ÿWPCp DÑTJàñ:6ÂèŽOá³r´3ð:6 ê%.Ý—°P5 ½b¤\Â)@ƒ9ÚÝâ/e;Ö*Ë%ŠÉ(U  {vÔö*”Žj‡ì >²k*U–4i¯'Á•>\,pä¹qŽo@¹»Âäþ8öxB󩬗„C»!ÿŽðMx¦·µÞe.º™_®y@DEV浊>·ŒÙø&5˲l|VA»A}c¤Ôͼ×R“cÇ\ü/²¾¾Ö˜ÁÃî×wª¸«ž {Nñî!ç¨3—¼ƒ¸aË%ÑüR-ÜzM£–Dñdü.ý Dùâ_o¬Gð”m,JUjö?g@ÎQíšßºs«:¸ƒK]¬R:3•M$Ë]¯—"00*Vµ‚p ÞLY4í§çL¯I¶>¶ˆÃ…Ãæ2<ÀP<Ø™x!ÌÀä"|Óœœ¨/;Ý3m{+œ˜1( Hª$Qd¥!‹Ä C1#óʹŒû£!™§SæÚ'à}ÕîæÃ0r]„¸‰ÛuøÝÜRôï™c¸2™ Æ× Æ ÆcÆ)UNïN=ê??E))))))))))))))))))))))))b+++++++++++++++ 0:333333333333333333333 0ëmmmm BXX 0¤u D3 D-L 0Kyy ASÄÆ 0¤Ý 0D A«Å˜\\IB01S08\KNOXCLERK4ÈÈ,,,,ÈÈ0»on2Þ (`£ª$¡¡Ñ€.ÑÑ8€½­»»d»»d8ÑÑ ý ÑÓ  Ó(í€"  Z6Times New Roman RegularÖƒF1ê:i¢×+00 ˜C:\PROGRA~1\COREL\WORDPE~1\TEMPLATE\CUSTOM~1\REVISE~1.WPTC:\Program Files\Corel\WordPerfect Office 2000\Template\Custom WP Templates\revised standard opinion.wpt3|xÿU‹ÿÀÀÀô\  `‹&Times New RomanLevel 1Level 2Level 3Level 4Level 5‚Level 1Level 2Level 3Level 4Level 5„Level 1Level 2Level 3Level 4Level 5…Level 1Level 2Level 3Level 4Level 5(ÖÃ9 Z‹6Times New Roman Regular  COA P.J.MorristownLeadbettervomitusPhenergan PCAPhenergena]dvance h]e h]isemesisJellob]ecause i]fClelandF.C.A.P.s]omeempyematacycardiaBuntonintubateLoudonWadleys]eldomprofersHowmetRaines t]het]hat a]sSWINEYGooge DelkMcCordf]ailure uninterrogatedFulkersonWiseman- ù-4ÿÿ2Emphasisòòóó(|G2¼1$¤¤Ý ƒ£ª!ÝÑ€.ÑÑ8€U»»dd8ÑÑ ý ÑÓ  ÓÝ  Ýà  àòòÚ  Ú0Ú  ÚóóÔ€ô§ò»»Ô d(|3k$££Ý ƒ£ª!ÝÑ€.ÑÑ8€U»»dd8ÑÑ ý ÑÓ  ÓÝ  ÝVVVV'ÿÿdxd)!ÈÈÈÈdxdx( ±þ$’’ò òFigure€Ú  Ú1Ú  Úó ó^_X`YEþÿ<<CÿÿƒLevel 1Level 2Level 3Level 4Level 5(|3k$¢¢Ý ƒ£ª!ÝÑ€.ÑÑ8€U»»dd8ÑÑ ý ÑÓ  ÓÝ  Ý($$””ò òÚ  Ú1Ú  Úó óX[Z&OLE 2.0 Box <=8ÿÿÿÿÿÿÿÿÿÿCÿÿ HKKKKÝ ƒ£ª!ÝÑ€.ÑÑ8€U»»ddÈ8ÑÑ ý ÑÓ  ÓÝ  ÝÔ_ÔÑ  ÑÔ€¼U»»»ÔÑ8€KÑXXdì»»d8ÑÑ  Ñà@ü ü ìàÔ‡îŒî»¼UÔIN€THE€COURT€OF€APPEALS€OF€TENNESSEEˆÐ ° Ðà@WW$ìàAT€KNOXVILLEÔ#†¼U»îîŒ #ԈРÖ& ÐÓ  ÓSeptember€21,€2004€SessionÐ üL ÐÔ‡XKÑX»¼UÔÌò òÔ#†¼U»XXKÑ÷#ÔPATSY€SMITH,€AS€NEXT€OF€KIN€AND€MOTHER€OF€SHAWN€SMITHòòÐ úJ Ðóóv.€STATE€OF€TENNESSEEòòóóÔ‡XKÑX»¼UÔó óÐ  ^ ÐÌà@@½½ìàò òAppeal€from€the€Claims€Commission€for€the€Eastern€DivisionÐ  ^ Ðà@@øøìàNo.€401372€€€€€€Vance€W.€Cheek,€Jr.,€CommissionerÐ ú J ÐÌà@@ìì*ìàßA€V) °°` d€÷E<Ñ` AßÐ Ò"  ÐÌà@@TTìàNo.€E2004„0737„Ô_ÔCOAÔ_Ô„R3„CV€„€FILED€MARCH€14,€Ô_Ô2005Ô_ÔÐ Í  ÐÌßA€V) °°` dE<¤` AßÐ ¥õ  Ðó óÌÓ  ÓShawn€Smith€died€of€aspiration€of€gastric€contents€Ô#†¼U»XXKѨ#ÔÔ‡XKÑX»¼UÔwhile€a€patient€at€the€University€of€TennesseeÐ  ð  ÐMedical€Center.€€Shawn€Smithððs€mother,€Patsy€Smith€(ð ðPlaintiffðð),€sued€the€State€of€Tennessee€(ð ðtheÐ ŒÜ ÐStateðð).€€The€case€was€transferred€to€the€Claims€Commission€(ð ðthe€Commissionðð).€€After€trial,€theÐ xÈ ÐCommission€entered€a€judgment€Ô#†¼U»XXKÑY#ÔÔ‡XKÑX»¼UÔfor€the€State€holding,€òòinter€aliaóó,€that€there€was€no€breach€of€theÐ d´ Ðstandard€of€careòòóó.€€Plaintiff€appeals€claiming€that€the€Commission€erred€in€holding€there€was€noÐ P  Ðbreach€of€the€standard€of€care,€that€the€Commission€erred€in€making€certain€factual€findings,€and€thatÐ <Œ Ðthe€Commission€erred€in€refusing€to€find€that€the€integrity€of€the€medical€record€had€beenÐ (x Ðcompromised.€€We€affirm.Ô#†¼U»XXKÑÿ#ÔÔ‡XKÑX»¼UÔÐ d ÐÓ÷ÓÌÌò òTenn.€R.€App.€P.€3€Appeal€as€of€Right;€Judgment€of€the€Claims€Commission€Affirmed;Ð Ø( ÐCase€Remandedó óÐ Ä ÐÌÌòòÓ  ÓÔ#†¼U»àXKÑ #ÔÔ‡XKÑX.¼UÔD.€Michael€Swiney,€J.óó,€delivered€the€opinion€of€the€court,€in€which€òòHerschel€P.€Franks,€P.J.,óó€andÐ ˆØ ÐòòCharles€D.€Susano,€Jr.,€J.óó,€joined.Ð t Ä ÐÌLeslie€A.€Muse€and€Gary€E.€Brewer,€Morristown,€Tennessee,€for€the€Appellant,€Patsy€Smith,€as€nextÐ L"œ! Ðof€kin€and€mother€of€Shawn€Smith.Ð 8#ˆ" ÐÌRonald€C.€Leadbetter,€Associate€General€Counsel,€for€the€Appellee,€State€of€Tennessee.Ð %` $ ÐÓô ÓÌÌÌÌÌÌÌÌÐ \-¬(-ý ÐÔ_Ôò òOPINIONó óÔ#†¼U»XXKÑ# #ÔÔ‡XKÑX»¼UÔÐ ° ÐÌòòóóÔ#†¼U»XXKщ #ÔÔ€XKÑX»¼UÔÓÓò òòòBackgroundóóó óÐ ˆØ ÐÓ  ÓÓÓà  àà ` àThis€appeal€results€from€the€trial€of€a€complicated€medical€malpractice€lawsuit.€Ð `° ÐBecause€of€the€issues€raised€on€appeal,€a€detailed€discussion€of€the€facts€as€reflected€in€the€recordÐ L œ Ðis€necessary.Ð 8 ˆ ЀÌà  àà ` àShawn€Smith€(ð ðMr.€Smithðð)€was€hospitalized€in€October€of€1993€for€orthopedicÐ  ` Ðsurgery€to€correct€problems€that€developed€as€a€result€of€an€automobile€accident€in€1992.€€ThisÐ ü L  Ðsurgery€was€performed€on€October€6,€1993€at€the€University€of€Tennessee€Medical€Center€(ð ðtheÐ è 8  ÐHospitalðð).€€Plaintiff€stayed€at€the€Hospital€with€her€son€during€his€admission.€€While€recuperatingÐ Ô$  Ðon€the€orthopedic€surgery€recovery€floor,€Mr.€Smith€aspirated€vomitus€and€died€some€time€duringÐ À  Ðthe€early€morning€hours€of€October€8,€1993.€€Mr.€Smith€was€twenty„six€years€old€at€the€time€of€hisÐ ¬ü  Ðdeath.€€Plaintiff€sued€the€State.€€The€case€was€transferred€to€the€Commission€and€tried€in€late€JanuaryÐ ˜è  Ðand€early€February€of€2004.Ð „Ô  ÐÌà  àà ` àMr.€Smithððs€surgery€on€October€6òòthóó€was€uneventful€and€post„surgery,€at€approximatelyÐ \¬ Ð6:15€or€6:30€p.m.òòóó,€Mr.€Smith€was€moved€to€the€orthopedic€surgery€recovery€floor.€€At€approximatelyÐ H˜ Ð3€a.m.€on€October€7òòthóó,€Mr.€Smith€vomited.€€The€evidence€at€trial€showed€it€is€not€unusual€for€a€patientÐ 4„ Ðto€vomit€post„surgery.€€In€fact,€Mr.€Smithððs€doctor€gave€post„surgery€medication€orders€forÐ  p ÐPhenergan€to€combat€nausea€in€addition€to€the€morphine€prescribed€for€pain.€€The€evidence€showedÐ  \ Ðthat€this€is€a€common€combination€of€drugs€prescribed€post„surgery.€€The€morphine€wasÐ øH Ðadministered€through€a€patient€controlled€analgesia€pump,€or€PCA€pump,€set€with€a€lock„out€toÐ ä4 Ðprevent€Mr.€Smith€from€utilizing€more€than€the€prescribed€amount.€€The€Phenergan€was€prescribedÐ Ð  Ðon€an€as€needed€basis€and€had€to€be€administered€each€time€by€a€nurse.€€Mr.€Smith€was€givenÐ ¼  ÐPhenergan€after€vomiting€at€3€a.m.€€Mr.€Smith€vomited€a€second€time€around€10€a.m.€on€October€7òòthóóÐ ¨ø Ðand€again€was€given€Phenergan.€Ð ”ä Ðà  àà ` àà ¸ àà  àÌà  àà ` àThe€post„surgery€orders€also€included€an€order€to€ð ð[a]dvance€to€regular€diet.ðð€Ð l¼ ÐPlaintiff€testified€at€trial€that€Mr.€Smith€had€no€solid€food€during€the€day€of€October€7,€1993,€but€laterÐ X ¨ Ðadmitted€she€could€not€remember€if€he€had€anything€to€eat€such€as€Jell„O€or€applesauce€during€theÐ D!” Ðday€or€not.€€Plaintiff€testified€that€at€dinner€time€on€the€7òòthóó,€Mr.€Smith€was€given€a€food€tray,€but€didÐ 0"€  Ðnot€want€to€eat€what€was€on€the€tray.€€Plaintiff€stated€that€Mr.€Smith€asked€for€a€cheeseburger.€Ð #l! ÐPlaintiff€testified€that€someone€on€the€hospital€staff€brought€Mr.€Smith€a€cheeseburger€around€5€orÐ $X" Ð6€p.m.€and€he€ate€most€of€it.€€Mr.€Smith€went€to€sleep€around€8€p.m.€€Plaintiff€testified€that€she€sleptÐ ô$D # Ðin€a€chair„bed€next€to€Mr.€Smithððs€hospital€bed€and€that€she€went€to€sleep€around€10€p.m.€Ð à%0!$ ÐÌà  àà ` àRegistered€Nurse€Ronald€George€Baer€(ð ðNurse€Baerðð)€came€on€duty€on€October€7òòthóóÐ ¸'#& Ðat€7€p.m.€and€cared€for€Mr.€Smith€during€the€relevant€time€period€involved€in€this€case.€€Nurse€BaerÐ ¤(ô#' Ðperformed€an€assessment€of€Mr.€Smith€at€the€beginning€of€his€shift.€€Thereafter,€the€medical€recordÐ )à$( Ðreflects€that€at€10€p.m.€Nurse€Baer€made€a€note€that€Mr.€Smith€was€resting€quietly€with€noÐ |*Ì%) Ðcomplaints.