Case Name: James ROBERSON v. PROVIDENT HOUSE
Court: Louisiana Court of Appeal
Jurisdiction: Louisiana
Decision Date: 1990-03-14
Citations: 559 So. 2d 838
Docket Number: No. 88-CA-2406
Parties: James ROBERSON v. PROVIDENT HOUSE.
Judges: Before BARRY, WARD and WILLIAMS, JJ.
Reporter: Southern Reporter, Second Series
Volume: 559
Pages: 838–845

Head Matter:
James ROBERSON v. PROVIDENT HOUSE.
No. 88-CA-2406.
Court of Appeal of Louisiana, Fourth Circuit.
March 14, 1990.
Rehearing Denied May 17, 1990.
James S. Conner, Sr., Kenner, in pro. per., and for plaintiff-appellant.
C. Wm. Bradley, Jr., Lemle, Kelleher, Kohlmeyer, Dennery, Hunley, Moss & Fri-lot, New Orleans, for defendants-appellees.
Before BARRY, WARD and WILLIAMS, JJ.

Opinion:
WARD, Judge.
James Roberson appeals the dismissal of his personal injury lawsuit against the defendant nursing home.
Roberson sued Gemar, Inc., d/b/a Provident House (nursing home), its insurer Western World Insurance Company, and Dr. Joseph Brenner, his physician at the home. Roberson alleged that while he was at Provident House a catheter was implanted which caused an infection and bleeding. Roberson dismissed Dr. Brenner, a medical health care provider under La.R.S. 40:1299.47(B), because a complaint was not filed with the Medical Review Panel.
In a supplemental petition Roberson alleges that a catheter was inserted on April 20 and removed May 2, re-inserted May 7 and removed May 9, 1982. Roberson also alleged pain and mental anguish because Provident's employees failed to clean his room and eradicate roaches which crawled on his body. St. Paul Fire and Marine Insurance was substituted as insurer of Provident House and Western World Insurance was dismissed with prejudice.
TESTIMONY AND EVIDENCE
Roberson's deposition was admitted in lieu of live testimony. La.C.C.P. art. 1450. Roberson stated he has been a quadriplegic after being shot during a robbery in 1972. He was in several Veterans Administration hospitals over the years including the hospital in New Orleans. He often lives with Marcelle and James Conner (his sister and her husband) but resides in a nursing home when they are unable to care for him.
Roberson stated that when he was in a nursing home only an external catheter was used. He testified that a Memphis V.A. doctor had warned not to insert a catheter into his bladder because it would cause bladder spasms and the inability to urinate. Roberson said an external catheter never caused a problem. Doctors tried an internal catheter in the Memphis hospital years ago but he could not urinate.
Roberson stated he went to Provident House in March, 1982 and a lady questioned him about the kind of food he liked and his hobbies, but he was never questioned about a catheter or medical matters. He claimed that Provident House employees did not take proper care of his external catheter.
Roberson said no one consulted him about changing the external catheter to an indwelling Foley catheter. He said he told the nurse that he did not want the internal catheter and he begged her not to insert it. She told him to shut up when he warned her that he could not tolerate an internal catheter.
Roberson testified it took about two days before he experienced pain and a burning sensation after the indwelling catheter was inserted and a nurse removed the catheter. Roberson tried to stop the nurse before it was re-inserted. Subsequently Roberson complained, the nurse got aggravated, jerked the catheter out, and blood ran from his penis. Roberson was rushed by ambulance to the Y.A. hospital and remained there for a number of days. When he was returned to Provident House his sister removed him from the premises.
When asked by defense counsel whether he experienced an irritation of the penis at Provident House, Roberson stated he did not. When defense counsel continued to ask whether Roberson could see if his penis was irritated, Roberson clearly stated that he could feel an irritation and that he was not "stupid." Roberson said he did not have an infection while at Provident House or when he arrived at the V.A. hospital. The V.A. hospital record indicates there was no infection. Roberson stated that he still experiences a burning sensation (which he did not have prior to the "jerking" incident) while urinating and takes medication for the problem.
Roberson's sister, Marcelle Conner, testified she cared for her brother for many years except when she was in the hospital. She stated that prior to the subject incident at Provident House her brother's urine was clear. During the day he used a urinal and at night an outdwelling catheter. She emphatically stated her brother was not incontinent, never previously had urinary infections, and he could tell her when he needed the urinal.
Mrs. Conner stated she was contacted by telephone by a Provident House representative who informed her that a Foley catheter was to be inserted. She was very upset and told the nursing home representative: "Please don't do this thing." After Roberson was rushed to the V.A. hospital, she testified he stayed for eight or nine days.
