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Workers’
Compensation Board
OPINION
ENTERED: April 14, 2017
CLAIM NO. 201456680
JACKSON PURCHASE MEDICAL CENTER PETITIONER
VS. APPEAL FROM HON. R. ROLAND CASE,
ADMINISTRATIVE LAW JUDGE
LARA HENLEY
HON. R. ROLAND CASE,
ADMINISTRATIVE LAW JUDGE RESPONDENTS
OPINION
VACATING
IN PART
AND
REMANDING
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* * * * *
BEFORE: ALVEY, Chairman, STIVERS and RECHTER, Members.
RECHTER,
Member. Jackson Purchase Medical Center
(“JPMC”) appeals from the September 12, 2016 Opinion, Award and Order and the
November 7, 2016 Order on Reconsideration rendered by Hon. R. Roland Case,
Administrative Law Judge (“ALJ”). The
ALJ awarded Lara Henley (“Henley”) temporary total disability, permanent
partial disability, and medical benefits for a work-related injury sustained on
December 5, 2014. JPMC argues the ALJ
improperly failed to enter findings as to whether Henley is entitled to future
medical benefits. We agree, and remand
the claim to the ALJ.
Henley
worked as a nurse at JPMC. She was
injured when the side rail of a hospital bed came loose and struck her on the
top of the head. She immediately
developed a headache and, later, a “click” at the base of her skull when she
moved her head.
From
the medical evidence submitted, it does not appear Henley sought immediate
treatment for the injury. On March 10,
2015, Henley visited JPMC with complaints of visual phenomena and difficulty
with speech. On March 25, 2015, Henley
was diagnosed with migraine with aura and demonstrated limited upper cervical
spine rotation.
Henley
began treating with Dr. Christopher King on March 26, 2015. He ordered an MRA and MRI of the brain, both
of which were negative for any acute injury.
Dr. King referred Henley to Dr. Clint Hill, an orthopedic surgeon. Dr. Hill ordered a cervical MRI, which
revealed no acute injury. He ordered six
weeks of physical therapy.
On July 8, 2015, Henley reported to the
Baptist Health emergency room with complaints of severe neck pain and
headaches. A CT scan was normal. She was diagnosed with a minor closed head
injury with no loss of consciousness and post-concussive syndrome.
From October 12, 2015 through November 6,
2015, Henley treated with Dr. Tanya Woods at the Orthopedic Institute of
Western Kentucky. She was diagnosed with
cervicalgia, migraine with aura, cervical radiculopathy and degenerative disc
disease of the cervical spine. Based on
the results of a later CT scan, Dr. Woods suspected ligamentous injury.
Henley
began treating with Dr. David Rouben on December 15, 2015. The initial diagnoses was post-concussion
syndrome and posterior occipital pain.
In a May 25, 2016 report, Dr. Rouben made five diagnoses which he
attributed to the work injury: post-concussion syndrome, herniated cervical
disc at C6-7, cervical ligamentous laxity, abnormal chronic post-traumatic
occipital headaches, and post-traumatic occipital neuralgia. He also diagnosed abnormal absence of normal
physiologic tissue of sells tursica of the skull, which he did not attribute to
the work incident. Referencing the American
Medical Association, Guides to the Evaluation of Permanent Impairment, 5th
Edition (“AMA Guides”), Dr. Rouben assessed an 8% whole person
impairment rating. He recommended
further treatment to explore the extent of neurologic, cervical disc and
ligamentous post-traumatic disease, including the possibility of surgery. In an April 8, 2016 report, Dr. Rouben
indicated he had reviewed an April 6, 2016 CT scan of her cervical spine. He interpreted the CT scan to confirm a
herniation at C6-7 as well as abnormalities at the two disc levels above
it. He recommended facet joint
injections.
Henley visited Dr. Louis Kastan on May 7,
2016, who ordered a digital motion x-ray of the cervical spine. His impression was excess posterior
angulation during extension at C4-5 consistent with spinal ligament laxity;
excess anteroposterior translation during flexion and extension at C4-5; and a
suggestion of ligamentous instability and subluxation of C1 and C2 on the
left.
Henley submitted the June 29, 2016 report
of Dr. Jeffrey Frank. Dr. Frank
diagnosed intractable migraines with aura and post-concussion syndrome with
cerviogenic headaches.
Dr. Henry Tutt conducted an independent
medical evaluation (“IME”) on August 28, 2015.
He noted Henley’s complaints of severe occipitocervical pain with a
grinding sensation. Dr. Tutt concluded
Henley’s subjective complaints do not comport with the objective findings, and
the December 5, 2014 incident did not result in a harmful change to the
cervical spine. He attributed her
migraines, if they are considered true migraines, to a pre-existing condition
rather than the work incident. He opined
she is capable of returning to full duty work.
Dr. David Shraberg conducted an IME on
September 3, 2015. Dr. Shraberg
diagnosed cervical sprain with possible mild concussion, which fully recovered
by the time of his evaluation. He also
diagnosed pre-existing cervicalgia. He
characterized her migraines as musculoskeletal headaches, and found no evidence
of a closed head injury. Dr. Shraberg
opined Henley was at maximum medical improvement as of the date of his
examination and could return to her usual work.
He assigned no impairment rating.