€Ð h+¸&* Їà  àà ` àAt€approximately€1€a.m.€on€October€8òòthóó,€Mr.€Smith€again€vomited.€€Plaintiff€testifiedÐ ° Ðthat€after€Mr.€Smith€vomited€this€time€she€called€for€the€nurse,€assisted€Nurse€Baer€in€cleaning€upÐ œì ÐMr.€Smith,€and€asked€if€Nurse€Baer€was€going€to€call€the€doctor.€€Plaintiff€testified€that€the€amountÐ ˆØ Ðof€vomitus€was€large€and€explained€ð ðwe€changed€the€sheets,€washed€him€up,€put€a€clean€gown€onÐ tÄ Ðhim€.€.€.€.ðð€€€Plaintiff€testified€that€she€then€cleaned€up€the€vomitus€that€had€dripped€on€the€floor.€Ð `° ÐPlaintiff€testified€that€Nurse€Baer€told€her€there€was€no€need€to€call€the€doctor€and€that€Mr.€SmithÐ L œ Ðwould€be€all€right.€Plaintiff€testified€that€Nurse€Baer€gave€Mr.€Smith€a€shot€of€Phenergan€around€1:30Ð 8 ˆ Ða.m.€and€some€Sprite.€€Plaintiff€spoke€to€Mr.€Smith€briefly€after€he€was€cleaned€up€and€testified€ð ð[h]eÐ $ t Ðacted€like€he€felt€better.ðð€€Mr.€Smith€then€went€back€to€sleep.€€After€assuring€herself€that€Mr.€SmithÐ  ` Ðwas€resting€comfortably,€Plaintiff€went€back€to€sleep.Ð ü L  ÐÌà  àà ` àNurse€Baer€made€an€entry€in€the€medical€record€at€4€a.m.€that€Mr.€Smith€was€restingÐ Ô$  Ðquietly€and€using€his€PCA€morphine€pump€moderately.€€The€medical€record€shows€Nurse€BaerÐ À  Ðrecorded€that€by€1€a.m.€on€October€8òòthóó,€Mr.€Smith€had€used€27.2€milligrams€of€morphine,€and€thatÐ ¬ü  Ðbetween€1€a.m.€and€5€a.m.€he€had€used€5.1€milligrams€of€morphine.€€Plaintiff€testified€she€wokeÐ ˜è  Ðagain€around€4€a.m.€and€looked€at€Mr.€Smith€and€it€appeared€he€was€sleeping.€€She€stated€ð ð[h]is€chestÐ „Ô  Ðwas€all€right.€€I€mean,€he€was€breathing€okay.ðð€€She€testified€she€could€see€him€breathing€and€did€notÐ pÀ Ðhear€any€gagging,€coughing,€or€rasping€sounds.€€In€addition,€Plaintiff€testified€she€is€a€light€sleeperÐ \¬ Ðand€she€would€have€heard€it€if€Mr.€Smith€had€gagged€or€coughed,€but€she€did€not€hear€anything€likeÐ H˜ Ðthat.Ð 4„ ÐÌà  àà ` àPlaintiff€stated€that€although€she€could€see€nothing€wrong€she€had€a€feeling€somethingÐ  \ Ðwas€wrong€so€she€buzzed€for€the€nurse.€€She€testified€that€when€the€nurse€did€not€respond,€she€leftÐ øH Ðthe€room€and€went€to€the€nurseððs€station€to€find€him.€€Plaintiff€testified€that€while€she€was€outÐ ä4 Ðlooking€for€the€nurse,€a€group€of€nurses€and€doctors€rushed€into€Mr.€Smithððs€room.€€They€were€thereÐ Ð  Ðwhen€Plaintiff€returned€to€the€room€and€she€was€escorted€out€of€the€room.€€Plaintiff€testified€that€sheÐ ¼  Ðwas€told€around€6:30€a.m.€that€her€son€had€died.€Ð ¨ø ÐÌà  àà ` àNurse€Baer€testified€at€trial€and€stated€he€only€remembers€two€specific€instancesÐ €Ð Ðduring€his€care€of€Mr.€Smith,€at€1€a.m.€when€Mr.€Smith€vomited€and€at€5:45€a.m.€when€Mr.€SmithÐ l¼ Ðwas€found€to€be€in€respiratory€distress.€€Nurse€Baer€relied€upon€the€medical€chart€for€the€remainderÐ X ¨ Ðof€his€testimony.€€Nurse€Baer€testified€he€was€not€aware€that€Mr.€Smith€had€been€given€a€hamburgerÐ D!” Ðand€stated€that€if€this€happened€it€occurred€before€his€shift,€which€started€at€7€p.m.€€Nurse€BaerÐ 0"€  Ðtestified€he€remembers€being€called€at€1€a.m.€when€Mr.€Smith€vomited€and€that€he€remembersÐ #l! Ðfinding€Mr.€Smith€sitting€up€in€bed€and€talking€at€that€time.€€Nurse€Baer€testified€that€he€and€Mr.Ð $X" ÐSmith€had€a€conversation€about€school€while€Mr.€Smith€was€being€cleaned€up.€€Nurse€Baer€testifiedÐ ô$D # Ðthat€Mr.€Smith€never€said€anything€about€experiencing€pain€or€nausea€at€that€time.€€Nurse€Baer€alsoÐ à%0!$ Ðtestified€that€he€observed€no€respiratory€distress€at€that€time.Ð Ì&"% ÐÌà  àà ` àNurse€Baer€testified€it€was€his€determination€that€Mr.€Smith€did€not€aspirate€at€1€a.m.Ð ¤(ô#' Ðbecause€Mr.€Smith€was€holding€a€normal€conversation€with€him.€€Nurse€Baer€stated€he€could€tell€ifÐ )à$( Ðsomeone€aspirated€by€observing€their€outward€appearance.€€He€explained€that€if€someone€aspirated,Ð |*Ì%) Ðtheir€color€would€change,€their€respiratory€status€would€change,€and€they€would€gasp€or€gag.€€NurseÐ h+¸&* ÐBaer€testified€that€Mr.€Smith€did€not€exhibit€these€signs.€€Nurse€Baer€does€not€remember€using€aÐ ° Ðstethoscope€at€1€a.m.€to€listen€to€Mr.€Smithððs€lungs€to€check€for€aspiration.€€He€testified€that€he€usesÐ œì Ðthe€stethoscope€for€initial€assessments€and€thereafter€uses€it€if€he€thinks€there€is€a€need€to€do€so.€Ð ˆØ ÐNurse€Baer€did€not€think€there€was€a€need€to€check€Mr.€Smith€for€aspiration€at€1€a.m.€€Nurse€BaerÐ tÄ Ðalso€testified€that€there€was€no€need€to€call€the€doctor€as€Mr.€Smithððs€vomiting€had€resolved€and€wasÐ `° Ðnot€continuous.€€Instead,€Nurse€Baer€explained,€there€were€long€time€periods€between€the€vomitingÐ L œ Ðepisodes.€€Ð 8 ˆ ÐÌà  àà ` àNurse€Baer€testified€that€he€remembers€that€at€approximately€5:45€a.m.,€the€LPN€cameÐ  ` Ðout€to€the€nurseððs€station€and€told€him€Mr.€Smith€was€in€distress.€€At€that€time,€Mr.€Smith€was€foundÐ ü L  Ðunresponsive€and€a€code€was€called.€€As€part€of€the€CPR€process,€Mr.€Smith€was€rolled€on€to€his€sideÐ è 8  Ðso€a€bed€board€could€be€placed.€€When€he€was€rolled€over,€coffee€ground€emesis€came€out€of€Mr.Ð Ô$  ÐSmithððs€mouth.Ð À  ÐÌà  àà ` àNurse€Baer€was€questioned€regarding€the€doctorððs€orders€and€entries€in€the€chart.€€HeÐ ˜è  Ðexplained€that€the€order€in€the€chart€to€advance€to€regular€diet€meant€Mr.€Smith€could€have€anythingÐ „Ô  Ðhe€wanted.€€Nurse€Baer€stated€that€if€he€had€been€required€to€start€with€liquids€or€do€a€progression,Ð pÀ Ðthe€order€would€have€stated€liquid€diet€then€advance€to€regular.€€Nurse€Baer€explained€that€a€patientððsÐ \¬ Ðvital€signs€are€typically€taken€by€an€LPN,€who€is€to€notify€the€nurse€of€anything€unusual.€€Nurse€BaerÐ H˜ Ðtestified€that€a€respiratory€rate€of€20,€which€is€what€Mr.€Smithððs€respiratory€rate€was€each€time€it€wasÐ 4„ Ðchecked,€is€normal.€Ð  p ÐÌà  àà ` àRuby€S.€Wiseman,€a€registered€nurse,€testified€as€an€expert€witness€for€Plaintiff.€Ð øH ÐAmong€other€things,€Ms.€Wiseman€had€criticisms€regarding€Mr.€Smithððs€having€been€given€aÐ ä4 Ðhamburger€to€eat.€€She€explained€that€Mr.€Smithððs€doctor€gave€orders€to€advance€diet€as€tolerated€andÐ Ð  Ðthat€to€her,€this€order:€Ð ¼  ÐÌà8  àmeans€you€start€them€out€on€clear€liquids.€€If€they€tolerate€that€and€donððt€getÐ ”ä Ðnauseated€or€vomit,€then€you€advance€them€to€soft€foods€like€apple€sauce,€Jello.€€JelloÐ €Ð Ðis€usually€the€cardinal€soft€food€and€then€advance€them€on€to€a€soft€diet,€a€regular€dietÐ l¼ Ðand€.€.€.€Very,€with€very€bland€items.€€You€donððt€want€to€give€them€anything€greasyÐ X ¨ Ðor€spicy€or€fried.€ÐD!”Ð Ð  ÐÌà  àà ` àMs.€Wiseman€testified€that€the€record€shows€Mr.€Smith€came€to€the€floor€after€hisÐ #l! Ðsurgery€around€6:15€or€6:30€on€October€6òòthóó€and€that€there€is€no€note€from€that€time€until€7€p.m.€onÐ $X" ÐOctober€7òòthóó€showing€Mr.€Smith€received€any€sustenance€or€that€he€was€tolerating€anything.€€AÐ ô$D # Ðnotation€in€the€medical€record€with€the€7€p.m.€assessment€on€October€7òòthóó€stated€that€Mr.€Smith€wasÐ à%0!$ Ðtolerating€liquids,€but,€Ms.€Wiseman€testified,€that€was€the€only€note€in€the€chart€regarding€diet.€Ð Ì&"% ÐThere€is€no€mention€in€the€medical€record€that€Mr.€Smith€ever€received€a€hamburger€and€fries.