Mrs. Conner said her brother does not urinate as well as in the past and he experi-enees a lot of pain. His urine has a dark color and he has urinary tract infections. His output decreased from about 1200 c.c. to 150 c.c. daily. Although he had been able to sit in his wheelchair for hours, now his kidneys hurt and wheelchair time has been severely restricted. On cross-examination Mrs. Conner stated that an indwelling catheter had been tried years earlier at a V.A. hospital and the doctors told her never to let an indwelling catheter be used because it could be fatal. Although she thought the V.A. hospital had sent written orders as to the use of a urinal and outd-welling catheter, Provident House records do not contain such instructions.
James Conner, Roberson's brother-in-law with his power of attorney, testified that he went with Roberson on his first day at Provident House. Roberson was taken by ambulance and Conner brought personal items including a pot chair, wheelchair, a lift to get Roberson out of bed, cotton pads, and a bag of 40 or 50 outdwelling catheters provided by the V.A. hospital.
The Provident House charts and medical records show Roberson was admitted March 15, 1982 and Dr. Joseph Brenner was his doctor. Dr. Brenner, internist, testified as to his relationship with Provident House and said its records did not contain written V.A. instructions in March, 1982. Roberson's health care plan dated March 17, 1982 provided that incontinence should be handled by:
a) External catheter
b) Assist to commode chair or
c) Diapers.
There is no mention of an internal catheter until an April 9, 1982 entry on the physician's order sheet which states: "Insert Foley (PRN)." Dr. Brenner testified that a nurse informed him that the external catheter was ineffective and irritation was occurring. No nurse testified. On April 9, 1982 Dr. Brenner told the nurse to insert the catheter "PRN", i.e., as needed. He said his decision to use the internal catheter was based on the nurse's report, but the doctor conceded that he never spoke to Roberson about his medical history or asked him about prior use of catheters or prohibitions.
The nurse's entry for April 20, 1982 shows the Foley catheter was inserted. The April 23, 1982 nurse's summary reflects:
Incontinent of urine & feces. Ext. cath D/ced due to irritation & ineffective. Foley cath inserted....
A nurse's notation on April 30, 1982 (the numbers are almost illegible) provides:
Family called and stated that they wanted internal cath. taken out and who (almost illegible) gave the order to put in (almost illegible) an external cath. Family stated that they want the internal cath. taken out.
The nurse's May 2 note shows the Foley catheter was removed "do burning sensation — and family also complained about fo-ley — " Dr. Brenner testified the Foley catheter was re-inserted May 7, 1982 and he saw Roberson May 11, 1982 but made no notation. The May 11, 1982 nurse's summary states Roberson was very upset when the catheter was inserted and his sister over-reacted when the family was notified.
Roberson complained of pain in the area of the catheter and it was removed on May 19, 1982. The nurse's notes show there was bright red blood when the catheter was removed. Dr. Brenner was called and he advised that Roberson be sent to the V.A. hospital for emergency treatment.
The V.A. hospital records cover May 19-May 28, 1982, therefore the V.A. instructions to Provident House in March, 1982 are not included. The hospital summary listing the admission date of May 19, 1982 provides Roberson's history:
He was seen initially in the Emergency Room with a gross bloody discharge from the meatus after a history of attempted urethral catheterization at the Nursing Home for questionable incontinence . He gave no history of previous urinary tract infection, pyelonephro-sis or previous GE surgery. At the time of admission he had an external Foley catheter....
On May 19, 1982 the diagnosis was gross hematuria [discharge of urine containing blood]. The reason for admission was "blood & pus coming from penis." The consultation sheet (May 21, 1982) states that Roberson is a sixty-year-old quadriplegic admitted "due to blood & pus from penis_ Urethral foley catheterization was attempted and caused bleeding."
The doctor's discharge note on May 27, 1982 lists the diagnosis as: (1) traumatic catheterization; (2) quadriplegic; (3) neuro-genic bladder. The clinical record signed by Dr. Weiner contains specific instructions to the patient and/or family upon Roberson's discharge on May 27, 1982:
It was requested that an external catheter be used and that an indwelling Foley catheter not be inserted into his bladder for incontinence as another episode of gross hematuria might well ensue and since his urine was uninfected he is stable with an external Foley catheter.
