipsa element consists of evidence that the precise cause of the accident is more accessible to the defendant than to the plaintiff. 42 ¶27 Heritage is required to chart and keep in its records extensive data about each resident's health, medical history, physician orders and overall medical treatment. Its records also contain information about the prescribed medication that is ordered, received, stored on its premises and administered to its residents. ¶28 The evidence adduced clearly demonstrates that information about the circumstances surrounding the administration to Kayser of excessive dosage of the wrong prescription is more accessible to the nursing home than to Kayser. D Foundation Fact IV - The Defendant's Negligence ¶29 The fourth res ipsa element required Harder to present reasonably supportive evidence that an overdose of a wrong prescription would not ordinarily occur [ 948 P.2d 309 ] absent negligence on the part of someone who had the instrumentality in its exclusive control and management. It need not be shown that negligence is the only explanation for the injury, but merely the most probable one. This element is satisfied if, under the facts of the case, common experience indicates that the injury was more likely than not the result of the defendant's negligence.43 ¶30 In light of the circumstances that surround the injurious event, and disregarding, as we must, the defendant's conflicting (refutational) evidence, it seems reasonably clear that Kayser's ingestion of a Tolbutamide overdose would not have taken place in the absence of negligence by the nursing home's responsible staff. The record shows that Kayser had not been prescribed any diabetes medication while a resident at Heritage and that she had never been prescribed that type of hypoglycemic drug. It is uncontradicted that Kayser was at the nursing home when she ingested the prescribed medication. There is no direct evidence that anyone else supplied to her the harm-dealing dosage or that the substance in question was kept in her room (or elsewhere within her control). Neither is there indication that any other cause contributed to the coma. According to Jackie Dixon, a LPN at the Center, the nursing home is responsible for the administration of medication to its residents. As Dr. Hays testified, the administration of the wrong medication in an amount so excessive as to harm a resident would be below the applicable professional standard of care. ¶31 In sum, Harder's evidence laid before the trial court the requisite res ipsa foundation facts from which the trier may infer that the injury - from an overdose of the wrong prescription - was one that would not ordinarily occur in the course of controlled supervision and administration of prescribed medicine in the absence of negligence on the Center's part. Because nothing in the record irrefutably negates any of the critical elements for application of res ipsa loquitur, Harder clearly met her probative initiative by establishing the necessary components for invoking the rule. The responsibility for producing proof that would rebut the inferences favorable to Harder's legal position thus came to be shifted to the defendant. The plaintiff was clearly entitled to have her case go to the jury - under the aid of a res ipsa instruction - for resolution of the disputed issues. SUMMARY ¶32 By the evidence adduced at trial Harder met the standards for submission of her claim with the aid of res ipsa loquitur pattern of proof. It is for the trier of fact to choose between the favorable inferences to be drawn from the pattern of proof she invoked and the defendant's refutational evidence. We hold that the trial court erred by directing a verdict for Heritage at the close of Harder's case. ¶33 On certiorari granted upon the plaintiff's petition, the Court of Civil Appeals' opinion is vacated, the trial court's judgment (on directed verdict) is reversed and the cause is remanded for further proceedings to be consistent with today's pronouncement. ¶34 KAUGER, C.J., SUMMERS, V.C.J., and HODGES, LAVENDER, HARGRAVE, OPALA, WILSON and WATT, JJ., concur; ¶35 SIMMS, J., dissents. FOOT