Nursing Homes Abuse Blog - By Jonathan Rosenfeld

A study published in the Achieves of Internal Medicine reveals an increase in the number of people who die at home from unsafe use of legal medications.  Most of the medications taken in peoples' homes have 'little or no  professional support'  according to Dr. Michael Negrete, a pharmacist and CEO of  the Pharmacy Foundation of  California.   The study further revealed that most Americans are aware of home medication error problems, but most assume that doctors and pharmacists are in possession of all their medications and are monitoring their use.  Read more about medication errors at home here.

The results of this study are particularly relevant to seniors who are in less structured programs or in long-term care facilities where there is relaxed supervision.  In those situations, it is important for seniors to make both the nursing staff and physicians aware of all medications they are on. 

Poor quality care is preventing some nursing homes in Tennessee from accepting new residents.  In the past several years, there has been a substantial increase in the number of complaints directed to health and safety of the residents.

Accusations of serious safety violations are getting attention from state inspectors.  At Nashville's RiverPark Health Center, a complaint of a resident fall caught investigators' attention.  The complaint alleged that following the fall, the nursing home staff ignored the resident's cries for help.  It turns out the resident had broken his neck and eventually died from his injuries.  The investigation revealed that not only did the staff act improperly following the fall, the staff conducted no internal investigation to determine if its employees acted improperly.

As the result of the above incident, the state suspended admissions at RiverPark.  In 2007, the State of Tennessee suspended admissions at 16 different nursing homes.  State investigators say their forceful actions are the result of directives from the Centers for Medicare and Medicaid Services. 

Suspending admissions is important in that it forces nursing home owners to correct violations in order for them to stay in business.  Most nursing homes are 'for profit' facilities are are paid a daily stipend for each resident.  A diminished resident population, means lower profits. 

Nursing home investigators in all states have difficult jobs.  Often they enter facilities where administrators and nursing home employees work together to cover up past wrongdoings.  Further, many of the victims of the safety violations are unable to communicate or may be severely injured or dead.  The investigators role is crucial to promoting the health and safety of the particularly susceptible nursing home residents.  Click on the news clip below for more information about nursing home violations in Tennessee.

Despite long standing warnings from the FDA, bed rail entrapment continues to be a real threat to the safety of people in nursing homes, hospitals, and long-term care facilities.  After FDA warnings were issued on rail safety, many manufacturers began production of safer designs.  Although the warnings have been issued, the FDA has not imposed any bed rail recalls on beds known to commonly be the source of injury and death.  The lack of formal action by the FDA will likely result in future incidents involving: injury, fractured bones, strangulation, asphyxiation and death.

The safer rail designs have yet to make there way to the places they are needed.  At many facilities there is little incentive to discard a usable bed, despite the fact that the design may be antiquated and unsafe.  Further, many beds are rented from medical supply companies that have a substantial inventory of beds with older designs. 

Rental beds are typically the least safe beds in use today.  Many rental companies pay little attention to the combination of parts used when distributing beds for home and facility use.  It is common to see a mattress designed for one bed used with the frame from a different manufacturer.  The combination of mattresses and bed frames results in unintended 'gaps' in which a person can easily get caught.

In 1985 the FDA issued a Safety Alert on the dangers of entrapment in bed rails, and other parts of hospital and nursing home beds.  The alert was directed to home healthcare agencies, hospices, and nursing homes.  The FDA based the alert on its published reports documenting deaths and injuries associated with beds and bed rails.

By 1999, bed safety had become such an important issue, the Hospital Bed Safety Workgroup (HBSW) was assembled by the FDA, the medical bed industry, national healthcare organizations, patient advocacy groups and other federal agencies. After years of debate, the HBSW produced a brochure, which provides guidance for selecting a bed and instructions on how to measure for dangerous gaps between the mattress and bed rails.

Lightweight patients are generally at the greatest risk for bed rail entrapment.   Smaller people are more likely to fall into gaps between the mattress and the bed frame.  Other factors in determining a persons susceptibility of bed rail injury are: their mobility, agitation and temporary or chronic reduced mental capacity.  Patients with the above conditions require ongoing monitoring from the staff in order to reduce their risk of harm.