€Ð ¸'#& ÐHowever,€Plaintiff€did€testify€that€her€son€received€a€cheeseburger€and€ate€most€of€it.Ð ¤(ô#' ÐÌà  àà ` àMs.€Wiseman€testified€that€the€general€practice€would€be€to€note€that€the€patient€wasÐ |*Ì%) Ðtolerating€liquids,€or€was€given€Jello€or€applesauce€without€nausea€or€vomiting€so€the€nursing€staffÐ h+¸&* Ðon€the€next€shift€would€know.€€Ms.€Wiseman€stated€that€giving€Mr.€Smith€a€hamburger€and€frenchÐ ° Ðfries€was€not€in€keeping€with€the€doctorððs€orders€because€it€was€ð ðapproximately€four€hours€after€theÐ œì Ðlast€bout€of€vomiting.ðð€€Ms.€Wiseman€stated€that€Mr.€Smith€never€should€have€been€given€aÐ ˆØ Ðhamburger€ð ð[b]ecause€every€time€a€patient€vomits,€youððve€got€to€go€back€to€Step€1,€clear€liquids.ðð€Ð tÄ ÐHowever,€Ms.€Wiseman€admitted€there€is€no€written€guideline€to€look€at€to€determine€how€manyÐ `° Ðhours€should€pass€between€a€vomiting€episode,€the€giving€of€liquid,€the€giving€of€soft€food,€and€theÐ L œ Ðgiving€of€regular€food.€€Rather,€this€is€a€judgment€call€and€the€judgment€of€the€nurse€is€based€in€partÐ 8 ˆ Ðon€interaction€with€the€patient€and€how€the€patient€reports€feeling.€Ð $ t ÐÌà  àà ` àMs.€Wiseman€was€also€critical€regarding€the€nursing€assessments€of€Mr.€Smith.€€TheÐ ü L  Ðdoctor€had€written€an€order€to€do€an€assessment€every€four€hours€for€72€hours.€€Ms.€Wiseman€statedÐ è 8  Ðthere€was€no€assessment€done€after€the€3€a.m.€or€10€a.m.€vomiting€episodes€on€October€7òòthóó.€€Ms.Ð Ô$  ÐWiseman€stated:€Ð À  ÐÌà8  àI€would€have€gone€in,€I€would€have€talked€to€the€patient.€€I€would€have€assessed€hisÐ ˜è  Ðlungs€sounds.€€I€would€have€assessed€his€bowel€sounds.€€I€would€have€asked,€if€thereÐ „Ô  Ðwas€anybody€in€the€room€I€would€have€asked€them€if€he€had€eaten€anything,€becauseÐ pÀ Ðsometimes€well€meaning€family€members€can€bring€things€in€that€the€nursing€staffÐ \¬ Ðhave€no€idea€about€and€then€you€have€to€be€aware€of€that.ÐH˜Ð Ð  ÐÌMs.€Wiseman€also€stated€she€would€assess€the€lungs€and€bowels€using€a€stethoscope.€€However,€sheÐ  p Ðadmitted€there€is€no€written€standard€of€care€that€says€you€have€to€use€a€stethoscope€every€time€aÐ  \ Ðpatient€vomits.€€Ms.€Wiseman€stated€a€nurse€should€have€checked€on€Mr.€Smith€at€least€hourly.€€SheÐ øH Ðstated€she€would€have€done€this€and€she€bases€this€assertion€on€her€own€experience.€€Notations€inÐ ä4 Ðthe€medical€record€show€that€Nurse€Baer€made€rounds€at€least€every€other€hour.Ð Ð  ÐÌà  àà ` àMs.€Wiseman€was€critical€of€what€she€referred€to€as€ð ðsketchyðð€charting€and€stated,Ð ¨ø Ðð ð[i]f€itððs€not€documented,€it€wasnððt€done.ðð€€Ms.€€Wiseman€did€acknowledge,€however,€that€theÐ ”ä Ðpractice€on€the€orthopedic€surgery€recovery€floor€at€the€Hospital€at€that€time€was€to€chart€byÐ €Ð Ðexception,€which€means€that€only€things€out€of€the€ordinary€needed€to€be€noted.€€Ð l¼ ÐÌà  àà ` àThe€medical€record€shows€that€Mr.€Smithððs€vital€signs€were€taken,€including€hisÐ D!” Ðtemperature,€pulse,€and€blood€pressure,€with€some€regularity.€€Mr.€Smithððs€doctor€had€ordered€thatÐ 0"€  Ðhis€vital€signs€were€to€be€taken€every€four€hours.€€The€medical€record€shows€this€was€done€exceptÐ #l! Ðfor€one€instance€when€the€vital€signs€should€have€been€taken€at€4€p.m.€on€October€7òòthóó€and€were€not.€òòóóÐ $X" ÐÌà  àà ` àMs.€Wiseman€admitted€that€the€medical€record€shows€Mr.€Smithððs€vital€signs€wereÐ à%0!$ Ðtaken€at€4€a.m.€on€October€8òòthóó,€after€the€1€a.m.€vomiting€episode€at€issue€in€this€case€and€before€Mr.Ð Ì&"% ÐSmith€was€found€unresponsive€at€5:45€a.m.€€Ms.€Wiseman€acknowledged€that€the€readings€of€Mr.Ð ¸'#& ÐSmithððs€temperature,€pulse,€respiratory€rate,€and€blood€pressure€as€recorded€wereòòóó€normal€and€showÐ ¤(ô#' Ðno€indication€that€Mr.€Smith€was€in€distress€of€any€sort€at€that€time.€€òòóóThe€readings€of€Mr.€SmithððsÐ )à$( Ðrespiratory€rate€did€not€change€throughout€his€hospitalization,€up€to,€and€including,€the€reading€takenÐ |*Ì%) Ðat€4€a.m.€on€October€8òòthóó,€shortly€before€his€death.€€Victoria€Henson,€(ð ðMs.€Hensonðð),€is€the€LPN€whoÐ h+¸&* Ðallegedly€made€various€entries,€including€the€vital€signs,€in€Mr.€Smithððs€chart€during€the€time€periodÐ ° Ðafter€1:00€a.m.€and€prior€to€Mr.€Smith€being€found€unresponsive€at€5:45€a.m.€€The€State€did€not€haveÐ œì ÐMs.€Henson€testify€at€trial.€€Neither€did€Plaintiff.Ð ˆØ ÐÌà  àà ` àMs.€Wiseman€stated€that€she€believes€Mr.€Smithððs€death€was€preventable.€€She€statedÐ `° Ðthat€the€nurses€should€have€ð ðupped€the€assessments.€€They€should€have€raised€the€head€of€his€bed.€Ð L œ ÐThey€should€have€taken€him€back€to€clear€liquids€.€.€.€.ðð€Ð 8 ˆ ÐÌà  àà ` àCleland€Blake,€M.D.,€F.C.A.P.,€who€stated€his€work€is€almost€totally€forensicÐ  ` Ðpathology,€testified€as€an€expert€witness€for€Plaintiff.€€Dr.€Blake€testified€that€the€cause€of€deathÐ ü L  Ðstated€in€the€autopsy€was€aspiration€asphyxia,€which€means€Mr.€Smith€vomited€then€aspiratedÐ è 8  Ðvomitus€that€went€into€his€trachea€bronchial€tree€and€caused€the€presence€of€fluid€filling€in€the€lungsÐ Ô$  Ðand€plugging€the€bronchioles.€€Dr.€Blake€explained€that€the€acid€from€the€stomach€causes€a€ð ðburningÐ À  Ðirritation€injury€of€the€bronchial€passages.ðð€Ð ¬ü  ÐÌà  àà ` àDr.€Blake€testified€that€neutrophils,€a€sign€of€inflammatory€insult,€were€present€in€theÐ „Ô  Ðlungs€upon€autopsy€and€that€this€is€abnormal.€€He€explained€that€neutrophils€would€be€caused€byÐ pÀ Ðð ð[s]ome€element€of€injury,€whether€it€is€chemical,€meaning€acid€particulate,€aspiration,€foodÐ \¬ Ðparticles.€€Some€extrinsic€toxins€or€bacteria€which€causes€a,€a€purulent€substantive€reaction€whichÐ H˜ Ðwe€know€as€empyema,€pus€in€the€lungs€or€chest€cavity,€or€acute€bronchial€pneumonia.ðð€€Dr.€BlakeÐ 4„ Ðbelieves€the€neutrophils€were€caused€by€aspiration€of€gastric€contents.€€He€stated€that€neutrophilsÐ  p Ðwould€begin€to€be€seen€in€twenty€to€thirty€minutes€after€injury.Ð  \ ÐÌà  àà ` àDr.€Blake€also€testified€regarding€the€medications€Mr.€Smith€was€given.€€He€explainedÐ ä4 Ðthat€morphine€is€a€central€nervous€system€suppressant€used€as€a€pain€killer€and€that€Phenergan€isÐ Ð  Ðused€to€control€nausea.€€Dr.€Blake€stated€that€when€used€together,€these€two€drugs€have€a€potentiatingÐ ¼  Ðeffect,€which€means€that€the€Phenergan€exaggerates€the€effect€of€the€morphine€causing€more€of€aÐ ¨ø Ðcentral€nervous€system€suppression.€€€Ð ”ä ÐÌà  àà ` àDr.€Blake€opined€that€Mr.€Smith€took€vomitus€into€his€lungs€after€the€1€a.m.€vomitingÐ l¼ Ðepisode€and€that€this€began€the€gradual€compromise€of€the€lungs.€€He€opined€that€the€process€thatÐ X ¨ Ðcaused€Mr.€Smithððs€death€happened€in€response€to€the€1€a.m.€vomiting€episode.€€In€support€of€hisÐ D!” Ðtheory,€Dr.€Blake€stated€it€is€his€understanding€that€Mr.€Smithððs€respiratory€rate€went€up€and€that€heÐ 0"€  Ðhad€breathing€difficulties€and€tacycardia€after€the€1€a.m.€vomit.€€Dr.€Blake€stated€that€Mr.€SmithÐ #l! Ðwould€have€had€difficulty€breathing€after€the€1€one€a.m.€vomit€and€his€respiratory€rate€would€haveÐ $X" Ðgone€up€to€compensate.€€Dr.€Blake€testified€that€a€patient€who€aspirates€would€have€immediateÐ ô$D # Ðknowledge€of€it€as€they€would€experience€a€burning€sensation€and€their€chest€muscles€would€struggleÐ à%0!