N O T R E C O M M E N D E D F O R F U L L

- T E X T P U B L I C A T I O N

F i l e N a m e : 1 3 a 0 8 1 0 n

. 0 6

N o

. 1 2

- 4 4 2 0

U N I T E D S T A T E S C O U R T O F A P P E A L S

F O R T H E S I X T H C I R C U I T

L I F E C A R E C E N T E R O F B A R D S T O W N

,

P e t i t i o n e r

,

v

.

S E C R E T A R Y O F U N I T E D S T A T E S

D E P A R T M E N T O F H E A L T H A N D

H U M A N S E R V I C E S

,

R e s p o n d e n t

. O n A p p e a l f r o m t h e

D e p a r t m e n t o f H e a l t h &

H u m a n S e r v i c e s

/

B e f o r e : B A T C H E L D E R

, C h i e f J u d g e ; G U Y a n d M O O R E

, C i r c u i t J u d g e s

.

R A L P H B

. G U Y

, J R

. , C i r c u i t J u d g e

. P e t i t i o n e r

, L i f e C a r e C e n t e r o f B a r d s t o w n

( “ t h e C e n t e r ” ) o p e r a t e s a s k i l l e d n u r s i n g f a c i l i t y i n B a r d s t o w n

, K e n t u c k y

. B e c a u s e t h e

C e n t e r p a r t i c i p a t e s i n t h e M e d i c a r e a n d M e d i c a i d p r o g r a m s

, t h e U n i t e d S t a t e s D e p a r t m e n t

o f H e a l t h a n d H u m a n S e r v i c e s ( “ H H S ” ) m a n d a t e s t h a t t h e f a c i l i t y m e e t c e r t a i n p a r t i c i p a t i o n

r e q u i r e m e n t s

. T h e C e n t e r s f o r M e d i c a r e a n d M e d i c a i d S e r v i c e s ( “ C M S ” ) o v e r s e e s

c o m p l i a n c e w i t h s u c h r e q u i r e m e n t s

.

A f t e r a n A p r i l 2 0 0 7 c o m p l i a n c e s u r v e y

, C M S f o u n d t h a t t h e C e n t e r w a s n o t i n

s u b s t a n t i a l c o m p l i a n c e w i t h s e v e r a l o f t h e p a r t i c i p a t i o n r e q u i r e m e n t s a n d f o u n d t h a t t h eNo. 12-4420

p r o b l e m s p u t r e s i d e n t h e a l t h a n d s a f e t y i n “ i m m e d i a t e j e o p a r d y

. ” A s a r e s u l t

, C M S i m p o s e d

a c i v i l m o n e t a r y p e n a l t y ( “ C M P ” ) o f $ 4

, 0 5 0 p e r d a y a g a i n s t t h e C e n t e r u n t i l s u c h c o n d i t i o n s

w e r e r e m e d i e d

.

T h e C e n t e r a p p e a l e d t h e n o n

- c o m p l i a n c e f i n d i n g a n d t h e i m p o s i t i o n o f t h e C M P t o

a n a d m i n i s t r a t i v e l a w j u d g e ( “ A L J ” )

. A f t e r a n i n v o l v e d a d m i n i s t r a t i v e a p p e a l s p r o c e s s

, t h e

H H S D e p a r t m e n t a l A p p e a l s B o a r d ( “ D A B ” ) s u s t a i n e d t h e A L J ’ s d e c i s i o n a n d t h e i m p o s i t i o n

o f t h e C M P

. T h e C e n t e r f i l e d t h i s t i m e l y a p p e a l

. F o r t h e f o l l o w i n g r e a s o n s

, w e A F F I R M

.

I

.

C e n t r a l t o C M S ’ s n o n

- c o m p l i a n c e f i n d i n g w a s t h e d e a t h o f o n e o f t h e C e n t e r ’ s

r e s i d e n t s o n J a n u a r y 3

, 2 0 0 7 ( r e f e r r e d t o a s “ R e s i d e n t 1 ” )

. C M S c o n d u c t e d a s u r v e y o f t h e

C e n t e r o n A p r i l 3

, 2 0 0 7

, w h i c h f o c u s e d o n t h e e v e n t s s u r r o u n d i n g R e s i d e n t 1 ’ s d e a t h

. O n 1

A p r i l 2 0

, 2 0 0 7

, C M S i s s u e d a S t a t e m e n t o f D e f i c i e n c i e s ( “ S O D ” ) t h a t i d e n t i f i e d t h r e e

p a r t i c i p a t i o n r e q u i r e m e n t s w i t h w h i c h t h e C e n t e r w a s n o t i n s u b s t a n t i a l c o m p l i a n c e t h a t a l s o

p u t r e s i d e n t h e a l t h a n d s a f e t y i n “ i m m e d i a t e j e o p a r d y ” : ( 1 ) t h e p h y s i c i a n c o n s u l t a t i o n

r e q u i r e m e n t ( 4 2 C

. F

. R

. § 4 8 3

. 1 0 ( b ) ( 1 1 ) ) ; ( 2 ) t h e q u a l i t y o f c a r e r e q u i r e m e n t ( 4 2 C