In order to minimize the risk of bed rail injury you should examine the bed and mattress to make sure the mattress 'fits' with the frame.  If you see gaps between the frame and the mattress, you should point out the situation to the facility.  Lastly, ask questions.  Do not be afraid to ask the nursing home or long-term care facility about the type of beds they use and if they have had any problems with the bed before.

For additional information on bed rail safety, review Professor William Hyman's article appearing on McKnight's website here.

An Ohio woman is bringing a lawsuit against Mansfield Memorial Homes for improper care resulting in bedsores.  Dorothy Modcap, 64, sought skilled rehabilitation for a fractured hip following an auto accident.  What she got instead was a bedsore and infection.  According to her attorney, no preventative measures were put in place to prevent the development of the bedsores.  Bill Campell, Modcap's attorney states:

When you have somebody at that age who is in a wheelchair already, you really have to put interventions in place to make sure the person is turned frequently, or a skin breakdown can develop that turns into a very nasty bedsore.  It is clear that she had absolutely no skin breakdown until she went into the nursing home.

According to public records, Mansfield Memorial Home was recently cited for nine health care violations and five fire safety deficiencies.  Read more about this lawsuit here.

The facts surrounding the above incident are familiar to most nursing home residents who suffer from pressure sores.  Nursing homes must identify people who are susceptible to bedsores and implement care plan for their prevention.  Even the most active and healthy nursing home residents should have preventative care plans in effect.  Failure to implement such a plan represents nursing home neglect.

Nursing Home Injury Laws: Ohio

More than 30 veterans will be forced to relocate from a Washington VA after an outside review raised concerns about the quality of care and an internal audit validated those concerns.  The Long Term Care Institute was contracted by the VA nationally to review nursing homes around the country.  A surprise inspection at the Jonathan M. Wainwright Memorial Veterans Affairs Medical Center on raised immediate concerns about the physical infrastructure of the nursing building. Concerns included sloping floors and patients' access to doors and stairwells.  The review was also critical of control of medication and the competence of nursing staff inserting intravenous catheter lines.

"We had to do the right thing for patients, and if we can't provide care that is equal to or better than the private sector, we shouldn't be doing it. So we had to shut it down," medical director DeAnn Dietrich said.

Established in 1858 on an 84-acre campus at Fort Walla Walla, the Jonathan M. Wainwright Memorial VA Medical Center serves an estimated 69,000 veterans in southeastern Washington, northeastern Oregon and northern Idaho. The center has 66 beds for acute care, nursing, psychiatric and substance abuse treatment. Thirty beds are devoted to nursing.  Inspectors raised concerns about patients' access to doors and stairwells at the end of long, blind corridors, as well as the aging building's sloping floors and narrow doors and hallways.

"While the building is seismically up to code, it's not adequate and it doesn't meet anyone's idea of what a long-term care facility should look like," Dietrich said. "We also realized the clinical competency issues weren't isolated. We did have staff doing some good work, but we didn't have a good system for ongoing training, documentation."

The medical center has a plan in place to address the immediate concerns and is conducting a feasibility study to determine if it should be reopened, according to Dietrich.  It is unfortunate that the facility is forcing residents to relocate, but the facility must be applauded for hiring an outside company to conduct a report and for acting on the reports findings.  If this facility were to remain open, there is little doubt the safety of the nursing home residents would be compromised.

Read more about VA nursing homes here.

Recent congressional testimony has highlighted the presence of sex offenders and other violent offenders amongst the general nursing home population. The American Health Care Association asked Congress to help improve the tracking of sex offenders and develop a definition of "sex offender" in an effort to improve residents' safety.

Oklahoma State Representative Kris Steele, who recently spoke before Congress, has come up with a solution to ensure the safety of the elderly in nursing homes. Representative Steele has authored a bill designed to establish separate long-term care facilities for sex offenders. The state Legislature passed the bill and Oklahoma is currently seeking contractors to build a facility.  For further information on Oklahoma's plan look here.