$ Ðto€get€air€in.€€Dr.€Blake€further€opined€that€by€4€a.m.€Mr.€Smith€was€unconscious€and€would€have€hadÐ Ì&"% Ða€weak€pulse.€€Dr.€Blake€admitted€that€he€did€not€see€the€vital€signs€in€the€medical€record,€but€thatÐ ¸'#& Ðif€Mr.€Smithððs€vital€signs€were€taken€at€4€a.m.€and€were€the€same€as€they€had€been,€that€would€mostÐ ¤(ô#' Ðlikely€indicate€that€his€condition€was€good.€Ð )à$( Ðâ âÐ |*Ì%) Ðà  àà ` àAccording€to€the€medical€record,€Mr.€Smithððs€vital€signs€were€taken€at€4€a.m.€andÐ ° Ðâ âwere€the€same€as€they€had€been.€€In€addition,€Plaintiffððs€testimony€regarding€Mr.€Smithððs€conditionÐ œì Ðbelies€Dr.€Blakeððs€opinion€that€Mr.€Smith€aspirated€as€a€result€of€the€1€a.m.€vomiting€episode.€Ð ˆØ ÐPlaintiff€testified€she€spoke€to€Mr.€Smith€briefly€after€the€1€a.m.€vomiting€episode€and€testified€ð ð[h]eÐ tÄ Ðacted€like€he€felt€better.ðð€€She€also€testified€that€Mr.€Smith€went€back€to€sleep€and€that€at€4€a.m.€sheÐ `° Ðobserved€ð ð[h]is€chest€was€all€right.€€I€mean,€he€was€breathing€okay.ðð€€She€testified€she€could€see€Mr.Ð L œ ÐSmith€breathing€and€never€heard€any€gagging,€coughing,€or€rasping€sounds.€Ð 8 ˆ ÐÌà  àà ` àTerri€Allison€Donaldson,€a€licensed€nurse€practitioner,€testified€as€an€expert€witnessÐ  ` Ðfor€the€State€and€opined€there€was€no€breach€of€the€standard€of€care€related€to€nursing.€€Ms.Ð ü L  ÐDonaldson€stated€there€are€no€hard€rules€regarding€how€many€hours€to€wait€before€giving€liquid€thenÐ è 8  Ðsoft€food€then€regular€food.€€She€stated€that€since€Mr.€Smith€ð ðhad€gone€through€the,€the€mid„day€andÐ Ô$  Ðafternoon€without€any€episodes€of€nausea€and€vomiting€.€.€.ðð€and€had€not€vomited€since€10€a.m.,€itÐ À  Ðwas€not€inappropriate€or€below€the€standard€of€care€to€give€him€a€hamburger.€Ð ¬ü  ÐÌà  àà ` àMs.€Donaldson€testified€she€believes€there€is€no€evidence€in€the€medical€recordÐ „Ô  Ðshowing€that€Mr.€Smith€aspirated€vomitus€after€his€1€a.m.€vomiting€episode.€€Ms.€DonaldsonÐ pÀ Ðexplained€that€usually€when€someone€aspirates€vomitus€they€cough€or€sputter,€unless€theyÐ \¬ Ðimmediately€lose€consciousness.€€Ms.€Donaldson€also€stated€that€if€Mr.€Smith€had€aspirated,€sheÐ H˜ Ðwould€expect€that€his€respiratory€rate€would€have€gone€up,€his€blood€pressure€might€have€changed,Ð 4„ Ðand€his€heart€rate€may€have€increased.€€None€of€these€things€happened.€€Ms.€Donaldson€testified€thatÐ  p Ðnothing€about€the€vital€signs€taken€at€4€a.m.€indicates€Mr.€Smith€had€a€respiratory€problem€prior€toÐ  \ Ðthat€time.€€In€addition,€Ms.€Donaldson€testified€there€is€nothing€in€the€record€to€suggest€that€Mr.Ð øH ÐSmithððs€gag€reflex€was€suppressed,€he€was€unconscious,€or€that€he€was€unable€to€recognize€anyÐ ä4 Ðrespiratory€problems€he€may€have€been€experiencing.€€Ms.€Donaldson€opined€it€was€not€beneath€theÐ Ð  Ðstandard€of€care€for€a€nurse€to€choose€not€to€use€a€stethoscope€after€Mr.€Smithððs€1€a.m.€vomitingÐ ¼  Ðepisode.€€Furthermore,€Ms.€Donaldson€testified€there€is€no€indication€that€the€combination€ofÐ ¨ø Ðmorphine€and€Phenergan€affected€Mr.€Smithððs€vital€signs,€which€remained€stable€during€hisÐ ”ä Ðhospitalization.€€Ð €Ð ÐÌà  àà ` àDr.€Paul€Bunton€Googe,€who€specializes€in€skin€pathology€and€surgical€pathology,Ð X ¨ Ðtestified€at€trial€that€he€was€in€charge€of€Mr.€Smithððs€autopsy.€€Dr.€Googe€concluded€that€Mr.€SmithÐ D!” Ðdied€of€aspiration€of€gastric€contents.€€Dr€Googe€testified€it€is€his€opinion,€and€the€opinion€of€theÐ 0"€  Ðother€physicians€involved€in€the€autopsy,€that€Mr.€Smith€died€of€acute€gastric€aspiration€into€theÐ #l! Ðlungs€in€ð ða€matter€of€minutes€or€probably€not€more€than€an€hour€from€when€he€died.ðð€€Dr.€GoogeÐ $X" Ðtestified€he€does€not€believe€that€an€event€at€1€a.m.€caused€the€death.€€Rather,€Dr.€Googe€believes€theÐ ô$D # Ðaspirations€that€led€to€death€occurred€ð ðsometime€in€the€ten€to€twenty€minutes€before€5:45€a.m.ðð€Ð à%0!$ ÐÌà  àà ` àDr.€Googe€explained€that€the€neutrophils€could€have€been€present€either€fromÐ ¸'#& Ðtraveling€with€the€vomitus€or€from€the€blood€vessels€in€the€lung€and€stated€ð ðto€see€neutrophils€inÐ ¤(ô#' Ðresponse€to€injury€coming€from€the€blood€stream,€itððs€usually€a€matter€of€hours,€four,€six,€eight€hoursÐ )à$( Ðor€longer.ðð€He€stated€there€were€ð ðjust€a€few€tiny€areas€of€neutrophils€.€.€.€I€donððt€believe€they€areÐ |*Ì%) Ðsufficient€to€have€caused€symptoms€and€certainly€[were]€not€sufficient€to€cause€death.ðð€€€Ð h+¸&* Їà  àà ` àThe€record€on€appeal€shows€that€the€medical€record€in€this€case€apparently€was€lostÐ ° Ðby€the€Hospital€for€approximately€five€years€before€it€finally€was€produced€to€Plaintiff.€€No€adequateÐ œì Ðexplanation€appears€in€the€record€as€to€where€the€medical€record€was€during€this€time€period€or€whyÐ ˆØ Ðit€was€not€produced€sooner.€€In€addition,€for€a€variety€of€reasons€having€nothing€to€do€with€theÐ tÄ ÐCommission€that€eventually€heard€the€case,€the€case€took€approximately€ten€years€€from€the€filingÐ `° Ðof€the€Complaint€until€the€time€of€trial.€€The€case€was€tried€in€late€January€and€early€February€ofÐ L œ Ð2004.Ð 8 ˆ ÐÌà  àà ` àThe€Commission€entered€a€judgment€on€February€26,€2004.€€In€its€memorandum€orderÐ  ` Ðincorporated€into€the€judgment,€the€Commission€made€specific€findings€of€fact€and€conclusions€ofÐ ü L  Ðlaw.€€The€Commission€found€Plaintiff€to€be€ð ða€very€honest€witness,€a€very€credible€witness€.€.€.Ð è 8  Ðhonest€to€the€point€where€her€testimony€became€damaging€to€her€claimðð€and€stated€ð ðmuch€of€thisÐ Ô$  ÐCommissionððs€decision€is€based€upon€her€testimony€.€.€.€.ðð€€The€Commission€also€found€Ms.Ð À  ÐWiseman€to€be€a€credible€witness€but€found€that€many€of€Ms.€Wisemanððs€criticisms€regarding€theÐ ¬ü  Ðnursing€care€admittedly€were€related€to€judgment€calls.€€In€addition,€the€Commission€found€that€theÐ ˜è  Ðdeviations€Ms.€Wiseman€claims€occurred,€specifically€the€failures€to€properly€advance€diet,€toÐ „Ô  Ðadequately€maintain€the€medical€chart,€and€€to€properly€follow€physicianððs€orders,€were€not€a€directÐ pÀ Ðand€proximate€cause€of€Mr.€Smithððs€death.€€Rather,€the€Commission€found€that:€Ð \¬ ÐÌà8  àThe€body€of€evidence€presented€at€trial€and€contained€in€the€entire€record€proves€byÐ 4„ Ða€preponderance€of€the€evidence€that€[Mr.€Smith]€aspirated€on€his€own€vomitusÐ  p Ðquickly€and€quietly,€so€quickly€and€so€quietly,€in€fact,€that€it€would€have€taken€aÐ  \ Ðnurse€providing€[Mr.€Smith]€with€a€level€of€care€akin€to€a€critical€care€patient€in€orderÐ øH Ðto€have€any€remote€possibility€of€catching€the€aspiration€and€saving€[Mr.€Smithððs]Ð ä4 Ðlife.€€ÐÐ Ð Ð  ÐÌThe€Commission€found€that€the€nursing€techniques€testified€to€by€Ms.€Wiseman€did€not€establishÐ ¨ø Ðð ðthe€standard€of€care€that€was€required€of€a€registered€nurse€on€a€general€orthopaedic€recovery€floorÐ ”ä Ðat€UT€Hospital.ðð€€Ð €Ð ÐÌà  àà ` àFurther,€although€the€Commission€found€Dr.€Blake€to€be€a€credible€witness,€it€foundÐ X ¨ Ðthat€Dr.€Blakeððs€testimony€was€not€supported€by€the€facts.€€Dr.€Blake€opined€that€Mr.€Smith€aspiratedÐ D!” Ðafter€the€1€a.m.