NJ Appeals Court Upends Nursing Home Negligence Suit

Executive Summary

In a decision with far-reaching ramifications for long-term care litigation, the Superior Court of New Jersey, Appellate Division held that § 30:13-4.2 of the Nursing Home Responsibilities and Residents' Rights Act (NHA) does not provide a cause of action to enforce the "responsibilities" of nursing homes, as enumerated in the NHA. Instead, § 30:13-4.2 only provides a cause of action for nursing home residents to enforce § 30:13-4.1, concerning security deposits. This ruling effectively bars plaintiffs from bringing claims predicated upon a facility's violation of a state or federal statute, rule, regulation or guideline.

The court's other holdings in Ptaszynski, while not as significant as the interpretation of the NHA, are nonetheless useful:

1. It was error for the judge to allow the plaintiff's nursing expert to testify as an expert in "nursing law" and to provide her opinion of the meaning of the word "dignity" in N.J.S.A. 30:13-5j, since that opinion amounted to an interpretation of a statute; 
2. It was error not to give the jury a Scafidi instruction explaining that plaintiff's preexisting comorbidities may have contributed to her injuries;
3. It was error not to instruct the jury on the principle of prohibiting double recovery for the same injuries; and
4. The case must be remanded to determine whether Mt. Kemble Rehabilitation (MKR) is entitled to charitable immunity.

Salient Facts

Ms. Ptaszynski (Decedent) was admitted to St. Peter's Hospital after a fall in her home in which she fractured her left hip and elbow. She was 86 years old. Prior to her fall, Decedent had numerous comorbidities, including: (1) heart disease, (2) high blood pressure, (3) abnormal heart rhythm, (4) diabetes, (5) hypothyroidism and (6) peripheral vascular disease. Additionally, Decedent had undergone triple-bypass surgery in 1998 and suffered a stroke in 2000 that left her weakened on her left side.

Decedent was transferred to Defendant MKR at Morristown Memorial Hospital. While at MKR, Decedent developed pressure ulcers and a fever. After one month, Decedent was transferred to Morristown Memorial Hospital, where doctors discovered one of her toes was infected with MRSA. The toe was amputated and Decedent's condition worsened. She ultimately died four days after the amputation.

Decedent's daughter (Plaintiff), in her capacity as executrix of Decedent's estate, filed a four count complaint alleging (1) negligence, including the failure to comply with state and federal regulations relating to the care of nursing-home residents, (2) a claim pursuant to the NHA, N.J.S.A. 30:13-3h, which requires nursing homes to comply with all applicable state and federal statutes, rules, and regulations, (3) a claim pursuant to the NHA, N.J.S.A. 30:13-8a, based on violations of Decedent's right under N.J.S.A. 30:13-5j "to a safe and decent living environment and considerate and respectful care that recognizes the dignity and individuality of the resident[,]" and (4) wrongful death.

Prior to trial, MKR asserted that the provisions of the Charitable Immunity Act (CIA) barred Plaintiff's claims or limited her right to damages. MKR further argued that the NHA was inapplicable because MKR was not a "nursing home." The trial court determined the MKR met the "very broad definition" of a nursing home under the NHA, and that it was subject to the statutory and licensing standard for long-term care facilities.

The matter was tried before a jury, which found MKR negligent, and that the negligence was the proximate cause of Decedent's injuries. The jury awarded $250,000 on the negligence claim and $250,000 on the claims asserted under the NHA. Additionally, the jury awarded $50,000 on the wrongful death claim. Plaintiff's claim for punitive damages was dismissed upon a motion from MKR. MKR filed a motion to cap the damages pursuant to the CIA. Because the cap was $250,000 and the negligence damages did not exceed that, the motion was denied. Appeal followed.

NHA Claims

On appeal, the court sought to determine whether the trial court erred by allowing plaintiff to pursue a claim under N.J.S.A. 30:13-4.2 for a violation of MKR's "responsibility" under N.J.S.A. 30:13-3h to comply with applicable state and federal statutes and regulations. The court noted that, as initially enacted, N.J.S.A. 30:13-8a permitted a person to bring a claim only for a violation of a nursing home resident's rights, not an action to enforce the nursing home's responsibilities. Only the Department of Health could bring the former action.