This is a simple solution for an increasingly dangerous problem for our elderly.  Unfortunately for the more than 1.6 million people living in nursing homes, they have no choice as to who they live with.  Under the current system most nursing homes are 'forced' to accept any person who qualifies under the Medicare / Medicaid system--violent offenders included.

Related: Nursing Home Injury Laws: Oklahoma

More than 1,600 registered sex offenders are currently living amongst the elderly in nursing homes throughout the country according to a nursing home watchdog group. Wes Bledsoe, a nursing home safety advocate, tracked the number of sex offenders living amongst the general nursing home population by matching addresses from the sex offender registry with the Medicare database. The total number of felons living in nursing homes is even higher as many criminal convictions are not publicly available.

Currently there are no federal or state laws to keep violent offenders out of nursing homes and other long-term care facilities. Many of the violent offenders could be easily identified by nursing home administrators prior to their admission. Conducting a criminal background check, similar to those used for nursing home employees, would alert the facilities to those individuals who have criminal histories.

A criminal background check should be conducted universally for all nursing home residents--not just the young or able bodied. Nursing home residents are entitled to live in a safe place--free from abuse and violence. The relative cost of conducting these checks is more than justified when it comes to enhancing the safety of our elderly population.  Read more about the criminals living amongst our elderly here.

The elderly are particularly susceptible to flu symptoms.  The elderly population who live in nursing homes is also particularly susceptible to contracting the virus.  Unfortunately, the 2.5 million people living in 18,000 nursing homes, there is no vaccine or other medicine proven to prevent the flu.  Moreover, the addition of new medication or vaccine can be harmful to an already weakened population.

Researchers at Arizona State University have determined the best way to prevent the flu is to prevent the introduction of the flu virus into the nursing home or long-term care facility. Non-pharmaceutical interventions (NPI) are what the study suggests as the best preventative  tools.  In order to maximize the effectiveness of the NPI's, the nursing home must have a prevention program in place before any resident contracts the flu.

The study suggests the following NPI's are useful in flu prevention:

• Screening visitors and staff who leave and return to the facility.  Did they come into contact with any sick people?
• Restricting visitors.  If a visitor has come in contact with a sick person, they may be asked to make a telephone call or communicate through email
• Modified work schedules for employee.  Studies have found that employees who spend time away from the facility may have less likelihood transferring disease
• Washing hands and using protective masks.

Lead study author, Miriam Nuno, states:

Facilities must eliminate disincentives.  For example, employees sick themselves with flu or forced to care for afflicted family members must be paid for time away.  A single act of non-cooperation can bring down and entire facility.  In return, those employees who recover become immune, become fully available for further service and no longer represent a threat for introducing the virus.

As with all treatment provided in nursing homes, it is up to the nursing home owners and administrators to create guidelines for the benefit of the residents.  It is ultimately the responsibility of each nursing home employee to implement the guidelines.  If either the administrators or employees do not follow the guidelines, the nursing home residents will be adversely affected.  Read more about the study here.

'Damages' refer to losses sustained do to physical or psychological injury for which you can be compensated. In cases involving injury or death, damages are assessed in terms of money compensation.  In order to recover damages, you first must establish that an employee of a nursing home or the facility itself did something wrong or negligent. There are three elements in proving fault in nursing home accident cases:

• Duty: The nursing home had a 'duty' to act as a reasonably safe facility.  In nursing home cases, the facilities must follow strict Federal and State Regulations setting forth both the type of care that needs to be provided and how the care is to be implemented.
• Breach of Duty: This refers to the nursing home not following physician orders, general nursing home policy or Federal or State Regulations.
• Proximate Cause: It is not enough that a nursing home acted improperly.  In order to address damages you are required to prove that the nursing homes improper actions caused your injuries. 