€vomit€and€that€he€would€have€begun€to€have€noticeable€problems€immediately.€€TheÐ 0"€  Ðmedical€record€and€the€testimony€of€the€two€witnesses,€including€the€Plaintiff,€who€observed€Mr.Ð #l! ÐSmith€after€the€1€a.m.€vomiting€episode€show,€however,€that€Mr.€Smith€was€not€experiencing€anyÐ $X" Ðrespiratory€problems€at€that€time€and,€in€fact,€he€stated€he€felt€better.€€The€Commission€stated:Ð ô$D # ÐÌà8  àDr.€Blake€testified€beyond€a€reasonable€degree€of€medical€certainty€that€the€failureÐ Ì&"% Ðof€[Nurse]€Baer€to€listen€to€[Mr.€Smithððs]€lungs€was,€in€essence,€the€sole,€direct€andÐ ¸'#& Ðapproximate€(sic)€cause€of€[Mr.€Smithððs]€death.€€As€was€Ms.€Wisemanððs€testimony,Ð ¤(ô#' Ðthis€opinion€is€not€consistent€with€the€entire€body€of€evidence€presented€at€trial€andÐ )à$( Ðthe€record€as€a€whole.€€Specifically,€the€reaction€of€[Mr.€Smith]€after€the€vomitingÐ |*Ì%) Ðepisode€would€not€cause€a€reasonable€healthcare€professional€to€take€the€drasticÐ h+¸&* Ðmeasures€that€Dr.€Blake€suggests,€which€is€suctioning€[Mr.€Smithððs]€lungs€orÐ ° Ðobtaining€a€new€airway€via€a€tracheotomy.€€Although€Dr.€Blake€testifies€thatÐ œì Ðsuctioning€is€necessary€in€accordance€with€the€standard€of€care,€the€CommissionÐ ˆØ Ðfinds€under€the€facts€of€the€circumstances€presented€that€such€action€was€notÐ tÄ Ðnecessary€and€did€not€equate€to€standard€of€care.Ð`°Ð Ð  ÐÌà  àà ` àIn€contrast€to€its€credibility€determinations€regarding€the€other€witnesses,€theÐ 8 ˆ ÐCommission€found€Nurse€Baer€to€be€a€horrible,€evasive,€and€elusive€witness.€The€Commission,Ð $ t Ðhowever,€also€stated€that€while€there€may€have€been€some€inadequacies€in€the€care€he€rendered€toÐ  ` ÐMr.€Smith,€ð ðthere€is€no€evidence€that€such€shortfalls€were€the€direct€and€proximate€cause€of€[Mr.Ð ü L  ÐSmithððs]€death€by€aspiration.ðð€Although€the€Commission€found€Nurse€Baerððs€testimony€not€to€beÐ è 8  Ðcredible,€it€noted€that€it€still€found€that€there€was€a€conversation€between€Mr.€Smith€and€Nurse€BaerÐ Ô$  Ðafter€the€1€a.m.€vomiting€episode€and€that€Mr.€Smith€exhibited€no€signs€of€distress€whatsoever€at€thatÐ À  Ðtime€because€Plaintiff,€who€was€a€credible€witness,€also€testified€to€these€facts.€€€The€CommissionÐ ¬ü  Ðstated€ð ðthere€is€no€evidence€that€the€standard€of€care€dictated€[Nurse]€Baer€to€have€acted€differently.ðð€Ð ˜è  ÐÌà  àà ` àThe€Commission€also€found€Dr.€Googeððs€testimony€to€be€credible€and€stated:Ð pÀ ÐÌà8  àHe€conducted€the€autopsy€on€[Mr.€Smith].€€He€stated€without€reservation€that€(1)Ð H˜ Ðvegetable€matter€was€found€deep€in€the€lungs€of€[Mr.€Smith].€€This€is€a€medicalÐ 4„ Ðfinding€of€a€previous€aspiration€occurring€some€time€prior€to€[Mr.€Smithððs]Ð  p Ðhospitalization€on€October€6th,€1993.€€Secondly,€the€neutrophils€in€[Mr.€Smithððs]Ð  \ Ðlungs€appeared€to€have€come€from€such€prior€aspiration.€€Thirdly,€[Mr.€Smith]€diedÐ øH Ðof€acute€aspiration€of€gastric€contents€into€the€lungs,€and€finally,€the€aspiration€thatÐ ä4 Ðcaused€[Mr.€Smithððs]€death€occurred€less€than€one€hour€prior€to€the€death.€€Dr.€GoogeÐ Ð  Ðstated€that€thereððs€no€credible€evidence€to€prove€Dr.€Blakeððs€theory€that€[Mr.€Smith]Ð ¼  Ðaspirated€at€1:00€A.M.€and€slowly€suffocated€as€his€lungs€shut€down€and€filled€upÐ ¨ø Ðwith€fluid.ДäÐ Ð  ÐÌà  àà ` àThe€Commission€found€that€Dr.€Blakeððs€testimony€and€his€opinion€that€Mr.€SmithÐ l¼ Ðaspirated€as€a€result€of€the€1€a.m.€vomit€also€were€rebutted€by€the€fact€that€Mr.€Smith€did€not€choke,Ð X ¨ Ðcough,€or€complain€of€any€burning€in€his€lungs€after€the€1€a.m.€vomit;€that€Mr.€Smith€carried€onÐ D!” Ðconversations€with€his€mother€and€with€Nurse€Baer€after€the€1€a.m.€vomit;€that€the€anesthesiologistÐ 0"€  Ðtrying€to€intubate€Mr.€Smith€during€the€code€found€secretions€in€Mr.€Smithððs€throat,€mouth,€andÐ #l! Ðupper€airways;€and€that€coffee€ground€emesis€was€found€in€Mr.€Smithððs€mouth€during€the€code.€€TheÐ $X" ÐCommission€stated€that€these€facts€show,€and€the€Commission€so€found,€ð ðthat€a€final€vomitingÐ ô$D # Ðepisode€took€place€an€hour€prior€to€[Mr.€Smithððs]€death,€somewhere€around€5:00€oððclock,€5:15€orÐ à%0!$ Ðthe€likeððand€stated€that€this€theory€is€more€logical€than€Dr.€Blakeððs€theory.€€The€Commission€foundÐ Ì&"% Ðthat€ð ðDr.€Googeððs€testimony€fit€the€factual€circumstance€by€a€preponderance€of€the€evidence.ðð€€Ð ¸'#& ÐÌà  àà ` àThe€Commission€stated€it€would€have€liked€to€have€heard€from€the€doctor€whoÐ )à$( Ðperformed€the€surgery€on€the€issue€of€whether€Mr.€Smith€suffered€a€suppressed€gag€reflex.€€SeveralÐ |*Ì%) Ðwitnesses€at€trial€testified€to€the€potentiating€effect€of€morphine€and€Phenergan.€€However,€theÐ h+¸&* ÐCommission€stated€ð ð[i]f€allegedly€there€was€a€problem€with€a€suppressed€gag€reflex€due€to€overÐ ° Ðmedication€.€.€.€then€we€have€to€look€to€the€fault€going€back€„€„€the€genesis€of€that€fault€being€theÐ œì Ðoriginal€doctor€order€.€.€.€ordering€the€Phenergan€and€the€morphine€combined€and€the€dosage€that€heÐ ˆØ Ðassigned€to€each€drug.ðð€€There€is€no€evidence€that€the€nursing€staff€failed€to€give€medications€inÐ tÄ Ðaccordance€with€the€doctorððs€orders.Ð `° ÐÌà  àà ` àThe€Commission€further€noted€that€it€would€have€liked€to€have€heard€testimony€fromÐ 8 ˆ Ðð ðVictoria€Henson,€the€LPN€who€supposedly€checked€and€charted€Mr.€Smithððs€vital€signs€during€theÐ $ t Ðcritical€period€of€time.ðð€€The€Commission€made€the€finding€that€the€State€did€not€offer€Ms.€HensonððsÐ  ` Ðtestimony,€but€declined€to€make€any€further€findings€regarding€this€issue.€€€€Ð ü L  ÐÌà  àà ` àThe€Commission€also€addressed€the€issues€surrounding€the€lost€chart€stating:Ð Ô$  ÐÌà8  àThe€chart€in€this€case€was€lost€for€five€and€a€half€years.€€Thereððs€absolutely€positivelyÐ ¬ü  Ðno€way€this€Commission€can€find€anything€but€that€such€an€act,€if€you€will,€such€anÐ ˜è  Ðoccurrence€is€unacceptable.€€There€is€no€proof€that€the€integrity€of€this€chart€wasÐ „Ô  Ðmaintained.€€However,€there€is€also€no€proof€that€this€chart€was€altered.€€TheÐ pÀ Ð[Plaintiff]€made€it€out€for€an€inference€to€be€drawn€that€it€could€have€happened.€€TheÐ \¬ ÐCommission€acknowledges€that€it€could€have€happened.€€The€Commission€finds€thatÐ H˜ Ðthere€is€no€evidence€supporting€that€it€happened.€€That€having€been€said,€thisÐ 4„ ÐCommission€cannot€let€it€go€by€without€stating€that€the€hospitalððs€failure€to€find€theÐ  p Ðfile€for€five€and€a€half€years€is€an€abomination,€and€we€would€hope€that€such€an€eventÐ  \ Ðwould€not€be€repeated.€.€.€.€There€was€an€inference€laid€before€the€Commission,Ð øH Ðwhich€the€Commission€respects,€for€the€Commission€to€make€of€it€as€it€would.€€AndÐ ä4 ÐI€find€that€while€the€integrity€of€the€chart€was€not€proven,€that€alteration€was€notÐ Ð  Ðproven€either.€€So,€in€essence,€itððs€a€wash.€Ð¼ Ð Ð  ÐÌà  àà ` àThe€Commission€entered€judgment€in€favor€of€the€State.Ð ”ä ÐÌÓ  Óò òòòDiscussionóóó óÐ l¼ ÐÓ  ÓÌà  àà ` àAlthough€not€stated€exactly€as€such,€Plaintiff€raises€three€issues€on€appeal:€1)€whetherÐ D!” Ðthe€Commission€erred€in€refusing€to€find€that€the€integrity€of€the€medical€record€had€beenÐ 0"€  Ðcompromised;€2)€whether€the€evidence€preponderates€against€the€Commissionððs€factual€findings;Ð #l! Ðand,€3)€€whether€the€evidence€preponderates€against€the€Commissionððs€holding€that€there€was€noÐ $X" Ðdeviation€from€the€standard€of€care.