Court Opinion

ID: 4661488
Source: CourtListenerOpinion
Date Created: 2021-02-19 15:04:55.499411+00
Date Added: 2024-06-11T08:02:13.718003
License: Public Domain

IN THE SUPREME COURT OF IOWA
                                No. 19–0981

            Submitted November 17, 2020—Filed February 19, 2021

STATE OF IOWA,

       Appellee,

vs.

MICHAEL BUMAN,

       Appellant.

       On review from the Iowa Court of Appeals.

       Appeal from the Iowa District Court for Plymouth County, Steven J.

Andreasen, J.

       The State seeks further review of the court of appeals reversal of

defendant’s conviction of wanton neglect of a resident in a health care

facility.    DECISION OF COURT OF APPEALS AFFIRMED; DISTRICT

COURT CONVICTION REVERSED AND CASE REMANDED.

       Appel, J., delivered the opinion of the court, in which all justices

joined.

       Priscilla E. Forsyth (argued), Sioux City, for appellant.

       Thomas J. Miller, Attorney General, Linda J. Hines (argued),

Assistant Attorney General, and Darin J. Raymond, County Attorney, for

appellee.
                                      2

APPEL, Justice.

      In this case, Michael Buman appeals his conviction following a jury

trial of the offense of wanton neglect of a resident of a heath care facility

in violation of Iowa Code section 726.7(1) and subsection (3) (2016). The

criminal charge arose out of the alleged failure of Buman to properly

ensure that a facility resident received medications as ordered by the

resident’s physician.   During the trial the State introduced evidence

regarding the standard of care in the nursing profession, and the trial

court provided the jury with instructions related to the use of the standard

of care in the case.

      Buman claims on appeal that the admission of the professional

standards and the subsequent instruction were improper and served only

to confuse the jury in its deliberations. A divided court of appeals agreed

with Buman, reversed his conviction, and remanded for a new trial. We

granted the State’s application for further review.

      For the reasons stated below, we reverse Buman’s conviction and

remand the matter to the district court for further proceedings.

      I. Background Facts and Proceedings.

      Defendant Michael Buman has been in the medical field for several
decades. He became an emergency medical technician in 1977 but moved

into nursing, becoming a registered nurse in 2004.

      In November 2015, Buman began working at the Pride Group

Residential Care Facility (Pride Group Facility) in Le Mars, Iowa. Buman

worked the night shift at the Pride Group Facility. His duties included

distributing medicine to residence and handling direct care with residents.

Buman worked at the Pride Group Facility during the relevant dates at

issue in this case in October 2016.
                                      3

      In October 2016, Joe Lenz was a resident of the Pride Group Facility

who had been at the facility for more than twenty years. Lenz suffered

from what was diagnosed as chronic paranoid schizophrenia with

catatonic features, obsessive compulsive disorder, and mild intellectual

disability.

      At the Pride Group Facility, an off-site psychiatrist or medical doctor

issued doctor’s orders for medications. The prescriptions were filled by

L & M Pharmacy.       The pharmacy delivered a two-week supply of

medication. The pharmacy placed the medications in a locked room where

the medication was then separated and organized for distribution by

placing the medication on trays that had individual drawers for each

medication the resident was taking.

      Lenz had been prescribed a number of medications, including

Clozapine. Another nurse testified that the Clozapine was available to be

administered to Lenz on October 12 and 13, but on October 15, the

Clozapine was not there. The nurse reported to the day-shift nurse that

the medication was missing so that the day-shift nurse could contact the

pharmacy.     She then marked “NA” on the medication administration

record for Lenz on October 15 and also on October 16 when the medication
was still not there. On October 17, the initials of “AW” appeared on the

Lenz medical record. AW is another nurse who did not testify and there is

no indication of whether AW’s initials signified administration of clozapine

on October 17.

      On October 18, Buman testified that he initialed Lenz’s medical

record, indicating that he administered the Clozapine, but he did so

automatically and that, in fact, the Clozapine was not present to be

administered. According to Buman, Lenz asked why he had not been
                                     4

receiving the drug, and Buman in response searched to see if the

medication was misplaced. He could not find the drug.

      After talking with Lenz and looking at the records, Buman testified

that he concluded that the medication must have been discontinued and

that no one had marked the chart indicating the discontinuation.

According to Buman, he entered the notation “DC’d” on the chart.

According to an administrator at the facility, by marking the record “DC,”

other medication passers would not administer the drug, but the marking

of the medication record with a “DC” would not affect the pharmacy’s

continued delivery of the medication. The record contained no evidence

for whether the Clozapine had been delivered to Lenz after Buman notated

“DC” on the medical record.

