Court Opinion

ID: 9497119
Source: CourtListenerOpinion
Date Created: 2023-08-05 16:43:38.22835+00
Date Added: 2024-06-11T17:58:00.670515
License: Public Domain

KENNEDY, Circuit Judge,
concurring in part, and dissenting in part.
I agree with the majority that the ALJ can grant a summary judgment without an in-person hearing and I agree that Crest-view’s argument about its ability to pay is without merit. However, I respectfully dissent from the majority’s finding that *758there ■ are unresolved factual disputes in this case.
The majority found that the ALJ committed a procedural error by canceling the in-person hearing on December 12, 2001 before any motion for summary judgment had been filed. In my opinion, the record before us does not support that legal conclusion. CMS stated in the conclusion to its Pre-Hearing Brief filed on October 19, 2001 that “should Crestview not raise a credible dispute to any material fact in its Response to CMS’ Pre-hearing Brief, then this tribunal should grant CMS a summary affirmance of its determinations in this matter.” CMS Pre-hearing Br. at 32. In my opinion, the ALJ was fully within her discretion when, upon receiving the parties’ pre-hearing briefs, she converted CMS’ Pre-hearing brief into a motion for summary judgment. Furthermore, CMS’ Reply Brief actually included a motion for summary judgment. ' It is true that the Reply Brief was not filed until December 17, 2001. However, the reply brief was already scheduled to be filed prior to the December 12, 2001 letter and, more importantly, the ALJ afforded Crestview an opportunity to respond, in writing, to the motion.
I also disagree with the majority’s conclusions with respect to Residents 44, 68, and 90. Crestview argued, and the majority agrees, that genuine issues of material fact remain as to whether it provided necessary care and services to Residents #’s 44 and 90. However, the ALJ found, and Crestview does not dispute, that Resident # 44’s care plan called for heel protectors at all times (with ankle rings) and bilateral elbow protectors at all times, and that Resident # 90’s care plan called for heel protectors, elbow protectors, and 'Cone splint from 7 am to 7 pm. The survey also charged that on each of the three days of the August survey, at several different times of the day, Patient #44 was observed without protectors and Resident # 90, who. had a history of skin breakdowns, was observed sleeping without such protectors and seated in chairs on two occasions without elbow protectors. .The regulations require that the facility provide care “in accordance with the comprehensive assessment and plan of care.” 42 C.F.R. § 483.25. Crestview, in contesting these two charges before the ALJ, indicated its position was that the protective pads were removed by the staff to check and access the skin. No specific witnesses were mentioned to substantiate that claim. Nor do the disclosures of Crestview’s administrative and nursing personnel contain any reference to this claim. Hrybiniak, in her disclosure, does mention that residents do remove protectors. She also states ■ that whether protectors are needed is a nursing judgment and that they are not needed when patients are in bed on a pressure relieving mattress. Crestview’s brief in response to the motion for summary judgment argues only that the protective pads were not needed because the patients were on pressure-relieving mattresses. The ALJ found that the claim that the protectors were removed for examination or bathing was unsupported and refuted by the circumstances of the observations, and that it was a violation of the regulations to fail to carry out the doctors’ directions. The ALJ also noted that these patients’ records include no notations that these patients removed other protecting pads. The ALJ concluded that there was no material issue of fact with respect to whether the physicians’ orders had not been complied with.
Crestview also argued, and the majority agrees, that genuine issues of material fact remain as to whether Crestview failed to ensure that one of its residents not develop avoidable pressure sores, and failed to ensure that a resident having pressure sores *759received the treatment and services necessary to promote healing, prevent infection, and prevent new sores from developing. More specifically, Resident # 68 was diagnosed with multiple sclerosis, dysphagia, iron deficient anemia, and dermatitis. As of July 23, 1999, her pressure sores had healed. Her physician ordered pillowed pressure relieving devices on both feet and both elbows at all times. Resident # 68 was unable to position herself. On two different days, the surveyor observed Resident # 68 without a relieving device on her left elbow. On August 11, 1999, the surveyor observed that Resident # 68 had pressure sores on her left hip, left buttock area, and left elbow. I agree with the ALJ that:
The facility is obliged to go beyond what seems reasonable to, instead, always furnish what is necessary to prevent new sores unless clinically unavoidable, and to treat existing ones as needed. Koes-ter, DAB No. 1750, at 32. Allowing Resident # 68, a high-risk individual to lie, unprotected, on vulnerable points, in contravention of physician orders, does not establish that the facility took “all necessary precautions.”
Crestview Parke Care Ctr., DAB CR867, at 28.
In summary, these Residents had specific needs that were addressed in their physicians’ orders. Crestview did not comply with those orders. I would end the inquiry at this point. The majority, on the other hand, has decided to allow Crestview to essentially challenge the “wisdom” and/or “practicality” of those specific orders in the administrative hearing, and, in the case of Resident # 68, to argue whether a violation of the physician’s orders was the actual cause of the pressure sore. This decision, in my view, would cause shambles in the administrative oversight of the nursing facilities because it frees these facilities from having to comply with the physician’s orders. Instead of simply checking to see whether the facilities complied with the physicians’ orders, the ALJs will be required to conduct hearings to weigh the advantages and the disadvantages of the alternative courses of care provided by the facilities. In my opinion, disagreement with the necessity of strict compliance with physicians’ orders ought to be made in the discussions between the physicians and the facility administrators at the time of the physicians’ orders. Congress has authorized the ALJs to simply review the facilities’ compliance with the physicians’ orders; it did not authorize them to review the wisdom or the practicality of those orders.