. F

. R

. §

4 8 3

. 2 5 ) ; a n d ( 3 ) t h e f

a c i l i t y a d m i n i s t r a t i o n r e q u i r e m e n t ( 4 2 C

. F

. R

. § 4 8 3

. 7 5 )

. B a s e d o n t h e s e

T h e Kent uck y O ff ic e of th e I n spe ct or G en er al act u al ly con d u ct ed th is su rve y (pu rs u an t to 4 2 U .S .C

. 1

§ 1 3 9 5 i- 3 (g) an d 4 2 U .S .C

. § 1 3 9 5 aa) an d is su ed th e su bse qu en t S ta te me n t of D ef ic ie n ci es (“ S O D ”)

, w h ic h

C M S ad opt ed w h en it im pos ed th e C M P

.

2No. 12-4420

d e f i c i e n c i e s

, C M S i m p o s e d t h e $ 4

, 0 5 0 p e r d a y C M P

, e f f e c t i v e J a n u a r y 3

, 2 0 0 7 ( t h e d a y o f

R e s i d e n t 1 ’ s d e a t h ) t h r o u g h M a r c h 2 7

, 2 0 0 7

. 2

T h e C e n t e r a p p e a l e d C M S ’ s d e t e r m i n a t i o n s t o a n A L J

. A f t e r a h e a r i n g

, t h e A L J

i s s u e d a d e c i s i o n o n J u l y 1 6

, 2 0 0 8 ( t h e “ i n i t i a l d e c i s i o n ” )

, f i n d i n g t h a t t h e C e n t e r w a s i n

s u b s t a n t i a l c o m p l i a n c e w i t h 4 2 C

. F

. R

. § § 4 8 3

. 1 0 ( b ) ( 1 1 )

, 4 8 3

. 2 5

, a n d 4 8 3

. 7 5

, a n d t h a t t h e

C M P w a s

, t h e r e f

o r e

, n o t w a r r a n t e d

. C M S a p p e a l e d t h a t d e c i s i o n t o t h e D A B

, w h i c h v a c a t e d

t h e A L J ’ s i n i t i a l d e c i s i o n a n d r e m a n d e d t h e m a t t e r s o t h a t t h e A L J c o u l d a d d r e s s c o n f l i c t i n g

e v i d e n c e

. T h e D A B a l s o c o n c l u d e d t h a t t h e A L J e r r e d i n f i n d i n g t h a t t h e a l l e g e d v i o l a t i o n s 3

o f 4 2 C

. F

. R

. § § 4 8 3

. 2 5 a n d 4 8 3

. 7 5 w e r e d e r i v a t i v e o f a v i o l a t i o n o f 4 2 C

. F

. R

. §

4 8 3

. 1 0 ( b ) ( 1 1 )

, a n d o r d e r e d t h e A L J t o c o n s i d e r t h o s e a l l e g e d d e f i c i e n c i e s i n d e p e n d e n t l y

.

F i n a l l y

, t h e D A B r e v e r s e d t h e A L J ’ s i n i t i a l d e c i s i o n w i t h r e s p e c t t o v i o l a t i o n s o f 4 2 C

. F

. R

.

§ § 4 8 3

. 2 0 ( d ) ( 3 ) a n d 4 8 3

. 1 0 ( k ) ( 2 ) ( t h e c o m p r e h e n s i v e c a r e p l a n r e q u i r e m e n t s )

. B e c a u s e t h e

C e n t e r d o e s n o t c h a l l e n g e t h i s r e v e r s a l

, w e d o n o t a d d r e s s i t

.

O n r e m a n d

, t h e A L J u p h e l d C M S ’ s f i n d i n g s t h a t t h e C e n t e r f a i l e d t o s u b s t a n t i a l l y

c o m p l y w i t h 4 2 C

. F

. R

. § § 4 8 3

. 1 0 ( b ) ( 1 1 )

, 4 8 3

. 2 5

, a n d 4 8 3

. 7 5

, a n d t h a t s u c h n o n c o m p l i a n c e

p u t r e s i d e n t h e a l t h a n d s a f e t y i n “ i m m e d i a t e j e o p a r d y ” f r o m J a n u a r y 3

, 2 0 0 7 t h r o u g h M a r c h

F rom M ar ch 2 8

, 2 0 0 7 u n ti l A pri l 1 0

, 2 0 0 7

, C M S im pos ed a C M P of $ 1 0 0 per d ay bec au se, 2

al th ou gh th e pro ble m con d it ion s w er e n o lon ger at th e “ im me d ia te j eop ar d y” le vel

, th e C en te r w as st il l n ot

in su bst an ti al com pli an ce w it h al l p ar ti ci pat ion re qu ir em en ts . T h e C en te r d oes n ot app eal th e $ 1 0 0 C M P

im pos ed fo r t h e l at te r t im e- per iod

.