      On October 27, Lenz had a psychotic episode. He believed a bomb

went off in the building and that the building was on fire—eventually

running out into the night. With the assistance of law enforcement, he

was taken to the hospital. Lenz’s physician assistant testified at trial that

he believed that Lenz was not receiving his Clozapine and that this led to

the October 27 event.

      During the trial, the State introduced, over Buman’s objection, a
portion of the Iowa Administrative Code related to the practice of nursing

as Exhibit 15. Specifically, Exhibit 15 provided, in relevant part:

      The registered nurse shall recognize and understand the legal
      implications of accountability. Accountability includes but
      need not be limited to the following:

            ....

            e. Executing the regimen prescribed by a physician. In
      executing the medical regimen as prescribed by the physician,
      the registered nurse shall exercise professional judgment in
      accordance with minimum standards of nursing practice as
      defined in these rules. If the medical regimen prescribed by
      the physician is not carried out, based on the registered
                                     5
      nurse’s professional judgment, accountability shall include
      but need not be limited to the following:

            (1) Timely notification of the physician who prescribed
      the medical regimen that the order(s) was not executed and
      reason(s) for same.

            (2) Documentation on the medical record that the
      physician was notified and reason(s) for not executing the
      order(s).

      The district court also gave the jury an instruction related to Exhibit

15. Specifically, Instruction No. 17 provided:

             In accordance with the standards in the Iowa
      Administrative Code, a registered nurse is required to follow
      a medical regimen prescribed by a physician. If a medical
      regimen prescribed by a physician is not carried out by a
      registered nurse, the registered nurse is required to timely
      notify the physician who prescribed the medical regimen and
      also document on the medical record that the physician was
      notified and the reason for not executing the physician’s
      order. A violation of this standard, in and of itself, is not a
      criminal act. You may consider this standard only in
      determining whether the State has proven beyond a
      reasonable doubt the elements of the charge set forth in
      Instruction 15.

      The jury found Buman guilty of wanton neglect of a resident of a

health care facility but found that Buman’s actions or omissions did not

cause serious injury to Lenz.
      Buman appealed his conviction.          On appeal, he claims that

Exhibit 15, which related to professional nursing standards, was

improperly admitted into evidence. Buman further claims that Instruction

No. 17 was erroneous because it misled and confused the jury. Finally,

Buman claims there was insufficient evidence to support the verdict.

      We transferred the case to the court of appeals. In a divided opinion,

the court of appeals reversed Buman’s conviction and remanded the case

to the district court. For the reasons expressed below, we affirm the court

of appeals decision and remand the case for a new trial.
                                      6

      II. Standard of Review.

      “We review evidentiary rulings for abuse of discretion.”       State v.

Huston, 825 N.W.2d 531, 536 (Iowa 2013). “We reverse a ruling that the

district court makes in the balancing process . . . only if the district court

has abused its discretion.”    Id. (quoting McClure v. Walgreen Co., 613

N.W.2d 225, 235 (Iowa 2000) (en banc)).

      “[W]e review challenges to jury instructions for correction of errors

at law.” Alcala v. Marriott Int’l, Inc., 880 N.W.2d 699, 707 (Iowa 2016)

(quoting Anderson v. State, 692 N.W.2d 360, 363 (Iowa 2005)). We reverse

erroneous jury instructions when prejudice results. State v. Coleman, 907

N.W.2d 124, 138 (Iowa 2018). But we presume errors in jury instructions

are prejudicial “unless the record affirmatively establishes there was no

prejudice.” State v. Hanes, 790 N.W.2d 545, 551 (Iowa 2010).

      “We review the sufficiency of the evidence for correction of errors at

law.” State v. Kelso-Christy, 911 N.W.2d 663, 666 (Iowa 2018). “We view

the evidence in the light most favorable to the State, ‘including legitimate

inferences and presumptions that may fairly and reasonably be deduced

from the record evidence.’ ” State v. Tipton, 897 N.W.2d 653, 692 (Iowa

2017) (quoting State v. Williams, 695 N.W.2d 23, 27 (Iowa 2005)). We
evaluate the sufficiency of the evidence by considering whether the record

contains substantial evidence to support conviction. Kelso-Christy, 911

N.W.2d at 666. “Substantial evidence exists when the evidence ‘would

convince a rational fact finder the defendant is guilty beyond a reasonable

doubt.’ ” Kelso-Christy, 911 N.W.2d at 666 (quoting State v. Meyers, 799

N.W.2d 132, 138 (Iowa 2011)).