After you have proved the three elements of liability on the part of a nursing home, you may address damages.  There are several components to damages relating to nursing home cases:

• Medical Bills:  You are entitled to recover the value of past and future medical expenses.  This may include past or future surgery, physical therapy, rehabilitation, visits with physician specialists, medication and special medical equipment
• Pain and Suffering: Both past and future pain and suffering is an element of damages
• Disfigurement: Any type of physical change on the outside of your body
• Disability: Things you are unable to to do after the incident that you were capable of doing before

Assessing damages in nursing home cases can be difficult.  Because many elderly suffer from various ailments before an incident occurred, it is important to distinguish what injuries are directly related to the incident.  Only damages related to the conduct of the nursing home may receive compensation.  The amount of damages may be determined by a jury, judge, mediator or through negotiation between the injured party and the insurance company for the nursing home. 

Punitive damages may be awarded if the nursing home's conduct is reckless or rises to a level of willful and wanton conduct.  Unlike damages designed to compensate the injury victim, punitive damages are designed to punish the wrongdoer. 

Further complicating the assessment of damages in nursing home cases is that many nursing homes are uninsured or under-insured.  The insurance coverage issues must be factored in when making decisions about nursing home case resolution.

Related:

Nursing Home Injury Laws

• Loneliness, helplessness and boredom are plagues and account for most of the suffering among elders.
• An elder-centered community is committed to a human habitat where life revolves around contact with plants, animals and children.
• Loving companions are the antidote to loneliness.
• An elder-centered community creates opportunity to give and receive.
• The community creates an environment where the unexpected can happen; it is an antidote to boredom.
• The opportunity to find something meaningful is essential to human health.
• Medical treatment should be the servant, not the master, of human caring.
• The community honors its elders by de-emphasizing top-down bureaucratic authority, placing decision-making with the elders or those closest to them.
• Creating an elder-centered community is a process, not a program.
• Wise leadership is the lifeblood against the plagues of loneliness, helplessness and boredom.
  

A lawsuit was filed on behalf of the Estate of Ivory Jackson, a 77-year-old resident of All Faith Pavilion Nursing Home.  Last month, Mr. Jackson was brutally murdered by his roommate at the Chicago-area nursing home. 

The alleged perpetrator, Solomon Owasanoye, has been charged with first-degree murder of Mr. Jackson.  According to the lawsuit, the nursing home acted improperly in pairing Mr. Jackson and Mr. Owasanoye as roommates.  Read more about this incident in the Chicago Tribune article here.

Nursing homes have a duty to provide a safe environment for their residents--free from violence from nursing home staff and other residents.

Unlike nursing home employees, home aides remain a largely unregulated entity.  Many home aides are unlicensed and are not subject to the same criminal background checks as nursing home employees.  The number of home health care workers for the elderly is on the rise.  Currently, there are 1.6 million people employed in the home health care industry.

An incident involving an 85-year-old Priscilla Stovall, who was lethally drugged by her home care aid, draws attention to the need for extensive criminal background checks and ongoing monitoring of home aids who work with the elderly.  Although Ms. Stovall's aid was hired by an agency which specializes in providing home care workers for the elderly, the worker had an extensive criminal background.   The worker had a criminal background involving domestic assault, drug smuggling and had done time in prison.

Conducting criminal background checks for the health care workers can be difficult because there is no centralized database with employee information.  In a recent Michigan State University study sponsored by Centers for Medicare & Medicaid Services, researchers screened 214,167 people who held or sought jobs working with the elderly.  Of the sample group, 5,462 had criminal histories which should have excluded them from the position.  Read more about abuse among home care aids amongst the elderly in the Wall Street Journal here.

Before hiring a home care worker for an elderly person or yourself, keep the following in mind:

• Do a criminal background check through a local police department or licensed investigator
• Check all references
• Conduct face-to-face interviews
• Look to the U.S. Administration on Agings website
• Check names in the national sex-offender registry website

Seniors in Connecticut will soon have an easier time obtaining State-run services.  Under the new plan, Connecticut will have a centralized cabinet-level office on aging created by the Governor.  The new agency makes it easier for seniors to get information on long-term care and assisted living care. 

Services will range from help with basic daily chores to around the clock medical care.  The new program will provide alternatives for seniors who may have ordinarily gone to a nursing home.  68% of  Connecticut's Medicaid spending goes to institutionalized nursing home care. 