T h e C en te r re pea te d ly mi sch ar act er iz es th e D A B ’s re ma n d ord er st at in g th at th e D A B : (1 ) ord er ed 3

th e A LJ to fi n d vio la ti on s of th e par ti ci pat ion re qu i r e m e n t s ; ( 2 ) ove rr u le d th e A LJ ’s in it ia l cr ed ibi li ty

fi n d in g w it h re spe ct to a key w it n ess (N u rs e S u ff ole tt a) ; an d (3 ) ass u me d th e A LJ ’s rol e of fa ct -f in d er

. A ft er

a t h oro u gh re vie w of

th e A LJ d eci si on s a n d th e D A B or d er s, w e f in d n o ba si s f

or su ch ch ar act er iz at ion s.

3No. 12-4420

27, 2007. The ALJ also upheld the imposition of the $4,050 per day CMP as reasonable (we

refer to this decision as the “ALJ’s final decision”). The DAB sustained that decision and

the Center appealed to this Court.

II.

We sustain HHS’s factual findings “if supported by substantial evidence on the record

considered as a whole.” Woodstock Care Ctr. v. Thompson , 363 F.3d 583, 588 (6th Cir.

2003); see also 42 U.S.C. § 1320a 7a. We only overturn HHS’s interpretation of its

regulations where such interpretation is “arbitrary, capricious, an abuse of discretion or

otherwise not in accordance with the law.” Id . (citing Thomas Jefferson Univ. v. Shalala

,

512 U.S. 504, 512 (1994)). “Substantial evidence is defined as ‘such relevant evidence as

a reasonable mind might accept as adequate to support a conclusion.’” Myers v. Sec'y of

Health & Human Servs. , 893 F.2d 840, 842 (6th Cir. 1990) (citing Richardson v. Perales

,

402 U.S. 389, 401 (1971)). “[W]e do not consider the case de novo , nor resolve conflicts in

the evidence, nor decide questions of credibility.” Id

.

III.

A. The ALJ’s Decision Is Supported By Substantial Evidence 4

1. Background

The Center makes general arguments that CMS: (1) failed to make a prima facie case of non- 4

compliance; (2) changed its basis for sanctions in its request for review; and (3) produced new evidence on

appeal. After a review of the record, we find no merit to these arguments.

4No. 12-4420

R e s i d e n t 1 w a s a n 8 7

- y e a r

- o l d w o m a n w h o s u f f e r e d f r o m A l z h e i m e r ’ s d i s e a s e

,

d i a b e t e s

, a n d h y p e r t e n s i o n

. O n t h e n i g h t o f J a n u a r y 2

, 2 0 0 7

, N u r s e S u f f o l e t t a

, a l i c e n s e d

p r o f e s s i o n a l n u r s e w i t h t h e C e n t e r

, w a s r e s p o n s i b l e f o r R e s i d e n t 1 ’ s c a r e

. A t a p p r o x i m a t e l y

4 a

. m

. o n J a n u a r y 3

, R e s i d e n t 1 w a s f o u n d u n r e s p o n s i v e w i t h u n s t a b l e v i t a l s i g n s

. P e r t h e

C e n t e r d i r e c t o r ’ s i n s t r u c t i o n s

, N u r s e S u f f o l e t t a c a l l e d f

o r e m e r g e n c y m e d i c a l s e r v i c e s

( “ E M S ” )

. E M S a r r i v e d a t a p p r o x i m a t e l y 4 : 2 0 a

. m

. a n d t r a n s p o r t e d R e s i d e n t 1 t o t h e h o s p i t a l

w h e r e s h e d i e d a t 7 : 1 0 a

. m

.

2

. P h y s i c i a n C o n s u l t a t i o n R e q u i r e m e n t

– 4 2 C

. F

. R

. § 4 8 3

. 1 0 ( b ) ( 1 1 )

C M S a l l e g e d t h a t t h e C e n t e r f a i l e d t o s u b s t a n t i a l l y c o m p l y w i t h t h e p h y s i c i a n

c o n s u l t a t i o n r e q u i r e m e n t

, w h i c h p r o v i d e s :

A f a c i l i t y m u s t i m m e d i a t e l y i n f o r m t h e r e s i d e n t ; c o n s u l t w i t h t h e r e s i d e n t ' s

p h y s i c i a n ; a n d i f k n o w n

, n o t i f y t h e r e s i d e n t ' s l e g a l r e p r e s e n t a t i v e o r a n

i n t e r e s t e d f

a m i l y m e m b e r w h e n t h e r e i s

. . . [ a ] s i g n i f i c a n t c h a n g e i n t h e

r e s i d e n t ' s p h y s i c a l

, m e n t a l

, o r p s y c h o s o c i a l s t a t u s ( i

. e

. , a d e t e r i o r a t i o n i n

h e a l t h

, m e n t a l

, o r p s y c h o s o c i a l s t a t u s i n e i t h e r l i f e

- t h r e a t e n i n g c o n d i t i o n s o r

c l i n i c a l c o m p l i c a t i o n s )

.

