Court Opinion

ID: 9962158
Source: CourtListenerOpinion
Date Created: 2024-04-22 20:24:36.75235+00
Date Added: 2024-06-11T08:19:56.602694
License: Public Domain

IN THE INTERMEDIATE COURT OF APPEALS OF WEST VIRGINIA

                                                                              FILED
JENNIFER JORDAN,                                                           April 22, 2024
Appellant Below, Petitioner                                             ASHLEY N. DEEM, DEPUTY CLERK
                                                                       INTERMEDIATE COURT OF APPEALS
                                                                              OF WEST VIRGINIA
v.) No. 23-ICA-263          (Bd. of Review, Case No. 22-BOR-2409)

WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES,
BUREAU FOR SOCIAL SERVICES,
Respondent Below, Respondent

                             MEMORANDUM DECISION

       Petitioner Jennifer Jordan appeals the May 19, 2023, Decision of State Hearing
Officer from the West Virginia Department of Health and Human Resources’ Board of
Review (“Board”). This Decision upheld the West Virginia Department of Health and
Human Resources, Bureau for Social Services’ (“Bureau”) administrative finding of
maltreatment committed by Ms. Jordan based upon its determination that she failed to
distribute medications to multiple nursing home residents where she was employed as a
nurse. The Bureau filed a response.1 Ms. Jordan did not file a reply. The issue on appeal is
whether the Board’s decision was supported by the evidence presented at the administrative
hearing.

       This Court has jurisdiction over this appeal pursuant to West Virginia Code § 51-
11-4 (2022). After considering the parties’ arguments, the record on appeal, and the
applicable law, this Court finds that the Board’s decision lacks sufficient findings of fact
and conclusions of law for a meaningful appellate review. Accordingly, a memorandum
decision vacating the decision and remanding the matter to the Board for entry of an
amended decision is appropriate under the “limited circumstances” requirement of Rule
21(d) of the Rules of Appellate Procedure.

       The underlying events occurred in June of 2022. According to the Board’s decision,
Ms. Jordan was employed at Mountain View Care Center as a nurse and regularly worked
the 7:00 p.m. to 7:00 a.m. shift. One of her duties was to distribute medication to nursing
home residents. It was common practice for the nurses at this facility to share a medication
cart containing blister packs of the various medications to be distributed.

       1
       Ms. Jordan is represented by Todd W. Reed, Esq. The Bureau is represented by
Chaelyn W. Casteel, Esq.
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       A staff nurse who routinely used the medication cart after Ms. Jordan’s shift
expressed a concern to the Assistant Director of Nursing, Heidi Oldham (“Assistant
Director Oldham”), that medications were not being properly distributed and were being
returned to the pharmacy. Assistant Director Oldham reported this concern to the Director
of Nursing, Sheila Massey (“Director Massey”).

       Director Massey discussed the concern with Unit Manager, Amy Balcoe (“Unit
Manager Balcoe”). Thereafter, they instituted a medication audit for Ms. Jordan’s shift. On
June 2, 2022, Unit Manager Balcoe counted and marked certain blister packs of medication
which were scheduled to be distributed during Ms. Jordan’s shift. She then wrote the date
and number of medications in each medication package and provided the information to
Director Massey.

       On the morning of June 3, 2022, after the conclusion of Ms. Jordan’s shift, Director
Massey counted the medications that were previously marked and counted by Unit
Manager Balcoe. Director Massey found that thirteen residents failed to receive thirty-two
medications during Ms. Jordan’s shift, and that all but one of those residents were non-
verbal or without mental acuity. It was determined that Ms. Jordan had logged the
medications as administered to those residents in the facility’s electronic medication
distribution records.

       A referral was made to Adult Protective Services (“APS”), a division of the Bureau,
alleging that Ms. Jordan’s actions constituted maltreatment in the form of neglect. Ms.
Jordan categorically denied the allegation that she failed to distribute the medications. An
APS worker investigated the allegations; and at the conclusion of the investigation, the
APS worker determined that Ms. Jordan neglected the thirteen residents by failing to
distribute prescribed medications.2 Ms. Jordan challenged this finding.