      III. Discussion.

      A. Positions of the Parties. On appeal, Buman maintains that the

admission of Exhibit 15 was contrary to Iowa Rule of Evidence 5.403. In
                                     7

particular, he attacks the language of the exhibit which provides: “The

registered nurse shall recognize and understand the legal implications of

accountability.   Accountability includes but need not be limited to the

following . . . .” He maintains that the standard of accountability in the

professional standard is not the same as the standard of “knowingly

act[ing] in a manner likely to be injurious” to a resident under Iowa Code

section 726.7 and thus could confuse the jury.        A jury, according to

Buman, could have easily believed that if a nurse does not comply with

the professional standards, they are guilty of the offense.

      Buman also points to language in Exhibit 15 that describes a range

of activities such as performing and supervising activities, assigning and

supervising persons, using professional judgment, and delegating tasks.

None of these activities, according to Buman, were issues at trial. Further,

Buman argues that he simply made a clerical notation and did not

discontinue the medication.

      Buman further takes on Instruction No. 17. According to Buman,

the instruction was confusing in the context of the evidence adduced at

trial. While Instruction No. 17 states that a violation of a standard is not

a criminal act, Exhibit 15 has language emphasizing accountability for
violation of the standards. But nowhere do the instructions zero in on the

relevance of the standards to any element of the offense. So the standards,

according to Buman, emphasize “accountability” but not how exactly the

standard of “accountability” relates to the criminal charge in the case.

      Finally, Buman claims there was insufficient evidence to support the

verdict.   Buman maintains that there was no evidence that when he

marked “DC’d” on the chart, he knowingly acted in a manner that would

likely be injurious to Lenz. According to Buman, the evidence showed that

the medicine was not there and that Buman told the director of nursing it
                                     8

was missing.   There was no evidence that the pharmacy ever saw the

notation nor discontinued sending the medication. Therefore, there was

not substantial evidence to support the jury verdict.

      The State responds by noting that Iowa Rule of Evidence 5.401

provides that evidence is relevant if it “has any tendency to make a fact

more or less probable than it would be without the evidence” and is “of

consequence in determining the action.” Citing the New York case People

v. Speringo, the State maintains that the evidence of the standard of care

of nurses in Exhibit 15 was relevant evidence to show “a risk attendant

with that act.” 686 N.Y.S.2d 8, 9 (N.Y. App. Div. 1999) (Mem.). Further,

the State points out that other witnesses at trial testified about the

standard of care expected of a nurse dispensing medication and described

the proper protocol for nurses to utilize when a medication is unavailable.

The State emphasizes that the probative value of Exhibit 15 was not

outweighed by its prejudicial effect.    The jury, the State notes, was

specifically instructed that a violation of the nursing standard of care did

not equate with a criminal act.

      Turning to the instructions, the State emphasizes that the jury was

properly instructed on the elements of the offense in Instruction No. 15.
Among the elements, the instruction clearly required that in order to

convict Buman, the State was required to show that he “knowingly acted

in a manner likely to be injurious to the physical or mental welfare of

Joseph Lenz.” The State observes that Instruction No. 15A provided that

for Buman to have acted knowingly means “he had a conscious awareness

that he was acting in a manner likely to be injurious to the physical or

mental welfare of Joseph Lenz.” These instructions, according to the State,

accurately described the law for the jury to apply.
                                     9

      On the question of substantial evidence, the State asserts that the

evidence at trial showed that a registered nurse would not fail to

administer a prescribed medication simply because it was not present.

The State maintains the evidence showed that when a drug was not

present, a nurse at the facility was required to notify a nursing supervisor

or physician.

      B. Merits. We begin with a brief review of the applicable statute.

Iowa Code section 726.7 provides that “[a] person commits wanton neglect

of a resident of a health care facility when the person knowingly acts in a

manner likely to be injurious to the physical or mental welfare of a resident

of a health care facility.” In State v. McKee, we upheld the statute from a

vagueness attack. 392 N.W.2d 493, 495, (Iowa 1986).