4 2 C

. F

. R

. § 4 8 3

. 1 0 ( b ) ( 1 1 )

. T h e p a r t i e s a g r e e t h a t i f R e s i d e n t 1 e x p e r i e n c e d t w o e p i s o d e s o f

v o m i t i n g o n t h e n i g h t i n q u e s t i o n

, N u r s e S u f f o l e t t a w a s r e q u i r e d t o c o n t a c t t h e r e s i d e n t ’ s

p h y s i c i a n p u r s u a n t t o t h i s r e g u l a t i o n

. I t i s u n d i s p u t e d t h a t R e s i d e n t 1 v o m i t e d a r o u n d 8 p

. m

.

o n J a n u a r y 2

. C M S a r g u e s t h a t s h e v o m i t e d a g a i n b e t w e e n m i d n i g h t a n d 1 a

. m

. o n J a n u a r y

3

. T h e C e n t e r d i s p u t e s t h a t c l a i m

, a r g u i n g t h a t R e s i d e n t 1 m e r e l y c o u g h e d u p m e d i c i n e

r a t h e r t h a n v o m i t e d

. I n i t s f i n a l d e c i s i o n

, t h e A L J d e t e r m i n e d t h a t R e s i d e n t 1 v o m i t e d r a t h e r

5No. 12-4420

t h a n s p i t u p a t 1 a

. m

. , a n d t h a t N u r s e S u f f o l e t t a ’ s f a i l u r e t o c o n t a c t R e s i d e n t 1 ’ s p h y s i c i a n

a t t h a t t i m e c o n s t i t u t e d a f a i l u r e t o s u b s t a n t i a l l y c o m p l y w i t h 4 2 C

. F

. R

. § 4 8 3

. 1 0 ( b ) ( 1 1 )

.

A f t e r a t h o r o u g h r e v i e w o f t h e r e c o r d

, w e c o n c l u d e t h a t t h i s f i n d i n g i s s u p p o r t e d b y

s u b s t a n t i a l e v i d e n c e

. T h e A L J b a s e d h i s f i n d i n g o n : ( 1 ) N u r s e S u f f o l e t t a ’ s n u r s i n g n o t e s

,

w h i c h i n d i c a t e d t h a t v o m i t w a s p r e s e n t o n R e s i d e n t 1 ’ s n i g h t c l o t h e s a f t e r t h e 1 a

. m

. e p i s o d e

( s o m u c h v o m i t

, i n f

a c t

, t h a t t h e n u r s e c h a n g e d R e s i d e n t 1 ’ s c l o t h e s ) ; a n d ( 2 ) N u r s e

S u f f o l e t t a ’ s s t a t e m e n t t o s u r v e y o r s t h a t R e s i d e n t 1 v o m i t e d a g a i n b e t w e e n 1 2 a

. m

. a n d 1 a

. m

.

T h e C e n t e r a r g u e s t h a t s u c h i n t e r v i e w s n e v e r t o o k p l a c e

, y e t t w o s u r v e y o r s t e s t i f i e d a t t h e

A L J h e a r i n g t h a t t h e y d i d i n f a c t i n t e r v i e w N u r s e S u f

f o l e t t a a l t h o u g h t h e y f

a i l e d t o t a k e n o t e s

a t s u c h i n t e r v i e w

.

A r e a s o n a b l e m i n d c o u l d c o n c l u d e

, b a s e d o n s u c h e v i d e n c e

, t h a t R e s i d e n t 1 d i d i n f a c t

e x p e r i e n c e a s e c o n d e p i s o d e o f v o m i t i n g

. T h e C e n t e r a r g u e s t h a t N u r s e S u f f o l e t t a ’ s

t e s t i m o n y a t t h e A L J h e a r i n g e s t a b l i s h e d t h a t R e s i d e n t 1 d i d n o t v o m i t b e t w e e n m i d n i g h t a n d

1 a

. m

. A s d i s c u s s e d b e l o w

, t h e A L J r e j e c t e d s u c h t e s t i m o n y a s n o t c r e d i b l e ( a d e t e r m i n a t i o n

w e a f f i r m )

.

3

. Q u a l i t y o f C a r e R e q u i r e m e n t

– 4 2 C

. F

. R

. § 4 8 3

. 2 5

C M S a l l e g e d t h a t t h e C e n t e r f a i l e d t o s u b s t a n t i a l l y c o m p l y w i t h t h e q u a l i t y o f c a r e

r e q u i r e m e n t

, w h i c h p r o v i d e s : “ [ e ] a c h r e s i d e n t m u s t r e c e i v e a n d t h e f a c i l i t y m u s t p r o v i d e t h e

n e c e s s a r y c a r e a n d s e r v i c e s t o a t t a i n o r m a i n t a i n t h e h i g h e s t p r a c t i c a b l e p h y s i c a l

, m e n t a l

, a n d

p s y c h o s o c i a l w e l l

- b e i n g

, i n a c c o r d a n c e w i t h t h e c o m p r e h e n s i v e a s s e s s m e n t a n d p l a n o f

6No. 12-4420

care.” 42 C.F.R. § 483.25. In support of this allegation, CMS noted six findings in its SOD

any one of which would independently establish a violation of this requirement. Because 5

we need not address each of those findings, we limit our focus to CMS’s finding that the

Center failed to implement Resident 1’s physician’s order to take her oxygen saturation

readings daily. In his final decision, the ALJ found that the Center failed to comply with

such order, constituting a failure to substantially comply with the quality of care requirement.

