A resident of an assisted living facility presented to her doctor with constipation, and the doctor prescribed the woman an over-the-counter laxative to be taken once daily. The nursing staff at the assisted living facility failed to administer the medicine as frequently as prescribed. The resident returned to her doctor complaining of constipation. The doctor told the nursing staff to give the woman three to four enemas per day. That day the woman received one enema. She received no enemas on the next day, during which she complained of stomach pain. The woman's abdomen was distended and her bowel sounds were overactive in all four quadrants, classic signs of an intestinal obstruction for which an enema is not appropriate. The third day she received an enema. Shortly after receiving the enema on the third day, the woman died from a perforated colon.
The woman’s daughters sued the nurse who gave the enema, the director of nursing at the assisted living facility, the owner of the facility, and its management company for wrongful death. The complaint alleged that the management company failed to provide adequately trained medical staff who were capable of meeting the needs of the decedent and that they failed to provide trained personnel sufficient in skill and number to provide necessary and adequate care to the decedent. After a trial in the Circuit Court of Bedford County, the jury returned a verdict finding the nurse thirty percent at fault, the director of nursing twenty percent at fault, and the management company fifty percent at fault based on its failure to provide adequate staffing at the facility. The jury awarded compensatory damages in the amount of $300,000 and punitive damages in the amount of $10,000 against the nurse; $5,000 against the director of nursing; and $5,000,000 against the management company.
The management company appealed. The Court of Appeals, Middle Section, found that there was no material evidence that the management company’s staffing decisions proximately caused the woman’s death and reversed the judgment with respect to the finding of direct liability on the part of the management company.
The Supreme Court of Tennessee reversed the decision of the Court of Appeals. The court held that the jury's verdict was supported by material evidence. In so holding the court applied a three part test to determine proximate cause: (1) the tortfeasor's conduct must have been a “substantial factor” in bringing about the harm being complained of; (2) there is no rule or policy that should relieve the wrongdoer from liability because of the manner in which the negligence has resulted in the harm; and (3) the harm giving rise to the action could have reasonably been foreseen or anticipated by a person of ordinary intelligence and prudence. Where the evidence in a negligence action supports more than one reasonable conclusion, causation in fact and proximate causation are issues of fact which should be decided by the jury and not the appellate court.
The court held that material evidence supported a finding that the management company provided insufficient staffing to meet the needs of the assisted living facility’s residents and was aware of understaffing problem. The court noted that the facility's administrator testified that she let the management company know that she did not have enough staff to get the job done right for the patients, that there was too much to do and too few staff to get the job done, and that the staff's workload was overwhelming sometimes. The management company’s regional operations director confirmed having such conversations with the facility's administrator.
The court held that material evidence supported a finding that the lack of adequate staffing at the assisted living facility led to lapses and deviations from the applicable standard of care. In so holding the court noted that the trial court had ruled that there were twenty-one acts or omissions that constituted a breach of the standard of care. The court reasoned that the evidence presented to the jury supported a rational inference that the management company’s failure to staff the assisted living facility with adequate personnel to meet the needs of its patients contributed to the woman's death. The court explained that it was a matter of reason and common sense within the jury's fact-finding province to infer that, in an employment setting, if there is too much work required of too few employees, either the work will not get done or the quality of the work will be diminished.
The court held that material evidence supported a finding that failure to provide adequate nursing staffing at facility was a substantial factor in causing the resident's death. The court noted that there was evidence that the resident received significantly fewer doses of a laxative than were prescribed by her physician and that the resident became constipated as a result, that a nurse violated the standard of care after the resident became constipated by administering an enema when the resident showed signs of a bowel obstruction, and that the likely cause of the resident's death was a colon perforation due to that enema.
The court concluded that the proof, taking the strongest legitimate view of all the evidence in favor of the verdict, assuming the truth of all evidence that supported the verdict, allowing all reasonable inferences to sustain the verdict, and discarding all countervailing evidence, amounted to material evidence supporting the jury's finding that the management company's understaffing was more probably than not a substantial factor in bringing about the woman's death.
See: Wilson v. Americare Systems, Inc., 2013 WL 658078 (Tenn., February 25, 2013) (not designated for publication).