€€Ð ô$D # ÐÌà  àà ` àÔ‡ X 7 XXXKÑÔOur€review€is€Ý‚=ÿÿÿÝòòÝ  Ýde€novoóóÝ‚=ÿŸmateÝÝ  Ý€upon€the€record,€accompanied€by€a€presumption€of€correctnessÐ Ì&"% Ðof€the€findings€of€fact€of€the€trial€court,€here€the€Commission,€unless€the€preponderance€of€theÐ ¸'#& Ðevidence€is€otherwise.€€Tenn.€R.€App.€P.€13(d);€òòBogan€v.€Boganóó,€60€S.W.3d€721,€727€(Tenn.€2001).€Ð ¤(ô#' ÐA€trial€court's€conclusions€of€law€are€subject€to€a€Ý‚=ÿÿÿÝòòÝ  Ýde€novoóóÝ‚=ÿÑ mateÝÝ  Ý€review€with€no€presumption€of€correctness.€Ð )à$( ÐÝ‚=ÿÿÿÝòòÝ  ÝS.€Constructors,€Inc.€v.€Loudon€County€Bd.€of€Educ.Ý‚=ÿÿÿj¡ƒÝóóÝ  Ý,€58€S.W.3d€706,€710€(Tenn.€2001).€Ô#†XKÑX X X 7Õž#ÔÔ‡X 7 XXXKÑÔÐ |*Ì%) ÐÐ h+¸&* Ðà  àà ` àWe€first€will€discuss€Ô#†XKÑX XX 7'¢#Ôwhether€the€Commission€erred€in€refusing€to€find€that€theÐ ° Ðintegrity€of€the€medical€record€had€been€compromisedÔ‡X 7 XXXKÑÔ.€€Ô#†XKÑX XX 7C£#ÔPlaintiff€argues€that€she€should€have€receivedÐ œì Ða€presumption€that€the€medical€record€was€altered.€€Plaintiffððs€argument€rests€upon€the€doctrine€ofÐ ˆØ Ðspoliation€of€evidence,€which€ð ðpermits€a€court€to€draw€a€negative€inference€against€a€party€that€hasÐ tÄ Ðintentionally,€and€for€an€improper€purpose,€destroyed,€mutilated,€lost,€altered,€or€concealedÐ `° Ðevidence.ðð€€òòLeatherwood€v.€Wadleyóó,€121€S.W.3d€682,€703€(Tenn.€Ct.€App.€2003).€€Ð L œ ÐÌà  àà ` àTo€begin,€we€note€that€the€record€in€this€case€is€devoid€of€evidence€showing€that€theÐ $ t Ðmedical€record€was€destroyed,€mutilated,€or€altered.€€There€is€evidence€in€the€record,€however,Ð  ` Ðshowing€that€the€medical€record€was€lost€and€not€produced€for€a€period€of€approximately€five€yearsÐ ü L  Ðbefore€being€produced€by€the€Hospital.€€More€importantly,€however,€the€record€is€devoid€of€evidenceÐ è 8  Ðshowing€that€the€Hospital€ð ðintentionally,€and€for€an€improper€purposeðð€lost€or€concealed€the€medicalÐ Ô$  Ðrecord€during€this€time€period.€€òòIdóó.€€The€medical€record€eventually€was€produced€and€was€madeÐ À  Ðavailable€to€Plaintiff€and,€as€the€Commission€noted,€Plaintiff€relied€on€the€medical€record€at€trial.€Ð ¬ü  ÐAs€there€is€nothing€in€the€record€showing€the€intent€necessary€to€support€an€inference€under€theÐ ˜è  Ðdoctrine€of€spoliation€of€evidence,€Plaintiff€was€not€entitled€to€such€an€inference.€€Ð „Ô  ÐÌà  àà ` àThe€Commission,€however,€did€state:€Ð \¬ ÐÌà8  àThere€is€no€proof€that€the€integrity€of€this€chart€was€maintained.€€However,€there€isÐ 4„ Ðalso€no€proof€that€this€chart€was€altered.€€The€[Plaintiff]€made€it€out€for€an€inferenceÐ  p Ðto€be€drawn€that€it€could€have€happened.€€The€Commission€acknowledges€that€itÐ  \ Ðcould€have€happened.€€The€Commission€finds€that€there€is€no€evidence€supportingÐ øH Ðthat€it€happened.€€That€having€been€said,€this€Commission€cannot€let€it€go€by€withoutÐ ä4 Ðstating€that€the€hospitalððs€failure€to€find€the€file€for€five€and€a€half€years€is€anÐ Ð  Ðabomination,€and€we€would€hope€that€such€an€event€would€not€be€repeated.€.€.€.€ThereÐ ¼  Ðwas€an€inference€laid€before€the€Commission,€which€the€Commission€respects,€forÐ ¨ø Ðthe€Commission€to€make€of€it€as€it€would.€€And€I€find€that€while€the€integrity€of€theÐ ”ä Ðchart€was€not€proven,€that€alteration€was€not€proven€either.€€So,€in€essence,€itððs€aÐ €Ð Ðwash.€Ðl¼Ð Ð  ÐÌà  àà ` àPlaintiff€argues€that€she€need€not€prove€alteration€in€order€to€impeach€the€medicalÐ D!” Ðrecord€and€cites€to€òòRichardson€v.€Milleróó,€which€states€that€ð ð[s]eldom€will€parties€be€able€to€prove€thatÐ 0"€  Ðtheir€adversary€maliciously€destroyed€or€secreted€a€missing€document.ðð€€òòRichardson€v.€Milleróó,€44Ð #l! ÐS.W.3d€1,€28€(Tenn.€Ct.€App.€2000).€€òòRichardsonóó,€however,€dealt€with€allegations€regarding€aÐ $X" Ðspecific€allegedly€missing€document€and€stated€that€a€factual€issue€ð ðis€created€when€the€party€seekingÐ ô$D # Ðthe€missing€evidence€instruction€puts€on€evidence€showing€(1)€that€the€document€exists,€(2)€that€theÐ à%0!$ Ðdocument€is€relevant,€and€(3)€that€the€opposing€party€had€exclusive€control€of€the€document€and€theÐ Ì&"% Ðparty€possessing€the€document€proffers€an€explanation€for€not€producing€it.€€òòIdóó.€€In€the€instant€case,Ð ¸'#& Ðthere€are€no€allegations€regarding€a€specific€missing€document€or€documents.€€Plaintiff€did€not€showÐ ¤(ô#' Ðthat€any€specific€document€existed€and€was€not€produced€at€or€before€trial.€€Plaintiff€apparentlyÐ )à$( Ðargues€that€the€five€year€delay€in€producing€the€medical€record€is€equivalent€to€having€maliciouslyÐ |*Ì%) Ðdestroyed€or€totally€failed€to€produce€the€record.€€Plaintiff€then€argues€that€because€of€this€delay,€anÐ h+¸&* Ðalteration€of€the€record€by€the€Hospital€should€be€presumed.€€We€fail€to€see€any€correlation€betweenÐ ° Ða€delay,€even€an€unreasonable€five€year€delay,€in€producing€the€medical€record€and€a€claim€ofÐ œì Ðalteration€of€the€medical€record.€€There€has€been€no€reason€presented€as€to€why€the€Hospital€or€anyÐ ˆØ Ðindividual€allegedly€wanting€to€alter€the€medical€record€would€have€required€a€five€year€period€inÐ tÄ Ðwhich€to€make€the€claimed€alteration.€€In€short,€the€fact€that€the€State€or€the€Hospital€unreasonablyÐ `° Ðdelayed€for€five€years€the€production€of€the€medical€record€does€not€necessarily€mean€that€theÐ L œ Ðmedical€record€was€altered€in€any€way.€€The€record€on€appeal€presented€to€us€does€not€show€anyÐ 8 ˆ Ðcausal€relationship€between€the€delay,€even€an€unreasonable€five€year€delay,€in€producing€the€medicalÐ $ t Ðrecord€and€the€claimed€alteration€to€that€medical€record,€and€we€find€no€reason€to€believe€that€suchÐ  ` Ða€causal€relationship€automatically€exists.€€Therefore,€Plaintiffððs€reliance€upon€òòRichardsonóó€isÐ ü L  Ðmisplaced.€€€€€€€€Ð è 8  ÐÌà  àà ` àAdditionally,€we€note€that€Plaintiff€did€not€bring€the€matter€of€the€missing€medicalÐ À  Ðrecord€to€the€attention€of€the€Commission€until€after€the€State€had€been€granted€an€Order€ofÐ ¬ü  ÐDismissal€for€failure€to€prosecute€two€years€after€the€filing€of€suit.€€Plaintiff€filed€a€Motion€toÐ ˜è  ÐReconsider€and€the€Commission€did€enter€an€Order€Setting€Aside€Order€of€Dismissal.€€However,€theÐ „Ô  Ðonly€relief€requested€by€Plaintiff€was€to€have€the€Order€of€Dismissal€set€aside.€€Plaintiff€did€not€askÐ pÀ Ðfor€any€other€relief€at€that€time.€€Plaintiff€did€not€seek€any€relief€relative€to€the€once€missing€medicalÐ \¬ Ðrecord€until€trial€and,€as€the€Commission€noted,€Plaintiff€relied€upon€the€medical€record€at€trial.€€WeÐ H˜ Ðare€unpersuaded€by€the€Plaintiffððs€argument€that,€basically,€those€portions€of€the€medical€record€thatÐ 4„ Ðare€helpful€to€Plaintiffððs€case€are€reliable€and€those€portions€of€the€medical€record€that€are€harmfulÐ  p Ðto€Plaintiffððs€are€unreliable.€€Ð  \ ÐÌà  àà ` àThe€Commission€did€acknowledge€that€an€inference€had€been€laid€before€it,€whetherÐ ä4 ÐPlaintiff€was€entitled€to€one€or€not,€and€clearly€considered€the€matter.