We conclude that such finding is supported by substantial evidence. The parties agree

that Resident 1’s physician had ordered the Center to take her oxygen saturation readings

daily, and the Center does not dispute that there is no record of such daily readings. Rather,

the Center argues that it was complying with such order through a “documentation by

exception” policy where nurses document only abnormal readings. In rejecting that

argument, the ALJ found that the Center had not proven that it had adopted a “documentation

by exception” policy or that it had trained its staff in such practice. Given that the Center has

not pointed to any record evidence to the contrary, a reasonable mind could conclude that the

Specifically, the SOD cited the following failures: (1) the Center failed to implement Resident 1’s 5

physician’s orders to take routine vital signs and daily oxygen saturation readings; (2) the Center’s policy

of “documentation by exception” of vital signs and oxygen saturation levels was not acceptable given

Resident 1’s physician’s explicit orders; (3) between 4:00 a.m. and 4:21 a.m. on January 3, 2007, the Center

failed to suction or administer oxygen to Resident 1 (when her oxygen level was 46%) despite her

physician’s order that oxygen be administered when such levels fell below 88%; (4) the Center failed to give

EMS a verbal report of Resident 1’s allergies, recent medical history, or inform them that Resident 1 had

been vomiting; (5) the Center’s transfer paperwork for EMS failed to reveal that Resident 1 had been

repeatedly vomiting; and (6) the Center’s attending physician who reviewed the nursing documentation

opined that the Center did not do anything for Resident 1 until they “found her on death’s door.” In his final

decision, the ALJ found that citations one through five supported a finding of noncompliance with the

quality of care requirement (individually) but that the sixth finding did not.

7No. 12-4420

Center was not complying with the physician’s order, through a documentation by exception

policy or otherwise.

The Center claims CMS failed to establish that the Center’s failure to comply with the

physician’s order constituted a violation of the quality of care standard. We disagree. The

DAB has held that the quality of care standard requires facilities to “carry out every

applicable [physician] order and ensure the sufficiency of resident care plans so that each

resident receives all of ‘the necessary care and services to attain or maintain the highest

practicable physical, mental, and psychosocial well-being.’ 42 C.F.R. § 483.25.” Alexandria

Place , DAB No. 2245, at 6 (2009) (emphasis in original). Because the Center failed to carry

out the physician’s order as directed, a finding of a violation was appropriate.

4. Facility Administration Requirement – 42 C.F.R. § 483.75

CMS alleged that the Center failed to substantially comply with the facility

administration requirement, which provides, “[a] facility must be administered in a manner

that enables it to use its resources effectively and efficiently to attain or maintain the highest

practicable physical, mental, and psychosocial well-being of each resident.” 42 C.F.R. §

483.75. In support of this allegation, CMS noted three findings in its SOD any one of

which would independently establish a violation of this requirement. 6

The SOD cited the following failures as a basis for the facility administration violation: (1) the 6

Center administrator failed to take necessary actions to correct deficient practices involving residents with

a significant change in condition and investigate events contributing to deficient practices; (2) the Center

administrator failed to ensure all staff were properly trained in the Center’s physician notification policy;

and (3) the Center administrator failed to investigate the incident involving Resident 1’s death to determine

the cause.

8No. 12-4420

T h e A L J u p h e l d C M S ’ s f i n d i n g s a n d a l s o d e t e r m i n e d t h a t

, a s a n a l t e r n a t i v e b a s i s

, t h e

C e n t e r h a d v i o l a t e d t h e f a c i l i t y a d m i n i s t r a t i o n r e q u i r e m e n t b e c a u s e i t f a i l e d t o s u b s t a n t i a l l y

c o m p l y w i t h b o t h t h e q u a l i t y o f c a r e r e q u i r e m e n t a n d t h e p h y s i c i a n p a r t i c i p a t i o n r e q u i r e m e n t

,

w h i c h p u t r e s i d e n t h e a l t h a n d s a f e t y i n “ i m m e d i a t e j e o p a r d y

. ” T h e A L J r e l i e d o n A s b u r y

C t r

. , a t J o h n s o n C i t

y

, w h e r e t h e D A B h e l d t h a t :

[ W ] h e r e a f

a c i l i t y h a s b e e n s h o w n t o b e s o o u t o f c o m p l i a n c e w i t h p r o g r a m

r e q u i r e m e n t s t h a t i t s r e s i d e n t s h a v e b e e n p l a c e d i n i m m e d i a t e j e o p a r d y

, t h e

f a c i l i t y w a s n o t a d m i n i s t e r e d i n a m a n n e r t h a t u s e d i t s r e s o u r c e s e f f e c t i v e l y t o

a t t a i n t h e h i g h e s t p r a c t i c a b l e p h y s i c a l

, m e n t a l

, a n d p s y c h o s o c i a l w e l l

- b e i n g o f

e a c h r e s i d e n t

.

A s b u r y C t r

. , a t J

o h n s o n C i t

y

, D A B N o

. 1 8 1 5

, a t 7 ( 2 0 0 2 )

, a f f ’ d

, A s b u r

y C t r

. , a t J

o h n s o n C i t

y

v

. U

. S

. D e

p ' t o f He a l t h & H

u m a n S e r v s

. , 7 7 F

. A p p ' x 8 5 3

, 8 5 7

- 5 8 ( 6 t h C i r

. 2 0 0 3 )

.

