Archives for August 2009 : Nursing Homes Abuse Blog : Jonathan Rosenfeld's Nursing Homes Abuse Blog : Jonathan Rosenfeld's Nursing Homes Abuse Blog | Lawyer & Attorney : Rosenfeld Injury Lawyers | Bed Sores, Senior Neglect, Elder Abuse, Sexual Abuse: Chicago, Illinois

Nursing Home Spotlight: Heartland Of Springfield Nursing Home, Springfield, OH

Posted by Jonathan Rosenfeld on August 30, 2009

Heartland of Springfield Nursing Home is a large 126 bed nursing home located in Springfield, Ohio. According to the government’s Medicare website, the facility received only one out of five stars, which is a much below average rating. In the past year, the nursing home had eighteen health deficiencies, which is eleven more than the average number of health deficiencies in Ohio and ten more than in the United States. The number of health deficiencies has increased in the past year, especially in the area of quality care.

The nursing home has an obligation to provide a safe and secure facility for its residents and to provide proper care and supervision to maintain the health of its residents. According to the survey reports, the facility received violations for failing to:

Ensure that the facility remains free of accident hazards
Provide medically-related social services to attain or maintain the highest well-being of each resident
Develop a comprehensive care plan for each resident
Ensure that residents who enter the facility to not develop pressure sores and treat existing pressure sores
Provide routine and emergency drugs to residents
Provide services to maintain good nutrition, grooming, and personal and oral hygiene

The facility failed to provide medically-related services to maintain the highest practicable well-being of a resident when it failed to monitor the mental status of a resident who was at risk for side effects of her medications for depression. On another occasion, the Licensed Practical Nurse (LPN) changed the dressing on a resident’s leg wound without pre-medicating him, causing the resident pain.

On another occasion, the facility failed to develop an effective care plan for a resident who required above the knee amputations due to complications involving diabetes mellitus. The facility failed to address the resident’s psychosocial needs regarding his feelings of loss and phantom pain. Another resident who was on a feeding tube suffered a decline in status, becoming non-verbal. The facility failed to update his care plan since the decline in his status, despite the fact that he could not hold a conversation.

Heartland of Springfield failed to prevent residents from developing pressure sores when a resident suffering from Parkinson’s disease developed a Stage 2 pressure sore on her right heel. Also, the doctor’s order for a thick pad to be placed under the heel to relieve pressure was not observed by the facility’s nursing staff.

Heartland of Springfield also failed to ensure that hazardous materials were secured. An inspector noted that a cigarette and lighter were left on the counter at the nurses’ station, while several residents were in the area. The facility’s policy required that the lighter be secured. Also, the beauty salon was left unlocked with no one present. A container of disinfectant was left out on the counter, which can cause eye damage and skin irritation.

On several occasions, the facility failed to ensure that drugs and supplies were properly stored and maintained. In the medication room, the inspector discovered expired blood collection tubes, expired catheters, and medication carts covered in a dried and sticky residue.

The many health deficiencies cited in the past year contribute to the one star rating for the facility. Heartland of Springfield, is owned and operated by nursing home giant HCR ManorCare

Related Nursing Homes Abuse Blog Entries

The Most Important Job In America.... Nursing Home Surveyors

Woman Dies From Hypothermia After Wandering From Assisted Living Facility

A New Resource For Bed Sores: BedSoreFAQ.com

Comments

A Graphic Example Of Nursing Home Negligence: Amputation Of A Leg Due To Untreated Bed Sores

Posted by Jonathan Rosenfeld on August 29, 2009

One of the more tragic cases, my office is working involves a woman who developed pressure sores on her heels during an admission to a New Mexico nursing home. Despite the fact that the woman was bed-bound, the facility took virtually no preventive measures to avoid pressure sores.

In fact, by the time the staff at the nursing home began to treat the wounds, much of her heels and feet were covered with necrotic tissue. A systematic infection developed and both of the woman's legs required above-the-knee amputation to prevent the infection from spreading--- and probably save her life.