€€We€hold€the€Commission€didÐ Ð  Ðnot€err€in€refusing€to€find€that€the€integrity€of€the€medical€record€had€been€compromised€as€noÐ ¼  Ðalteration€of€the€medical€record€either€was€proven€or€properly€presumed€to€have€occurredÔ‡X 7 XXXKÑÔ.€€Ð ¨ø ÐÌà  àà ` àWe€next€consider,€in€light€of€our€discussion€above,€whether€the€evidenceÐ €Ð Ðpreponderates€against€the€Commissionððs€factual€findings.€€Ô#†XKÑX XX 7c¿#Ôð ðWhen€a€trial€court€has€seen€and€heardÐ l¼ Ðwitnesses,€especially€where€issues€of€credibility€and€weight€of€oral€testimony€are€involved,Ð X ¨ Ðconsiderable€deference€must€be€accorded€to€the€trial€court's€factual€findings.ðð€€òòSeals€v.Ð D!” ÐEngland/Corsair€Upholstery€Mfg.€Co.óó,€984€S.W.2d€912,€915€(Tenn.€1999)€(quoting€òòCollins€v.Ð 0"€  ÐHowmet€Corp.óó,€970€S.W.2d€941,€943€(Tenn.1998)).€€Ô‡X 7 XXXKÑÔÐ #l! ÐÔ#†XKÑX XX 7;Â#ÔÔ‡X 7 XXXKÑÔÌà  àà ` àPlaintiff€claims€the€evidence€preponderates€against€the€Commissionððs€factual€findingsÐ ô$D # Ðbecause€the€medical€record€was€unauthenticated€and€uncorroborated;€Nurse€Baerððs€testimony€wasÐ à%0!$ Ðfound€to€be€elusive,€evasive,€and€not€credible;€the€State€did€not€offer€the€testimony€of€Ms.€Henson,Ð Ì&"% Ðthe€LPN;€and€the€Stateððs€experts€relied€upon€the€medical€record€to€opine€that€there€were€noÐ ¸'#& Ðdeviations€below€the€standard€of€care.€€This€argument€breaks€down€into€several€main€points.€€Ð ¤(ô#' ÐÌà  àà ` àFirst,€Plaintiff€complains€about€the€medical€record,€which€she€asserts€should€not€haveÐ |*Ì%) Ðbeen€relied€upon€because€it€was€not€produced€for€approximately€five€years.€€Plaintiff€again€cites€toÐ h+¸&* ÐòòRichardsonóó€in€support€of€her€contention.€€òòRichardsonóó,€44€S.W.3d€1.€€As€we€discussed€above,Ð ° ÐPlaintiffððs€reliance€upon€òòRichardsonóó€is€misplaced.€€òòóóIn€addition,€we€note€that€the€CommissionððsÐ œì Ðfindings€and€ultimate€decision€were,€in€large€part,€ð ðbased€upon€[Plaintiffððs]€testimony...ðð€and€theÐ ˆØ Ðtestimony€of€Dr.€Googe,€testimony€which€strongly€supports€the€Commissionððs€factual€findings€evenÐ tÄ Ðif€the€medical€record€itself€were€discounted.€€Plaintiffððs€claim€that€the€testimony€of€the€StateððsÐ `° Ðexperts€should€be€given€no€weight€because€they€relied€upon€the€medical€record€to€opine€that€thereÐ L œ Ðwere€no€deviations€below€the€standard€of€care€also€must€fail€given€our€resolution€of€Plaintiffððs€issueÐ 8 ˆ Ðconcerning€the€medical€record.€Ð $ t ÐÌà  àà ` àSecond,€it€is€true€that€the€Commission€found€Nurse€Baerððs€testimony€to€be€evasive,Ð ü L  Ðelusive,€and€not€credible.€€However,€the€Commission€specifically€stated€that€Ô#†XKÑX XX 7’Â#Ôeven€if€Nurse€BaerððsÐ è 8  Ðtestimony€were€discounted,€it€could€and€did€still€find€that€there€was€a€conversation€between€Mr.Ð Ô$  ÐSmith€and€Nurse€Baer€after€the€1€a.m.€vomiting€episode€and€that€Mr.€Smith€exhibited€no€signs€ofÐ À  Ðdistress€whatsoever€Ô‡X 7 XXXKÑÔat€that€time€because€PlaintiffÔ#†XKÑX XX 7ÁË#Ô,€who€was€a€credible€witness,€also€testified€to€theseÐ ¬ü  Ðfacts.€Ô‡X 7 XXXKÑÔÐ ˜è  ÐÌà  àà ` àFinally,€Plaintiff€argues€that€because€the€State€did€not€offer€the€testimony€of€Ms.Ð pÀ ÐHenson,€the€LPN,€Plaintiff€should€have€been€entitled€to€an€inference€that€the€testimony€that€wouldÐ \¬ Ðhave€been€given€by€Ms.€Henson€ð ðwould€not€sustain€the€contention€of€[the€State].ðð€€òòRaines€v.€ShelbyÐ H˜ ÐWilliams€Indus.óó,€814€S.W.2d€346,€349€(Tenn.€1991)€(quoting€òòDelk€v.€Stateóó,€590€S.W.2d€435,€448Ð 4„ Ð(Tenn.€1979)€(dissenting€opinion)).€€In€essence,€Plaintiff€argues€she€was€entitled€to€the€benefit€of€theÐ  p Ðmissing€witness€rule.€€This€Court€discussed€the€missing€witness€rule€in€òòDickey€v.€McCordóó,€stating:Ð  \ ÐÌà8  àà ` àà ¸ àThe€missing€witness€rule€provides€that€Ðä4Ð Ð  Ðà8  àÐ Ð Ð  Ðà8  àà8` Ð Ð à[f]ailure€of€a€party€to€call€an€available€witness€possessing€peculiarÐ ¼  Ðknowledge€concerning€the€facts€essential€to€a€partyððs€case,€direct€orÐ ¨ø Ðrebutting,€or€to€examine€such€witness€as€to€the€facts€covered€by€hisÐ ”ä Ðspecial€knowledge,€especially€if€the€witness€would€naturally€beÐ €Ð Ðfavorable€to€the€partyððs€contention,€relying€instead€upon€the€evidenceÐ l¼ Ðof€witnesses€less€familiar€with€the€matter,€gives€rise€to€an€inferenceÐ X ¨ Ðthat€the€testimony€of€such€uninterrogated€witness€would€not€sustainÐ D!” Ðthe€contention€of€the€party.€€No€such€inference€arises€where€the€onlyÐ 0"€  Ðobject€of€calling€such€witness€would€be€to€produce€corroborative,Ð #l! Ðcumulative,€or€possibly€unnecessary€evidence;€or€when€an€adverseÐ $X" Ðinference€would€be€improper€for€any€other€reason€.€.€.€.€Ðô$D #` x` x Ðà8  àÐ Ð Ð  Ðà8  àòòStevens€v.€Mooreóó,€24€Tenn.€App.€61,€139€S.W.2d€710,€717€(Tenn.€Ct.€App.€1940)Ð Ì&"% Ð(citation€omitted);€òòsee€also€State€v.€Francisóó,€669€S.W.2d€85,€88„90€(Tenn.€1984).€€AsÐ ¸'#& Ða€prerequisite€to€commenting€on€a€missing€witness,€the€evidence€must€show€ð ðthat€theÐ ¤(ô#' Ðwitness€had€knowledge€of€material€facts,€that€a€relationship€exists€between€theÐ )à$( Ðâ âwitness€and€the€party€that€would€naturally€incline€the€witness€to€favor€the€party€andÐ |*Ì%) Ðthat€the€missing€witness€was€available€to€the€process€of€the€Court€for€the€trial.ðð€€òòDelkÐ ° Ðv.€Stateóó,€590€S.W.2d€435,€440€(Tenn.€1979).МìÐ Ð  Ðâ âÌòòDickey€v.€McCordóó,€63€S.W.3d€714,€721€(Tenn.€Ct.€App.€2001).€€Ð tÄ ÐÌà  àà ` àIt€is€true€that€the€State€did€not€offer€Ms.€Hensonððs€testimony.€€We€note,€however,€thatÐ L œ Ðthere€is€absolutely€nothing€in€the€record€to€show€that€at€the€time€of€trial,€more€than€ten€years€afterÐ 8 ˆ ÐMr.€Smithððs€tragic€death,€Ms.€Henson€still€was€employed€by€the€Hospital€or€that€she€even€still€wasÐ $ t Ðalive.€€There€is€nothing€in€the€record€to€show€that€a€relationship€exists€between€Ms.€Henson€and€theÐ  ` ÐHospital€that€would€incline€Ms.€Henson€to€favor€the€Hospital.€€It€may€be€that€Ms.€Henson€still€worksÐ ü L  Ðfor€the€Hospital,€or€it€may€just€as€likely€be€that€Ms.€Henson€quit€or€was€fired€and€maintains€someÐ è 8  Ðhostility€toward€the€Hospital.€€There€simply€is€nothing€in€the€record€to€show€that€Ms.€Henson€wasÐ Ô$  Ðuniquely€under€the€Stateððs€control€or€that€she€was€not€as€equally€available€to€Plaintiff€as€to€the€State.€Ð À  ÐIn€fact,€there€is€nothing€in€the€record€to€show€that€Ms.€Henson€ð ðwas€available€to€the€process€of€theÐ ¬ü  ÐCourt€for€the€trial.ðð€€òòIdóó.€€For€all€we€know,€Ms.€Henson€may€no€longer€be€living,€or€may€no€longer€beÐ ˜è  Ðresiding€within€the€jurisdiction.€€We€simply€have€nothing€in€the€record€to€show€the€prerequisites€thatÐ „Ô  Ðwould€entitle€Plaintiff€to€the€missing€witness€rule.€€If€Plaintiff€wanted€to€call€Ms.€Henson€as€aÐ pÀ Ðwitness,€Plaintiff€was€as€free€to€do€so€as€was€the€State.€€This€being€so,€we€find€no€error€by€theÐ \¬ ÐCommission€as€to€this€issue€raised€by€Plaintiff.Ð H˜ ÐÔ#†XKÑX XX 7rÌ#ÔÌà  àà ` àIn€her€reply€brief,€Plaintiff€also€argues€that€the€testimony€of€Dr.€Fulkerson,€offeredÐ  p Ðby€the€State,€was€not€credible€and€was€ð ðnot€sufficient€to€support€the€verdict.ðð€€We€find€nothing€in€theÐ  \ Ðrecord€showing€that€the€Commission€relied€in€any€significant€way€upon€the€testimony€of€Dr.Ð øH ÐFulkerson€in€support€of€its€holding.€€Instead,€the€Commission€held€that€Plaintiff€did€not€establish€theÐ ä4 Ðstandard€of€care,€and,€therefore,€failed€to€establish€any€breach€of€the€standard€of€care.