W e n o t e t h a t C M S ’ s d e t e r m i n a t i o n t h a t t h e c i t e d d e f i c i e n c i e s p u t r e s i d e n t h e a l t h a n d

s a f e t y i n “ i m m e d i a t e j e o p a r d y ” u n d e r 4 2 C

. F

. R

. § 4 8 8

. 3 0 1 m u s t b e u p h e l d u n l e s s i t w a s

c l e a r l y e r r o n e o u s

. 4 2 C

. F

. R

. § 4 9 8

. 6 0 ( c ) ( 2 )

. T h e C e n t e r h a s f a i l e d t o p r o v e t h e r e w a s c l e a r

e r r o r i n s u c h f

i n d i n g

. B e c a u s e w e a f f i r m t h e A L J ’ s f

i n d i n g s t h a t t h e C e n t e r f a i l e d t o

s u b s t a n t i a l l y c o m p l y w i t h t h e p h y s i c i a n c o n s u l t a t i o n r e q u i r e m e n t a n d t h e q u a l i t y o f c a r e

r e q u i r e m e n t

, a n d t h a t s u c h n o n

- c o m p l i a n c e p u t r e s i d e n t h e a l t h a n d s a f e t y i n “ i m m e d i a t e

j e o p a r d y

, ” w e a l s o u p h o l d t h e f i n d i n g t h a t t h e C e n t e r f

a i l e d t o s u b s t a n t i a l l y c o m p l y w i t h t h e

f a c i l i t y a d m i n i s t r a t i o n r e q u i r e m e n t

.

C M S ’ s J a n u a r y 2 0 0 7 C o m p l i a n c e F i n d i n g

9No. 12-4420

T h e p a r t i e s a g r e e t h a t C M S m a d e a f i n d i n g i n J a n u a r y 2 0 0 7 t h a t t h e C e n t e r w a s i n

c o m p l i a n c e w i t h t h e f

a c i l i t y a d m i n i s t r a t i o n r e q u i r e m e n t ( 4 2 C

. F

. R

. § 4 8 3

. 7 5 )

. I n t h e S O D

, 7

h o w e v e r

, C M S n o t e d t h a t t h e C e n t e r f a i l e d t o c o m p l y w i t h s u c h r e q u i r e m e n t

. T h e C e n t e r

a r g u e s t h a t t h e S O D i s t h e r e f o r e i n c o n s i s t e n t w i t h t h e J a n u a r y 2 0 0 7 f i n d i n g o f c o m p l i a n c e

a n d t h e A L J ’ s d e c i s i o n i s n o t s o u n d

. W e d i s a g r e e

.

F i r s t

, a m e r e f

i n d i n g b y C M S t h a t t h e C e n t e r ’ s p o l i c y w a s i n c o m p l i a n c e w i t h t h e

f a c i l i t y a d m i n i s t r a t i o n r e q u i r e m e n t i s n o t a f i n d i n g t h a t a l l o f t h e C e n t e r ’ s s t a f f w e r e p r o p e r l y

t r a i n e d t o a d m i n i s t e r t h a t p o l i c y

. A s t h e A L J n o t e d i n h i s f i n a l d e c i s i o n : 8

T h e p r o b l e m i n t h i s c a s e h a s n e v e r b e e n t h e [ C e n t e r ’ s p h y s i c i a n n o t i f i c a t i o n ]

p o l i c y

, w h i c h e s s e n t i a l l y r e s t a t e s t h e [ A m e r i c a n M e d i c a l D i r e c t o r ’ s

A s s o c i a t i o n ] g u i d e l i n e s

. T h e p r o b l e m i s N u r s e S u f f o l e t t a ’ s u n d e r s t a n d i n g a n d

a p p l i c a t i o n o f t h a t p o l i c y

. I a c c e p t t h a t [ t h e C e n t e r ] t r a i n e d N u r s e S u f f o l e t t a

o n t h e p o l i c y

. H o w e v e r

, a s s u m i n g [ t h e C e n t e r ] d i d s o

, t h e t r a i n i n g w a s

d e f i c i e n t

.

S e c o n d

, a s w e n o t e a b o v e

, t h e A L J ’ s f i n d i n g t h a t t h e C e n t e r f a i l e d t o s u b s t a n t i a l l y c o m p l y

w i t h t h e f

a c i l i t y a d m i n i s t r a t i o n r e q u i r e m e n t i s s u p p o r t e d b y s u b s t a n t i a l e v i d e n c e

. F i n a l l y

,

t h e f a c t t h a t C M S f

o u n d t h a t t h e C e n t e r w a s b e i n g a d m i n i s t e r e d i n a c c o r d a n c e w i t h t h e

p a r t i c i p a t i o n r e q u i r e m e n t s i n c e r t a i n i n s t a n c e s d o e s n o t c h a n g e t h e f a c t t h a t C M S d e t e r m i n e d

t h a t t h e C e n t e r w a s n o t b e i n g a d m i n i s t e r e d p r o p e r l y i n i t s c a r e o f R e s i d e n t 1

. G i v e n t h a t

T h is J an u ar y 2 0 0 7 fi n d in g of com pli an ce is n ot a pa rt of th e a d mi n is tr at ive re cor d , so w e c an n ot 7

eva lu at e t h is cl ai m in d epe n d en tl y.