Dr. John Potter, general practitioner, had treated Roberson in the past. He testified that the external outdwelling condom is preferred to an internal catheter which is much more dangerous and causes trauma. The internal catheter tends to cause inflammatory problems and infections when used for long periods of time (as with a-quadriplegic). An external catheter can be cared for by washing the penis with water or a soft saline solution once or twice a day. Dr. Potter emphatically stated the external catheter is always preferred, especially for a quadriplegic in a nursing home. He clearly stated that irritation would not be a cause to switch to an internal catheter. When a quadriplegic is admitted to a hospital on an emergency basis it is standard procedure to insert an indwelling catheter.
Dr. Potter stated the penis is highly sensitive and the more it is traumatized, the more sensitive it becomes. Jerking the tube out of a patient's urethra which is tied in by an inflated catheter can cause ex treme irritation, trauma, and bleeding. When asked what future problems Roberson might face because of the "jerking" incident at Provident House, the doctor said that the more an internal catheter is used, the more irritation and scar tissue builds up. There is stenosis (constriction or narrowing) and it becomes increasingly difficult to eatheterize the patient. The build up of scar tissue more likely than not will result in reduced urinary output. Dr. Potter stated that a reduction from 1200 c.c. to 150 c.c. daily indicates a urinary problem.
On cross-examination Dr. Potter read from the V.A. entry which stated Roberson had a gross bloody discharge from the penis after attempting to eatheterize him for questionable incontinence at the nursing home. Dr. Potter stated there was no history of a urinary infection or bleeding at Provident House, therefore, he would very strongly consider that the catheterization manipulation produced the injury and blood.
When asked whether he would question Roberson's treating physician's decision to write an order that an indwelling catheter could be used PRN, Dr. Potter emphatically stated he would question that decision. He testified that irritation from an external catheter does not warrant changing to an indwelling catheter.
On redirect Dr. Potter said it is standard medical practice to ask a patient for a medical history and to inquire about prior use of an internal catheter.
TRIAL COURT'S REASONS AS TO NEGLIGENCE
The trial court's reasons noted Roberson's allegation that as a result of the implantation of the indwelling catheter he began to discharge blood which caused an infection. The trial court concluded:
In the absence of a showing of negligence or the breach of a standard-of care by Gemar, Inc., d/b/a Provident House, its agents, servants and employees with respect to the injury or complaints of the plaintiff, and the Court being of the opinion that the care and treatment of the plaintiff by Gemar, Inc., its agents, servants and employees was at all times reasonable and proper and within the standard of care required of similar institutions, the suit will be dismissed with prejudice at plaintiff's cost.
SPECIFICATIONS
Roberson's appeal brief specifies three trial court errors:
1. Disregard of his deposition which specifies a tear in his urinal tract was caused by the nurse who jerked out the catheter.
2. Failure to consider Dr. Potter's testimony as to the injury and its consequences.
3. Failure to consider that Dr. Brenner acknowledged that the | injury was serious enough to send Roberson to the V.A. hospital for emergency treatment.
The trial court limited its conclusion to the issue of negligence (as pleaded in Roberson's petition) and concluded Roberson did not carry his burden of proving a breach in the standard of care of the nursing home.
It is the duty of a nursing home to provide a reasonable standard of care taking into account the patient's mental and physical condition. Doxey v. Riverside Guest Care Center, 520 So.2d 1118 (La.App. 3rd Cir.1987). Whether Provident House breached its duty of care to Roberson is an issue of fact to be determined by the trier of fact and cannot be disturbed on appeal absent a finding of manifest error. Lemoine v. Insurance Company of North America, 499 So.2d 1004 (La.App. 3rd Cir.1986), writ denied 501 So.2d 199 (La.1986).
Considering the record and lack of expert testimony to establish the standard of care, we cannot conclude the trial court was manifestly erroneous as to the negligence issue.
AFFIRMED.
. Although Roberson's deposition contains hearsay as to V.A. catheter instructions and defendants/appellees so argue in their brief, the testimony was not objected to at trial. Roberson's statements as to his protests against the indwelling catheter are not hearsay.
. Roberson's counsel stipulated that the issue of urinary infections would not be considered if damages were awarded.
. Roberson's counsel tried to elicit this testimony during direct examination, but his questions were met by defense objections. The court allowed statements as to V.A. hospital instructions given to Mrs. Conner for the limited purpose of explaining why she reacted as she did when she learned about the indwelling catheter.
. Roberson submitted to this Court a copy of a newspaper article on Provident House's problems. We cannot consider any documentation that was not before the trial court. Puccio v. Finch, 438 So.2d 597 (La.App. 4th Cir.1983).