€€In€itsÐ Ð  Ðmemorandum€opinion,€the€Commission€simply€mentions€that€ð ð[t]he€gist€of€Dr.€FulkersonððsÐ ¼  Ðtestimony€was€that€[Mr.€Smith]€was€not€high€risk.ðð€€The€Commission€then€noted:Ð ¨ø ÐÌà8  à[Mr.€Smith]€was€„€I€hate€the€term,€but€itððs€a€medical€term€„€morbidly€obese.€€He€wasÐ €Ð Ð300€pounds,€had€gastric€reflux€disease€as€well€as€he€had€been€injured€in€an€accidentÐ l¼ Ðprior.€€Dr.€Blake€testified€as€to€the€compressed€chest€cavity€of€[Mr.€Smith].€€He€statedÐ X ¨ Ðthat€in€his€opinion€[Mr.€Smith]€was€a€high€risk€candidate,€.€.€.€.ÐD!”Ð Ð  Ðà8  à€Ô‡X 7 XXXKÑÔÐ0"€ Ð Ð  Ðà  àà ` àThe€Commission€observed€the€witnesses€and€made€very€specific€credibilityÐ #l! Ðdeterminations€and,€as€we€must,€we€afford€considerable€deference€to€the€Commissionððs€credibilityÐ $X" Ðdeterminations€and€the€resulting€impact€of€these€determinations€on€the€Commissionððs€factualÐ ô$D # Ðfindings.€€The€evidence€does€not€preponderate€against€the€Commissionððs€factual€findings€and,Ð à%0!$ Ðtherefore,€we€will€not€disturb€those€findings€upon€appeal.€€€€€Ð Ì&"% ÐÔ#†XKÑX XX 7&ã#ÔÌà  àà ` àWe€next€consider,€given€our€holdings€above,€whether€the€evidence€preponderatesÐ ¤(ô#' Ðagainst€the€Commissionððs€findings€and€resulting€decision€that€there€was€no€deviation€from€theÐ )à$( Ðstandard€of€care.€€Medical€malpractice€actions€in€Tennessee,€such€as€this€case,€are€governed€by€Tenn.Ð |*Ì%) ÐCode€Ann.€ðð€29„26„115,€which€provides,€in€pertinent€part:Ð h+¸&* Їà8  à(a)€In€a€malpractice€action,€the€claimant€shall€have€the€burden€of€proving€by€evidenceÐ ° Ðas€provided€by€subsection€(b):МìÐ Ð  ÐÌà8  àà ` à(1)€The€recognized€standard€of€acceptable€professional€practice€in€theÐ tÄ Ðprofession€and€the€specialty€thereof,€if€any,€that€the€defendant€practices€in€theÐ `° Ðcommunity€in€which€the€defendant€practices€or€in€a€similar€community€at€the€timeÐ L œ Ðthe€alleged€injury€or€wrongful€action€occurred;Ð8 ˆÐ Ð  ÐÌà8  àà ` à(2)€That€the€defendant€acted€with€less€than€or€failed€to€act€with€ordinary€andÐ  ` Ðreasonable€care€in€accordance€with€such€standard;€andÐü L Ð Ð  ÐÌà8  àà ` à(3)€As€a€proximate€result€of€the€defendantððs€negligent€act€or€omission,€theÐ Ô$  Ðplaintiff€suffered€injuries€which€would€not€otherwise€have€occurred.à8@FÐ Ð àÐ À  ÐÌTenn.€Code€Ann.€ðð€29„26„115€(a)€(Supp.€2004).€€Ð ˜è  ÐÌà  àà ` àTo€begin,€the€Commission€found€that€the€nursing€techniques€testified€to€by€Ms.Ð pÀ ÐWiseman€did€not€establish€ð ðthe€standard€of€care€that€was€required€of€a€registered€nurse€on€a€generalÐ \¬ Ðorthopaedic€recovery€floor€at€UT€Hospital.ðð€€The€Commission€found€Ms.€Wisemanððs€criticismsÐ H˜ Ðregarding€the€nursing€care€admittedly€concerned€judgment€calls.€€In€addition,€the€Commission€foundÐ 4„ Ðthat€the€drastic€measures€of€suctioning€Mr.€Smithððs€lungs€or€obtaining€a€new€airway€via€aÐ  p Ðtracheotomy€after€the€1€a.m.€vomiting€episode€that€Dr.€Blake€testified€were€necessary€in€accordanceÐ  \ Ðwith€the€standard€of€care€were,€under€the€facts€and€circumstances€presented€in€this€case,€notÐ øH Ðreasonable€and€necessary€and€did€not€equate€to€the€standard€of€care.€€Thus,€the€Commission€foundÐ ä4 Ðthat€Plaintiff€did€not€prove€ð ð[t]he€recognized€standard€of€acceptable€professional€practice€in€theÐ Ð  Ðprofession€and€the€specialty€thereof,€if€any,€that€the€defendant€practices€in€the€community€in€whichÐ ¼  Ðthe€defendant€practices€or€in€a€similar€community€at€the€time€the€alleged€injury€or€wrongful€actionÐ ¨ø Ðoccurred€.€.€.€.ðð€€Tenn.€Code€Ann.€ðð€29„26„115€(a)(1)€(Supp.€2004).€€The€evidence€does€notÐ ”ä Ðpreponderate€against€this€finding€as€previously€discussed€in€this€Opinion.€Ð €Ð ÐÌà  àà ` àAdditionally,€the€Commission€found€that€the€deviations€Ms.€Wiseman€claimsÐ X ¨ Ðoccurred,€specifically€the€failure€to€properly€advance€diet,€to€adequately€maintain€the€medical€chart,Ð D!” Ðand€to€properly€follow€physicianððs€orders,€were€not€a€direct€and€proximate€cause€of€Mr.€SmithððsÐ 0"€  Ðdeath.€€The€Commission€stated€that€ð ðthere€is€no€evidence€that€such€shortfalls€[on€the€part€of€NurseÐ #l! ÐBaer]€were€the€direct€and€proximate€cause€of€[Mr.€Smithððs]€death€by€aspiration.ðð€€The€CommissionÐ $X" Ðstated€ð ðthere€is€no€evidence€that€the€standard€of€care€dictated€[Nurse]€Baer€to€have€acted€differently.ððÐ ô$D # ÐIn€addition,€although€Dr.€Blake€opined€ð ðbeyond€a€reasonable€degree€of€medical€certainty€that€theÐ à%0!$ Ðfailure€of€[Nurse]€Baer€to€listen€to€[Mr.€Smithððs]€lungs€was,€in€essence,€the€sole,€direct€andÐ Ì&"% Ðapproximate€(sic)€cause€of€[Mr.€Smithððs]€deathðð,€the€Commission€found€that€this€opinion€was€notÐ ¸'#& Ðð ðconsistent€with€the€entire€body€of€evidence€presented€at€trial€and€the€record€as€a€whole.ðð€€Thus,€theÐ ¤(ô#' ÐCommission€found€that€Plaintiff€failed€to€prove€ð ð[t]hat€the€defendant€acted€with€less€than€or€failedÐ )à$( Ðto€act€with€ordinary€and€reasonable€care€in€accordance€with€such€standard;€and€.€.€.€[that]€[a]s€aÐ |*Ì%) Ðproximate€result€of€the€defendantððs€negligent€act€or€omission,€the€plaintiff€suffered€injuries€whichÐ h+¸&* Ðwould€not€otherwise€have€occurred.ðð€€Tenn.€Code€Ann.€ðð€29„26„115€(a)(2€&€3)€(Supp.€2004).€€ForÐ ° Ðthese€reasons,€and€the€reasons€discussed€earlier€in€this€Opinion,€the€evidence€does€not€preponderateÐ œì Ðagainst€this€finding€by€the€Commission.Ð ˆØ ÐÌà  àà ` àPlaintiff€then€argues€that€the€Commission€erred€by€assigning€fault€to€the€doctor€whoÐ `° Ðperformed€the€surgery€because€the€Commission€stated€it€would€have€liked€to€have€heard€from€thisÐ L œ Ðdoctor€and€ð ð[i]f€allegedly€there€was€a€problem€with€a€suppressed€gag€reflex€due€to€over€medicationÐ 8 ˆ Ð.€.€.€then€we€have€to€look€to€the€fault€going€back€„€„€the€genesis€of€that€fault€being€the€original€doctorÐ $ t Ðorder€.€.€.€ordering€the€Phenergan€and€the€morphine€combined€and€the€dosage€that€he€assigned€to€eachÐ  ` Ðdrug.ðð€€However,€the€Commission€never€assigned€any€fault€to€this€doctor.€€We€find€no€merit€to€thisÐ ü L  Ðissue.€€Ð è 8  ÐÌà  àà ` àThe€reality€of€the€situation€is€that€Plaintiff,€despite€the€excellent€work€of€her€lawyers,Ð À  Ðwas€unable€to€make€the€required€showings€regarding€the€applicable€standard€of€care€and€the€breachÐ ¬ü  Ðof€such€standard.€€The€evidence€does€not€preponderate€against€the€Commissionððs€factual€findingsÐ ˜è  Ðand,€after€a€thorough€review€of€the€record,€we€hold€that€the€Commission€reached€the€correctÐ „Ô  Ðconclusions€of€law.€€As€we€find€no€error€by€the€Commission,€we€affirm€the€Commissionððs€grant€ofÐ pÀ Ðjudgment€to€the€State.Ð \¬ ÐÌò òòòÓ  ÓConclusionóóó óÐ 4„ ÐÌÓšþÓà  àà ` àThe€judgment€of€the€Claims€Commission€is€affirmed,€and€this€case€is€dismissed€withÐ  \ Ðthis€cause€being€remanded€to€the€Claims€Commission€solely€for€collection€of€the€costs€below.€€TheÐ øH Ðcosts€on€appeal€are€assessed€against€the€Appellant,€Patsy€Smith,€and€her€surety.€€Ð ä4 ÐÌÌÌÌÌÌÌÌà  àà ` àà ¸ àà  àà h àà À àà  à___________________________________€Ð 0"€  Ðà  àà ` àà ¸ àà  àà h àà À àà  àD.€MICHAEL€SWINEY,€JUDGEà Ð àÐ #l! Ðà  àà ` àà ¸ àà  àà h àà À àà  àà p à