T o th e ex te n t th e Ce n te r argu es th at th e 2 0 0 7 com pli an ce fi n d in g d et er mi n ed th at th e Ce n te r h ad 8

pro per ly tr ai n ed it s st af

f to ad mi n is te r th e ph ysici an n oti fi cat ion pol ic y, it fa il s to ci te to an y re cor d evi d en ce

to su ppor t t h at cl ai m.

10No. 12-4420

t h e r e i s n o e v i d e n c e t h a t t h e J a n u a r y 2 0 0 7 f i n d i n g o f c o m p l i a n c e r e v i e w e d t h e c a r e p r o v i d e d

t o R e s i d e n t 1

, w e f

i n d n o i n c o n s i s t e n c y

.

B

. T h e C M P ’ s D u r a t i o n

T h e C e n t e r a l s o c h a l l e n g e s t h e d u r a t i o n o f t h e C M P

. “ T h i s C o u r t m a y o n l y r e v e r s e

t h e d u r a t i o n o f n o n c o m p l i a n c e i f i t i s l e f t w i t h a d e f

i n i t e a n d f

i r m c o n v i c t i o n t h a t t h e

S e c r e t a r y c o m m i t t e d a c l e a r j u d g m e n t e r r o r i n r e a c h i n g i t s c o n c l u s i o n a f t e r w e i g h i n g t h e

r e l e v a n t f

a c t o r s

. ” G o l d e n L i v i n g C t r

. - F r a n k f o r t v

. S e c '

y O f H e a l t h A n d

H u m a n S e r v s

. , 6 5 6

F

. 3 d 4 2 1

, 4 2 9 ( 6 t h C i r

. 2 0 1 1 )

.

A l t h o u g h t h e C e n t e r a r g u e s t h a t t h e C M P s h o u l d b e l i m i t e d t o t h e d a y o f R e s i d e n t 1 ’ s

d e a t h

, w e d o n o t b e l i e v e t h a t i t w a s a c l e a r e r r o r f o r C M S t o i m p o s e i t f

r o m J a n u a r y 3

, 2 0 0 7

( t h e d a y o f R e s i d e n t 1 ’ s d e a t h ) t h r o u g h M a r c h 2 7

, 2 0 0 7

. I n h i s f i n a l d e c i s i o n

, t h e A L J n o t e d

t h a t C M S d i d n o t d e e m t h e “ i m m e d i a t e j e o p a r d y c a n c e l e d ” u n t i l t h e C e n t e r h a d c o n d u c t e d

a d d i t i o n a l i n

- s e r v i c e s r e g a r d i n g p h y s i c i a n n o t i f i c a t i o n

, d o c u m e n t a t i o n

, a n d c a r r y i n g o u t

p h y s i c i a n o r d e r s

. T h e C e n t e r f a i l s t o d e m o n s t r a t e h o w s u c h c o n c l u s i o n w a s “ c l e a r e r r o r

. ”

T h e C e n t e r a l s o a r g u e s t h a t t h e h o l d i n g i n G o l d e n L i v i n g C t r

. - F r a n k f o r t ( a s i d e n t i f

i e d

i n o t h e r D A B d e c i s i o n s ) r u n s a f o u l o f § § 5 5 6 ( d ) a n d 7 0 6 ( 2 ) ( A ) o f t h e A d m i n i s t r a t i v e

P r o c e d u r e A c t

. T h e C e n t e r ’ s a r g u m e n t o n t h i s p o i n t i s u n p e r s u a s i v e a n d w e d e c l i n e t o

o v e r t u r n p r e c e d e n t b a s e d o n i t

.

C

. T h e A L J ’ s C r e d i b i l i t y D e t e r m i n a t i o n

11No. 12-4420

T h e C e n t e r c l a i m s t h a t t h e D A B i m p r o p e r l y r e v e r s e d t h e A L J ’ s i n i t i a l d e c i s i o n t h a t

N u r s e S u f

f o l e t t a w a s c r e d i b l e a n d t h a t i t d i d s o b a s e d o n e v i d e n c e t h a t C M S r a i s e d f o r t h e

f i r s t t i m e o n a p p e a l

. A f t e r a t h o r o u g h r e v i e w o f t h e r e c o r d

, w e f i n d n o b a s i s f

o r e i t h e r

a r g u m e n t

.