      We think Buman is correct when he states that the admission of

Exhibit 15, when coupled with Instruction No. 17, posed a serious risk of

misleading or confusing the jury.     The language of “accountability” in

Exhibit 15 is ominous and creates a danger that the jury gave undue

emphasis to potential violation of professional standards in determining

his liability under the criminal statute.      It is true, of course, that

Instruction No. 17 stated that proving a violation of the professional
standards in Exhibit 15 did not amount to a crime, but if this is true, what

was the jury to make of the accountability language? And, by combining

the accountability language with substantive professional standards in the

exhibit, the danger exists that the jury would regard this case primarily as

one based on violation of professional standards rather than on the higher

level of proof required by the criminal offense. Prejudice occurs when

evidence prompts a jury to make a decision on an improper basis. State

v. Newell, 710 N.W.2d 6, 20 (Iowa 2006); Waits v. United Fire & Cas. Co.,

572 N.W.2d 565, 569–571 (Iowa 1997).
                                      10

      In context, then, we find that the introduction of the totality of

Exhibit 15, particularly its language regarding accountability as well as its

irrelevant passages, created substantial confusion of issues and should

have been excluded under Iowa Rule of Evidence 5.403. Under this rule,

relevant evidence may be excluded if any probative value of the evidence

is “substantially outweighed by a danger of . . . confusing the issues, [or]

misleading the jury.” Iowa R. of Evid. 5.403; see also United States v.

Robertson, 875 F.3d 1281, 1295–97 (9th Cir. 2017) (excluding admission

of entire U.S. Army Corp of Engineers Guidebook in Clean Water Act case

because of the danger of confusing issues and misleading jury as the

standards in the manual were not the same as those in the jury

instructions), cert. granted and judgment vacated and case remanded,

139 S. Ct. 1543 (2019); Torres-Arroyo v. Rullán, 436 F.3d 1, 8 (1st Cir.

2006) (“District courts have the right—indeed, the obligation [to exclude

evidence in order] to guard against juror confusion . . . .”); United States v.

Gibson, 568 F.2d 111, 112 (8th Cir. 1978) (per curiam) (holding that the

issue of defendant’s violation of methadone program regulations was a

collateral matter to witness impeachment and could be excluded).

      We recognize that we ordinarily defer to the district court in doing
the balancing under Iowa Rule of Evidence 5.403. See Graber v. City of

Ankeny, 616 N.W.2d 633, 638 (Iowa 2000) (en banc).             But here, the

probative value of the accountability language in Exhibit 15 was

indisputably low. The State certainly had no need for the evidence. It took

the jury far afield from the criminal charge at hand. And, there was a real

danger that Buman could have been found guilty by a jury that focused

on the accountability provisions of Exhibit 15 and not on the elements of

the criminal offense.      A demand for accountability in the nursing

profession should not be permitted to cloud the issues of criminal liability
                                    11

in this case.    In our view, the language in Exhibit 15 regarding

accountability had little probative value and yet had great potential to

confuse or mislead the jury in a case where the real issues were highly

contested. We conclude the accountability language should have been

excluded.

      Like the court of appeals majority, we do not broadly hold that

evidence of professional standards are never admissible in a criminal case.

But if the professional standards are admitted, the admission must be

appropriately limited and controlled by the court to ensure that a criminal

matter requiring the highest standards of proof and a high degree of

mens rea does not morph into a civil matter over whether a defendant

complied with a professional accountability standard.

      That said, we are not prepared to say that there was insufficient

evidence to support the verdict. Buman had been a registered nurse for

ten years and worked at the Pride Group Facility for nearly one year. Lenz

suffered from paranoid schizophrenia and had been prescribed the

antipsychotic medication Clozapine. On October 18, Buman initialed that

he had administered the Clozapine to Lenz despite not actually doing so.

Lenz asked Buman why he had not received the Clozapine. After a short
investigation and talk with Lenz, Buman concluded that the Clozapine

administration to Lenz had been discontinued—marking “DC’d” on the

medical record. The notation of “DC’d” meant that other drug passers

would not distribute the Clozapine to Lenz. Finally, there was evidence

that as a result of the failure to administer Clozapine, Lenz suffered a

psychotic episode.

      It could be inferred from this evidence that Buman knew marking

“DC’d” meant that the Clozapine would not be given to Lenz. And, it can

be further inferred that the discontinuation of the Clozapine drug therapy
                                     12

could cause harm to Lenz—namely, a potential psychotic episode. From

the evidence, and its implications, viewed in the light most favorable to the

State, there is substantial evidence to demonstrate that a rational fact

finder could rest a conviction for wanton neglect of a resident of a health

care facility beyond a reasonable doubt.

      But the jury could have drawn a different conclusion. In this case,

the jury was disserved by the introduction of confusing and misleading

evidence and the court’s jury instructions did not mitigate the problem.

      IV. Conclusion.

      For the above reasons, we reverse Buman’s conviction and remand

the matter to the district court for further proceedings.

      DECISION OF COURT OF APPEALS AFFIRMED; DISTRICT

COURT CONVICTION REVERSED AND CASE REMANDED.