Studies have shown well over 90% of seniors do not wish to be in a nursing home.  Studies have also shown that providing community based elder care is cost effective as it is less expensive than nursing home care.  Read more about Connecticut's efforts to change long-term care for the elderly here.

Where else can a business treat customers without any respect in run-down environment and continue to stay in business?

The answer is: The nursing home industry in America.

Nursing homes funded by Medicaid receive a daily payment from the government for each resident every day. The government pays the facilities regardless of the quality of service provided. As a result, many nursing home owners; will put off facility repairs, serve lousy food and hire some of the most inept people to run their facilities to maximize profit. Of course, fines may be imposed and facility closure may be threatened  The reality is that it is difficult to relocate nursing home residents to other facilities. Nursing home owners know this. Paying fines has become part of the nursing home business. The reality is the fines probably only result in even further reductions services to the residents of the facility.

An example of a nursing home choosing profits over the needs of its residents appeared here. Westside Health Care Center, an exclusively Medicaid funded facility, provides nursing home care to 40 residents in Ohio.  After health workers and police from the Ohio Department of Public Health found 27 housing and fire code violations, the Department attempted to shut down the facility. The inspectors described the facility as 'worse than any crack house they had come across.' (emphasis added)

To combat the potential closure of his facility, the administrator filed an injunction to keep the nursing home open. A judge ruled in his favor and has set the matter for hearing later this month. Meanwhile, the 40 residents of Westside will continue to be the real losers of the situation as they continue to live in an obviously deplorable facility.

Related: Nursing Home Injury Laws: Ohio

According to American Nurses Association, most of the 10,000 nurses participating in a recent poll believe the quality of nursing care has declined in the past year.  Other poll results are just as alarming.  A similar percentage (48.3%) of the nurses polled admit that they would not feel confident in having a person close to them receive care at the facility they work at.

The nurses recognize under-staffing as a major problem.  Almost three-quarters of the respondents believe there to be an insufficient number of nurses in their unit.  It appears the widespread under-staffing is forcing the nurses to look for work at better staffed facilities. 51.9% of the nurses are considering leaving their current positions due to inadequate staffing.

Under-staffing and high employee turnover at nursing homes leads to dangerous conditions for residents.  Most of the situations involving: pressure sores, malnutrition, dehydration, medication errors and inadequate supervision stem from an overall staffing problem.

The complete poll results are here.

No longer can nursing home owners look at potential lawsuit settlements and jury verdicts as a cost of doing business. Juries are sending a message to nursing home owners by handing down large awards to elders who may be victims of poor care or neglect.  This article also demonstrates the importance of nursing homes having adequate insurance coverage to satisfy a large verdict or settlement.

This article appearing in the Association of Trial Lawyer's magazine addresses the new message being sent to nursing home owners.  Below are excerpts from the article.

A growing number of civil lawsuits over elder abuse and neglect reflect both federal and state laws and growing public consciousness, and may be leading to long-overdue changes in the industry. Most such cases are brought against care-providing institutions, and six-figure awards are the norm, with multi-million dollar ones common. Plaintiffs' lawyers say juries have great empathy and sympathy for abuse victims and now consider quality of life an important factor, often more so than life expectancy.

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"Wandering' refers to a cognitively impaired person moving about a nursing home or long-term care facility aimlessly and without appreciation for what he or she is doing.

A nursing home resident's propensity to wander should be identified in an initial care plan.  Residents who are most likely to be wanderers are those who suffer from dementia, Alzheimer's or who may be heavily medicated.  Most frequently a nursing home resident who wanders, falls and gets injured.

It is up to the nursing home staff to provide a safe and secure environment for all residents.  In the case of a nursing home resident who wanders and receives injuries, the nursing home most likely did not:

• Provide an adequate number of staff to supervise residents
• Train nursing home staff on how to identify wanders
• Train the nursing home staff on how to supervise the nursing home residents
• Did not use bed, wheelchair or door alarms
• Re-direct the nursing home resident to another activity

Many people do not want to think about the future.  They cringe to think about the days when they are old and are unable to care for themselves.  Most of us do not want to even consider the reality that we may not be able to make decisions for ourselves. 