F i r s t

, t h e D A B d i d n o t r e v e r s e t h e A L J ’ s d e t e r m i n a t i o n t h a t N u r s e S u f f o l e t t a w a s

c r e d i b l e ; r a t h e r

, t h e D A B n o t e d s e v e r a l p i e c e s o f e v i d e n c e t h a t “ u n d e r c u t [ ] t h e A L J ’ s

a s s e s s m e n t o f N u r s e S u f f o l e t t a ’ s c r e d i b i l i t y ” a n d d i r e c t e d “ t h e A L J o n r e m a n d t o r e e v a l u a t e

a n d d i s c u s s h i s p r i o r a s s e s s m e n t o f N u r s e S u f f o l e t t a ’ s c r e d i b i l i t y a n d t h e r e l i a b i l i t y o f h e r

h e a r i n g t e s t i m o n y a n d n u r s i n g n o t e s i n l i g h t o f t h e c o n f l i c t i n g e v i d e n c e d i s c u s s e d i n t h i s

d e c i s i o n

. ” F a r f

r o m r e v e r s i n g t h e A L J ’ s c r e d i b i l i t y d e t e r m i n a t i o n

, t h e D A B w a s s i m p l y

a s k i n g f o r t h e A L J t o a d d r e s s c o n f l i c t i n g e v i d e n c e s o t h e D A B c o u l d p r o p e r l y r e v i e w h i s

f i n d i n g s

. S e c o n d

, t h e c o n f l i c t i n g e v i d e n c e t h a t t h e D A B c i t e d w a s r e f e r e n c e d i n e i t h e r

12No. 12-4420

C M S ’ s S O D o r t h r o u g h t e s t i m o n y a t t h e F e b r u a r y 1 9

, 2 0 0 8 A L J h e a r i n g

. T h e C e n t e r ’ s 9

a l l e g a t i o n t h a t s u c h e v i d e n c e w a s p r e s e n t e d f o r t h e f i r s t t i m e o n a p p e a l i s b a s e l e s s

.

A F F I R M E D

.

T h e D A B ’s fi rs t fi n d in g th at th e C en te r ch al le n ges con cer n ed w h et h er R esi d en t 1 vom it ed bet w een 9

mi d n igh t an d 1 a.m . on J an u ar y 3 , 20 0 7

. I t is u n d is pu te d th at , at th at ti me , Nu rs e Su ff ole tt a no ti ced som e

vom it on R esi d en t 1 ’s n igh tgo w n

. T h e A LJ in it ia ll y d et er mi n ed th at th e vom it w as li kel y “ th e fi n al

, mu ch

le ss- ser iou s, ma n if

est at ion of th e epi sod e th at h ad beg u n ear li er in th e eve n in g.” O n in it ia l re vie w

, th e D A B

n ote d th at th is fi n d in g con fl ic te d w it h a st at em en t N u rs e S u ff ole tt a ma d e to a su rve yor w h er e sh e “ re vea le d

th e re si d en t vom it ed aga in bet w een 1 2 :0 0 a.m

. an d 1 :0 0 a.m .” O n re ma n d

, th e D A B in st ru ct ed th e A LJ to

ad d re ss th is in con si st en cy. T h is st at em en t w as con ta in ed in C M S ’s S O D

. T h e seco n d fi n d in g th at th e C en te r c h al le n ges con cer n ed w h et h er N u rs e S u ff ole tt a t ook R esi d en t

1 ’s vit al si gn s in th e 1 2 h ou rs pre ced in g R esi d en t 1 ’s tr an spo rt by E M S

. T h e A LJ in it ia ll y d et er mi n ed th at

N u rs e S u ff

ole tt a too k (bu t fa il ed to re cor d ) R esi d en t 1 ’s vit al si gn s tw ic e bet w een 8 p.m

. on J an u ar y 2 an d

2 a. m

. o n J a n u a r y 3

, an d th at su ch vit al si gn s w er e n orm al

. T h e A LJ bas ed th is fi n d in g on N u rs e

S u ff ole tt a’ s te st im on y (w h ic h h e in it ia ll y fou n d cr ed ibl e) an d on th e fa ct th at “ C M S n eve r d is pu te d w h et h er

N u r se S u ff

ole tt a or [ th e C en te r] st af f act u al ly too k R esi d en t 1 ’s vit al si gn s an d d id n ot d i s p u t e t h a t

‘d ocu me n ta ti on by ex cep t i o n ’ i s a com mo n pra ct ic e.” T h e D A B re ma n d ed th is fi n d in g so th at th e A LJ

cou ld con si d er an d ad d re ss: (1 ) N u rs e S u ff ole tt a’ s st at em en ts to su rve yors w h er e sh e ad mi tt ed sh e d id n ot

ta ke R esi d en t 1 ’s vit al s af te r ei th er th e 8 p.m

. vom it in g epi sod e or af te r th e 1 a.m

. epi sod e; (2 ) te st im on y

fr om R esi d en t 1 ’s gra n d d au gh te r (w h o w as pre sen t th at n igh t) th at sh e ne ver obs er ved a Ce n te r em plo yee

ta ke R esi d en t 1 ’s vit al s ; ( 3 ) N u r s e S u ff ole tt a’ s equ ivo cal te st im on y th at som eon e el se “ pro bab ly” too k

R esi d en t 1 ’s vit al s at th e ti me in qu est ion ; an d (4 ) t h e s u rve yor’s n ote s i n th e S O D th at in d ic at ed th at th e

C N A re spo n si ble fo r R esi d en t 1 on th e n igh t i n qu est ion d id n ot ta ke h er vi ta l s ign s.

13