The NHA was amended in 1991, adding sections 30:13-4.1 and 30:13-4.2. These sections apply when a nursing home requires a security deposit and sets forth requirements concerning the use and return of those deposits, among other things. Section 30:13-4.2 provides that "a person shall have a cause of action against the nursing home for any violation of this act." (emphasis in original from court's opinion).

The court held that the phrase "this act" applied only to the amendatory legislation enacted in 1991 and not the whole of the NHA. Thus, the court held:

There is no indication that, in enacting the amendments to the NHA, the Legislature intended to confer upon nursing home residents the ability to bring actions to enforce any violation of the NHA. The 1991 legislation imposed upon nursing homes new, specific requirements pertaining to security deposits and allowed residents to bring actions to enforce those requirements, not other responsibilities that nursing homes have under the law.

Thus, because plaintiff's claim seeking to enforce the responsibility of MKR to comply with state and federal statutes, rules and regulations was not permitted by the NHA, the verdict on the NHA claims and the award of counsel fees was set aside. The immediate ramifications of this holding are discussed below in the Legal Analysis section.

Plaintiff's Expert Testimony

The court further held that the trial court erred by referring to the plaintiff's nursing expert as an expert in "nursing law." This gave the impression that the expert, not the judge, was instructing on the law. Moreover, the court held that it was error to allow plaintiff's expert to testify concerning her opinion on the meaning of the word "dignity" in N.J.S.A. 30:13-5j, since this allowed plaintiff's expert to impermissibly interpret a statute. This was compounded by the judge's reading the statute in question to the jury without explanation.

Pre-Existing Conditions and Substantial Factor

MKR's experts presented evidence that Decedent's pre-existing health conditions contributed to her pressure sores. Despite this, the trial court erred by failing to provide the jury with instruction pursuant to Scafidi v. Seiler, 119 N.J. 93, 110 (1990). A Scafidi instruction explains that "in cases where there is sufficient evidence to show within a reasonable degree of medical probability that the alleged negligent treatment may have increased the risk of harm posed by an individual's pre-existing injury, the jury must be instructed to consider whether the increased risk was a substantial factor in producing the ultimate result."

Double Recovery

The court began by noting the fundamental legal principle that there cannot be any duplication of damages. The court then explained that because the jury was not instructed that it could not award damages for MKR's alleged violations of the NHA and its negligence based upon the same injuries, those awards must be overturned and remanded for a new trial since the jury could have allocated the awards based on the same injuries or harm.

Charitable Immunity

Because MKR is a hospital, it argued it was entitled to charitable immunity pursuant to N.J.S.A. 2A:53A-8. This portion of the opinion is not applicable to long-term care facilities. In any event, this claim was ultimately remanded for the parties to present more evidence on the issue and in light of the Superior Court's recent decision in Bermudez v. Kessler Institute for Rehabilitation, which held that a comprehensive rehabilitation hospital is not a "nursing home" for purposes of the NHA.

Legal Analysis

The court's ruling that plaintiffs can no longer use N.J.S.A. 30:13-4.2 to assert a cause of action against long-term care providers essentially bars all future claims for failure to comply with state and federal statutes, rules, guidelines, and regulations. Ptaszynski also provides fertile ground to file motions in pending suits, either seeking dismissal or, summary judgment and prune any claim asserted by a plaintiff pursuant to N.J.S.A. 30:13-4.2 from the suit, effectively removing any possibility of cost shifting or punitive damages for violations of the state and federal statutes, rules and guidelines so often cited in nursing home negligence complaints.  

More importantly, after Ptaszynski, it will be much more difficult for a plaintiff to secure punitive damages, fees and cost shifting because residents are now only permitted to bring claims for violations of the actual "rights" enumerated under the NHA, rather than the facility's "responsibilities," which are often pinned to violations of rules and regulations. Indeed, many complaints in nursing home negligence actions often predicate a cause of action for negligence per se on N.J.S.A. 30:13-4.2, and the facility's alleged violations of state or federal statutes, rules or guidelines. Under Ptaszynski, such claims will no longer be permitted.