Pressure sores (also known as bedsores, pressure ulcers, or decubitus ulcers) are caused by pressure, which cuts off blood flow to parts of the body resulting in areas of injured skin and tissue. The areas of the body most vulnerable to pressure sores are the heels, hips, and buttocks. Persons who are bedridden, have limited mobility, or are confined to a wheelchair are especially at risk for pressure sores.

As such, elderly nursing home patients are particularly vulnerable to pressure sores because of prolonged bed rest, limited mobility, and weakness. Nursing home staff must turn residents who are bed ridden or have prolonged bed rest often enough so blood can circulate to areas that are under pressure.

Pressure sores can be a very serious condition depending on how much skin and tissue is damaged. Deep pressure sores can go all the way down to the muscle or even the bone. Stage III pressure sores result when the tissue below the skin is damaged, causing a deep wound. Stage IV pressure sores are the most serious pressure sores and involves destruction of large areas of skin accompanied by damage to the underlying muscle, bone, tendons, and joints. If not treated properly, infection can set in and even require amputations. Signs of infection include pus, bad smell, redness, swelling, tenderness, fever, and chills.

Surgical debridement (removal of damaged tissue) is one approach to treating serious pressure sores. This process can be very painful because it involves using a scalpel or other instrument to remove all the dead tissue. Some pressure sores reach a point where surgical repair is necessary. The treatment usually involves harvesting tissue from another area of the body and using it to pad the wound. In some situations, amputation is necessary.

When pressure sores are not treated properly, tissue damage can spread and infection, including gas gangrene, can set in. In severe cases (where surgical debridement, antibiotics, and oxygen treatment are unsuccessful), amputation of the limb might be required to prevent the infection from spreading further. This is especially true in elderly people, especially those who are malnourished, because of poor blood flow.

Amputation is the surgical removal of a limb or body part (arms, legs, feet, fingers, toes), usually to remove diseased tissue or relieve pain. The amputation procedure is performed by an orthopedic surgeon in a hospital operating room under regional or general anesthesia. The procedure varies depending on which limb is removed; however, all surgical amputations involve removing diseased tissue and constructing a stump, which will fit a prosthesis.

The procedure for an above-the-knee amputation includes: first cutting the skin and muscle layers, then clamping the major blood vessels and cutting them, then cutting the bone with a bone saw, and finally, the muscles are stitched together over the bone and the skin is closed over the wound.

The decision of how much of the limb to remove depends on how much tissue needs to be removed for proper healing, while saving as much of the healthy skin, blood vessels, and nerve tissue as possible for rehabilitative purposes. One test that the surgeon performs to determine the health of the limb is the amount of blood flow to the affected region (measurement of blood pressure in the limb).

As with other major surgeries, amputation carries with it the same risks including complications with anesthesia, blood loss, and blood clots; however, infection is the main complication following surgery. Amputation is a painful procedure, requiring treatment with pain medication and antibiotics post-surgery, and a hospital stay ranging from five to fourteen days, absent further complications. Following surgery, the newly formed stump must be moved often to encourage circulation, with physical therapy commencing as soon as possible.

The rehabilitative process is a long process, especially for above the knee amputees. The physical rehabilitation is often accompanied by grief counseling to help the patient cope with the sense of loss that comes with losing a limb. Patients also often have phantom limb pain, which is very difficult to treat. Amputation is a last resort for both physicians and patients, but in some cases, as with severe pressure sores (which are preventable), it becomes necessary.