       An evidentiary hearing was held before the Board’s hearing officer on March 6,
2023. At the hearing, the Board presented the testimony of several witnesses, including,
among others, Assistant Director Oldham, Unit Manager Balcoe, Director Massey, and the
APS worker. Ms. Jordan testified on her own behalf. According to the Board’s decision,
four exhibits were admitted into the record. On May 19, 2023, the Decision of State
Hearing Officer, containing just over four pages, was entered by the Board. After making
limited findings of fact, the Discussion section of this Decision states, in its entirety, as
follows:

       [APS] conducted an assessment into neglect allegations of [thirteen]
       Mountain View Care Center residents by [Ms. Jordan]. At the conclusion of
       the assessment, neglect was substantiated against [Ms. Jordan] for a failure

       2
         According to the parties’ briefs, Ms. Jordan was terminated from her employment
due to the finding of maltreatment.
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to provide necessary care by failing to distribute prescribed medications.
[Ms. Jordan] contests the [Bureau]’s finding.

To substantiate a finding of maltreatment against [Ms. Jordan] for neglect
under W. Va. Code § 9-6-1, the [Bureau] must show that [Ms. Jordan]
unreasonably failed to provide the care necessary to maintain the safety or
health of the [thirteen] Mountain View Care Center residents T.C., G.M.,
D.H., G.F., S.H., D.B., A.C., V.M., Z.P., D.C., E.M., T.S., and L.C. A
preponderance of evidence standard is applied.

The reliable evidence presented shows that [Ms. Jordan] was a nurse at
Mountain View Care Center responsible for passing medications on the 7p
to 7a shift. On June 2 to 3, 2022, [Ms. Jordan] failed to pass medications to
[thirteen] residents, [twelve] of which were non-verbal or without mental
acuity. Certain medications were counted by supervising nurses before and
after [Ms. Jordan]’s shift. Those counts indicated that a total of [thirty-two]
prescribed medications were not distributed by [Ms. Jordan], despite being
recorded as delivered by [her].

[Ms. Jordan] argues that she did pass the medications to the [thirteen] facility
residents. [Ms. Jordan]’s argument is without credibility or evidentiary
support. [Ms. Jordan] argues that the lack of detailed records or photos of the
count rendered the findings unreliable. Both nurses who testified at the
hearing regarding their accounting procedures were credible and persuasive.
For [Ms. Jordan]’s argument to be correct it would require multiple facility
staff to conspire together to fabricate information, which is not supported by
the evidence presented.

Based on the above, the [Bureau] correctly substantiated neglect against [Ms.
Jordan]. The evidence presented shows that [Ms. Jordan] failed to provide
the care necessary to maintain the safety or health of T.C., G.M., D.H., G.F.,
S.H., D.B., A.C., V.M., Z.P., D.C., E.M., T.S., and L.C. by failing to
distribute prescribed medication as required.

Based on that reasoning, the Decision made the following conclusions of law:

1. The [Bureau] correctly substantiated neglect against [Ms. Jordan].

2. The evidence presented shows that [Ms. Jordan] failed to provide the care
necessary to maintain the safety or health of Mountain View Care Center
residents T.C., G.M., D.H., G.F., S.H., D.B., A.C., V.M., Z.P., D.C., E.M.,

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       T.S., and L.C. R.G. [sic] by failing to distribute prescribed medications as
       required.3

       3. [Ms. Jordan]’s argument that the lack of detailed records or photos of the
       count rendered the findings unreliable is not persuasive as both nurses who
       testified at the hearing regarding their accounting procedures were credible
       and reliable. For [Ms. Jordan]’s argument to be true it would require multiple
       facility staff to conspire together to fabricate information, which is not
       supported by the evidence presented.

     This appeal followed. Our review of this matter is governed by the State
Administrative Procedures Act, which provides:

       The court may affirm the order or decision of the agency or remand the case
       for further proceedings. It shall reverse, vacate, or modify the order or
       decision of the agency if the substantial rights of the petitioner or petitioners
       have been prejudiced because the administrative findings, inferences,
       conclusions, decision, or order are:
       (1) In violation of constitutional or statutory provisions;
       (2) In excess of the statutory authority or jurisdiction of the agency;
       (3) Made upon unlawful procedures;
       (4) Affected by other error of law;
       (5) Clearly wrong in view of the reliable, probative, and substantial evidence
       on the whole record; or
       (6) Arbitrary or capricious or characterized by abuse of discretion or clearly
       unwarranted exercise of discretion.