I frequently have family members ask how then can help a loved one in a nursing home or long-term care facility who may be incapable of making their own financial decisions.  The answer is complicated if no discussion amongst the family was had prior to the admission.  As a result, I suggest everyone have a Power of Attorney For Property.

A Power of Attorney For Property is a document that allows a delegated person to make decisions concerning your financial affairs and the management of property.  You do not have to be an attorney to be a 'power of attorney.'

It is best to execute a Power of Attorney For Property when you are in good health and before you anticipate you may need it.  Executing the Power of Attorney For Property saves your family from being forced to make difficult finance decisions without your knowledge or input.  A properly executed Power of Attorney For Property allows you to specify what decisions your agent can and can not make. 

You may designate any person over 18 years old as your Power of Attorney For Property.  In order for a Power of Attorney For Property to carry its full weight and effectiveness it most states require the document to be witness by at least two people. Generally, the document is good from the date it is executed until death.

For more information on Power of Attorney For Property look here.  Many nursing homes have social workers on staff that have similar documents available.

The incidence of bedsores (or pressure sores or decubitus ulcers) is shockingly common in many nursing homes, hospital and assisted living facilities.  Determining who may be at risk for developing this potentially devastating condition is important to preventing the development of them in the first place.  If a family member has one or more of the conditions below they are at an increased risk for development of bedsores.  A daily monitoring of their condition should be done as the first step of prevention.

The following are risk factors identified by The Mayo Clinic:

Age: If you are over 70, you are at an increased risk for development of bedsores.  Older adults tend to have thinner skin than younger people do, making them more susceptible to damage from minor pressure. They're also more likely to be underweight, with less natural cushioning over their bones. And poor nutrition, a serious problem among older adults, not only affects the integrity of the skin and blood vessels but also hinders wound healing. Even with optimum nutrition and good overall health, wounds tend to heal more slowly as you age, simply because the repair rate of your cells declines.

Living In A Nursing Home:  In general, nursing home residents have higher rates of bedsores than do people who are hospitalized or cared for at home, in part because nursing home residents may be especially frail. On the other hand, rates are even higher for hospitalized patients who are immobilized, such as people who are recovering from a hip fracture or who are in a coma.

Lack of pain perception. Loss of sensation is usually due to spinal cord injuries or disease. An inability to feel pain means you're not aware when you're uncomfortable and need to change your position or that a bedsore is forming.

You Are Skinny:  You often lose weight when you're sick or hospitalized, and muscle atrophy and wasting are common in people living with paralysis. In either case, you lose fat and muscle that help cushion your bones. Some experts say the best way to prevent skin breakdown is to have at least 2 inches of muscle over bony areas.

Malnutrition : You're more likely to develop pressure sores if you have a poor diet, especially one deficient in protein, zinc and vitamin C. You're also more likely to have recurrent pressure sores, more severe infections and slower healing wounds than are people with healthier diets.

Urinary or fecal incontinence: Problems with bladder control can greatly increase your risk of pressure sores because your skin stays moist, making it more likely to break down. And bacteria from fecal matter not only can cause serious local infections but also lead to life-threatening systemic complications such as sepsis, gangrene and, rarely, necrotizing fasciitis, a severe and rapidly spreading infection.

Diabetes: Because certain health problems such as diabetes and vascular disease affect circulation, parts of your body may not receive adequate blood flow, increasing your risk of tissue damage. And if you have muscle spasms (spastic paralysis) or contracted joints, you're subject to repeated trauma from friction and shear forces.

Smoking Smokers have a higher incidence of pressure sores than nonsmokers do. They also tend to develop more severe wounds and to heal more slowly, mainly because nicotine impairs circulation and reduces the amount of oxygen in your blood. The risk increases with the number of years and cigarettes smoked.

Aside from living in a nursing home, many nursing home residents also have a number of other risk factors for developing bedsores.  There for the nursing home staff needs to monitor all residents on a daily basis to prevent bedsore development.  Further, identification of a bedsore at an early state is crucial to its treatment.