JPMC
submitted proof to establish Henley received treatment for neck pain and severe
headaches prior to the December 2014 injury.
She began visiting Dr. Douglas McAdoo, a chiropractor in 2012 and
continued to treat with him throughout 2013 and 2014 for neck and right
shoulder pain. An October 1, 2014 office
visit record indicates he diagnosed cervicalgia, somatic dysfunction of the
cervical region, upper extremity, thoracic region and pelvis region.
The
ALJ began his analysis with a determination Henley suffered a work-related
injury:
The
initial issue for the Administrative Law Judge to decide is whether the
plaintiff sustained a work related injury on December 5, 2014 resulting in
permanent impairment and/or disability. The ALJ is persuaded by the testimony
of the plaintiff that she did sustain an injury on December 5, 2014. The ALJ
finds the plaintiff to be a very credible witness and the ALJ was impressed by
her testimony at the hearing in this matter. The ALJ is further persuaded by
the evidence from Dr. David Reuben, one of the plaintiff’s treating physicians,
that she did sustain permanent impairment resulting from the injury of December
5, 2014. The issues then becomes whether the plaintiff sustained any temporary
total disability and whether she sustained any permanent impairment or
disability from the injury and whether or not she can return to work at her
customary occupation.
The ALJ then determined Henley’s
entitlement to temporary total disability and permanent partial disability benefits. In calculating her award of benefits, the ALJ
stated:
The ALJ is convinced from
review of the evidence that Dr. David Rouben correctly indicated the plaintiff
would have an impairment under the AMA Guides, 5th Edition of 8%
attributable to the injury.
The ALJ calculated Henley’s award of income
benefits based on an 8% impairment rating enhanced by the three
multiplier. He determined Henley is
entitled to recover for, “such medical expenses including but not limited to
provider’s fees, hospital (sic) required for the care and the relief from the
effects of the work-related injuries.”
JPMC
petitioned for reconsideration, arguing the ALJ failed to delineate
specifically Henley’s entitlement to future medical benefits. The ALJ denied the petition as a re-argument
of the merits. On appeal, JPMC contends
it is entitled to specific findings as to whether Henley is entitled to future
medical benefits.
In
her Form 101, Henley listed the body part injured as, “neck, head, memory loss,
blurred vision and migraines”. The ALJ
did not specify exactly which work-related injuries Henley sustained. He relied on Dr. Rouben’s report, as well as
his 8% whole person impairment rating.
Dr. Rouben made five diagnoses that he attributed to the work injury:
post-concussion syndrome, herniated cervical disc at C6-7, cervical ligamentous
laxity, abnormal chronic post-traumatic occipital headaches, and post-traumatic
occipital neuralgia. Dr. Rouben then
made the following notation regarding impairment rating:
DRE Cervical Category II 8%
to her body as a whole.
Page 392, table 15-5
Pain Impairment Class 3 –
“Moderate to Severe”- pg 584-88
The
pain-related impairment is felt to be ratable and causes encapsulating greater
than the impairment noted above.
By adopting Dr. Rouben’s 8% impairment
rating, we presume the ALJ concluded Henley suffered a work-related injury to
her cervical spine. However, it is
unclear whether the ALJ determined she suffered a work-related head
injury. Although Dr. Rouben diagnosed a
head injury, it appears he based his impairment rating solely on Henley’s
cervical spine. Therefore, because the
ALJ stated only that Henley suffered a work-related “injury”, it is unclear
whether Henley also suffered a compensable head injury, or whether she is
entitled to future medical benefits relating solely to her cervical spine.
In making this argument, JPMC highlights
the proof documenting Henley’s pre-injury complaints of and treatment for
severe headaches and neck pain. Clearly,
the ALJ rejected the medical opinions offered by Drs. Tutt and Shraberg, who
opined Henley’s current headaches are unrelated to the work injury. However, contrary to Henley’s assertions on
appeal, this proof is nonetheless relevant.
It also relates to the extent of JPMC’s liability for future medical
benefits. The ALJ offered no discussion
of Henley’s prior symptoms, and his reliance on Dr. Rouben’s opinion does not
clarify whether he believes Henley suffered a work-related head injury.
Therefore, we must remand this claim to the
ALJ. The ALJ is requested to identify
exactly which body parts were affected by Henley’s work accident, and which of
these injuries resulted in permanent impairment and disability. Additionally, the ALJ is requested to clarify
which injuries are included in Henley’s award of future medical benefits. If the ALJ determines Henley suffered a
work-related head injury entitling her to future medical benefits, the extent
of JPMC’s liability must be clearly delineated.
We direct no particular result.
Accordingly, the September 12, 2016
Opinion, Award and Order and the November 7, 2016 Order on Reconsideration
rendered by Hon. R. Roland Case, Administrative Law Judge, are hereby REMANDED for further proceedings as
ordered herein.
ALL CONCUR.
COUNSEL
FOR PETITIONER:
HON ROBERT FERRERI
614 W MAIN ST
#5500
LOUISVILLE, KY 40202
COUNSEL
FOR RESPONDENT:
HON DAVID C TROUTMAN
PO BOX 1837
PADUCAH, KY 42002
ADMINISTRATIVE
LAW JUDGE:
HON R. ROLAND CASE
PREVENTION PARK
657 CHAMBERLIN AVE
FRANKFORT, KY 40601
