“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,” a unanimous Tennessee Supreme Court stated, upholding a jury verdict against a nursing home’s corporate manager for the wrongful death of one of the home’s residents. Wilson v. Americare Sys. et al., 397 S.W.3d 552 (Tenn. 2013). Reversing the Tennessee Court of Appeals, the Court ruled the jury verdict was supported by sufficient evidence showing that the insufficient staffing levels led to deviations in the standards of care and ultimately caused the resident’s death. The Court returned the case to the Court of Appeals to review the $5 million punitive damages award against the management company.

Background

Mable Frances Farrar, an 83-year-old retired schoolteacher, lived at Celebration Way, an assisted living facility in Shelbyville, Tennessee. Shelbyville Residential, LLC was the owner and operator of Celebration Way and contracted with Americare Systems, Inc. to provide management services, including staffing, to Celebration Way. 

Except for occasional problems with constipation, Farrar was in good health. When Farrar was admitted to Celebration Way, her physician, Dr. Alma Tamula, prescribed Farrar one capful of MiraLAX, an over-the-counter powder laxative, to be taken every morning. Notwithstanding the physician’s orders, the nursing staff did not give the MiraLAX to Farrar as often as prescribed. As a result, she became constipated and returned to see Dr. Tamula. 

Dr. Tamula notified the nursing staff to give Farrar three to four enemas each day beginning on May 27, 2004. A nurse gave Farrar one enema on the evening of May 27, none on May 28, and one enema on the evening of May 29. Very soon after receiving the last enema on May 29, Farrar died from a perforated colon. Farrar’s surviving daughters filed a wrongful death action against the nurse who had administered the fatal enema, the Director of Nursing at Celebration Way, Shelbyville Residential, and Americare.

Following a trial, the jury found in favor of the plaintiffs. The jury found that the nurse and Director of Nursing were 30 percent and 20 percent at fault, respectively, for Farrar’s death, that Shelbyville Residential and Americare were liable for their employee’s actions, and that Americare was 50 percent at fault for its failure to provide sufficient personnel at Celebration Way. The jury awarded $300,000 in compensatory damages, $5 million in punitive damages against Americare, and $15,000 in punitive damages against the nurse and the Director of Nursing. Americare appealed, and the Court of Appeal reversed, holding that the evidence did not support the finding that Americare’s staffing decisions caused Farrar’s death. 

The plaintiffs appealed.

Applicable Law

To prevail on a wrongful death claim in Tennessee, a plaintiff must prove: “(1) a duty of care owed by the defendant to the plaintiff; (2) conduct by the defendant falling below the standard of care amounting to a breach of that duty; (3) an injury or loss; (4) causation in fact; and (5) proximate or legal cause.” Hale v. Ostrow, 166 S.W.3d 713, 716 (Tenn. 2005). 

To establish proximate cause, a plaintiff must demonstrate: (1) the wrongdoer’s conduct was a “substantial factor” in bringing about the harm 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. Hale, 166 S.W.3d at 719.

Jury Verdict Upheld

The Tennessee Supreme Court found the plaintiffs presented sufficient evidence from which the jury could conclude that Americare provided insufficient staffing to meet the residents’ needs. Further, Court found that Americare was aware of the problem, based on the Director of Nursing’s repeated complaints about the staffing and work levels at Celebration Way, although additional staff was not provided due to budgetary constraints.

The Court also found that the plaintiffs presented sufficient evidence showing that the lack of adequate staffing led to deviations from the applicable standards of care and ultimately contributed to Farrar’s death. Accordingly, the Court concluded that the jury’s verdict against Americare was supported by material evidence and reversed the Court of Appeals’ judgment. The Court returned the case to the Court of Appeals to review the punitive damages award against Americare.