W. Va. Code § 29A-5-4(g) (2021); accord W. Va. Code § 16-1-22a (2023) (stating that the
exclusive remedy for judicial review of Board decisions is governed by West Virginia Code
§ 29A-5-1).4 Further, “[t]he ‘clearly wrong’ and the ‘arbitrary and capricious’ standards
of review are deferential ones which presume the agency’s actions are valid as long as the
decision is supported by substantial evidence or by a rational basis.” Syl. Pt. 3, In re Queen,
196 W. Va. 442, 473 S.E.2d 483 (1996).

       3
         We presume R.G. to be a typographical error as there is no patient identified as
R.G. elsewhere in the Decision as the other thirteen patients have been consistently
identified.
       4
         This statute was repealed on February 8, 2024, and replaced by West Virginia
Code § 16B-2-2 (2024); however, the judicial review procedure remains substantively
unchanged. The former version of the statute is cited here as it was the statute in effect at
the time this appeal was filed.

                                              4
       On appeal, Ms. Jordan primarily argues that the Board’s findings of fact and
conclusions of law are not supported by the evidence presented at the administrative
hearing. Conversely, the Bureau contends there was no error, and that the Board’s findings
of fact and conclusions of law are entitled to deference. Upon review, we find that the
Board’s decision lacks adequate findings of fact and conclusions of law for this Court to
conduct a meaningful appellate review as required by the governing standard of review.

       Prior to making its findings of fact, the Decision states: “After a review of the
record, including testimony, exhibits, and stipulations admitted into evidence at the
hearing, and after assessing the credibility of all witnesses and weighing the evidence in
consideration of the same, the following findings of fact are set forth.” However, the
Decision lacks substantive findings, discussion, and analysis of the testimony, exhibits, and
stipulations that were part of the evidentiary record below. It also fails to support its
credibility determinations with sufficient findings and analysis of the witnesses’ testimony
provided below. Instead, the Board’s findings of fact consist of twenty-six numbered
paragraphs, each consisting of only one or two sentences with cursory findings, and with
thirteen of those paragraphs reserved for each of the thirteen residents that Ms. Jordan
allegedly neglected with a single sentence identifying them by initials and listing the
medications that she was alleged to have not administered. Likewise, the Decision’s
Discussion and Conclusions of Law sections also contain insufficient development and
analysis.

       Without the Board providing detailed findings of fact and conclusions of law that
are supported by adequate analysis, this Court is left to speculate as to the reasonings
behind its Decision. However, courts cannot engage in speculation, and we refuse to do so
here. While administrative decisions, as a general rule, are entitled to deference, we find
the decision below fails to conduct the necessary factual and legal analysis of the evidence
presented below for this Court to determine whether the Board is entitled to deference in
this case. Absent amplified findings of facts and conclusions of law, this Court is not in a
position to rule on the merits of the Board’s Decision or the merits of Ms. Jordan’s
arguments on appeal.

       As our Supreme Court of Appeals has recognized:

       Without findings of fact and conclusions of law, [an appellate court] is unable
       to determine the basis for the court's decision and whether any error has
       occurred. Consequently, in cases where there is an absence of adequate
       factual findings, it is necessary to remand the matter to the lower court to
       state or, at a minimum, amplify its findings so that meaningful appellate
       review may occur.

Mullins v. Mullins, 226 W. Va. 656, 662, 704 S.E.2d 656, 662 (2010) (citation omitted).
We have previously found this rationale to be equally applicable to administrative agency

                                             5
decisions. See, e.g., Logan Gen. Hosp., LLC v. Boone Mem’l Hosp., Inc., No. 23-ICA-134,
2023 WL 7203357, at *3 (W. Va. Ct. App. Nov. 1, 2023) (memorandum decision)
(vacating and remanding an administrative agency decision for entry of a more detailed
order).

       Accordingly, we vacate the Board’s May 19, 2023, Decision, and remand the matter
to the Board for entry of an amended order setting forth findings of facts and conclusions
of law sufficient to allow for meaningful appellate review should Ms. Jordan elect to file a
new appeal.

                                                                  Vacated and Remanded.

ISSUED: April 22, 2024

CONCURRED IN BY:

Chief Judge Thomas E. Scarr
Judge Charles O. Lorensen
Judge Daniel W. Greear

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