Resources:

MayoClinic.com – Pressure Sores

Merck – Pressure Sores

Encyclopedia of Surgery – Amputation

Vascular Web – Amputation

Bed Sore FAQ

Comments

Staff Must Be Diligent In Order To Avoid Clogged Breathing Tubes Amongst Nursing Home Patients

Posted by Jonathan Rosenfeld on August 27, 2009

In nursing homes, residents who have trouble breathing on their own (from illness or weakness) might require a breathing tube. A breathing tube, or endotracheal tubes can be used for multiple situations where a patient needs assistance breathing, most nursing home patients who require a breathing tube also require the use of a ventilator. In these patients, a breathing tube and ventilator allows staff to remove mucus from the patient’s lungs and keeps the person alive.

A breathing tube is a plastic tube that is used during artificial respiration to provide a patient with oxygen. The tube, which is attached to a breathing machine (ventilator) or breathing bag (manual resuscitator), is placed into the trachea (windpipe) through the mouth or nose and is held in place by tape or soft straps. A breathing tube is usually used only for short periods of time; if a patient requires a breathing tube for more than a couple days, the doctor might recommend a tracheostomy tube (see below).

A patient with a endotracheal tube, is usually unable to speak because the tube passes directly through the vocal cords. This can be very frustrating for residents because it is harder for them to communicate with nursing home staff. In addition, a patient on a breathing tube cannot eat or drink because it could cause choking. Instead, the patient has to receive fluid and nutrition through an intravenous (IV) tube or feeding tube. This makes the patient much more dependent on nursing home staff for everyday activities.

The nursing home staff must take precautions to ensure that the endotracheal tube does not become clogged. The tube must be suctioned from time to time to remove mucus from the patient’s lungs. Other complications can occur, including the breathing tube actually becoming displaced and requiring reinsertion. To prevent the patient from removing the tube, a patient’s hands are often restrained and a mild sedative might be used.

A tracheostomy tube can also be placed into a patient’s throat to help a resident breathe. With a tracheotomy, a surgeon creates a hole in the front of the neck that goes into the trachea. A tracheostomy might be required because of an emergency situation where the airway is suddenly blocked or impaired, the resident suffered an injury to the face or neck, or when a resident requires a ventilator for long-term breathing assistance.

Most tracheotomy procedures are planned procedures performed in a hospital setting, which reduces the risk for complications. The benefits of using a tracheostomy is that the patient can still talk and it is often more comfortable than an endotracheal tube that is inserted in the mouth and down the throat.

Many nursing home patients require either breathing tubes or tracheostomy tubes due to difficulty breathing and can be a short-term or a long-term solution for a resident. The nursing home staff must be properly trained to ensure that the tubes remain clean and free of mucus. Serious complications can occur if the staff allows the residents to become agitated and displace their breathing tubes or if the facility fails to provide regular maintenance to assure a clear airway.

If your family member is a victim of complications involving breathing tubes, I would honor the opportunity to discuss your situation. As always, our legal services are completely free if there is no recovery for you. Speak to our experienced nursing home lawyers today. (888) 424-5757.

Sources:

Endotracheal Tube (http://www.suru.com/endo1.htm)

ICU-USA – Breathing Tube (http://www.icu-usa.com/tour/equipment/ETT.htm)

Mayo Clinic – Tracheostomy (http://www.mayoclinic.com/health/tracheostomy/MY00261)

Related Nursing Homes Abuse Blog Entries:

Sputum Color As Indicator Of The Quality Of Nursing Care

Tracheotomy Care: Suctioning

Comments

Recovery for Loss Of Spouse's Services, A Loss Of Consortium Claim

Posted by Jonathan Rosenfeld on August 25, 2009

In a situation where your spouse is injured or killed because of nursing home abuse or neglect, you may be entitled to bring a claim for the loss of your spouse’s services that occurred as a result of their injury or death. The amount of recovery depends upon the personal nature of your relationship with your spouse, but can provide for the more emotional aspects of your loss.

Under Illinois law, a husband or wife can recover for loss of consortium because of a spouse’s injury or death. Loss of consortium claims are a derivative claim to the direct injury and cannot stand on their own. The recovery allowed under these claims can include loss of sexual relations, affection, guidance, happiness, and companionship.

In order to recover under a loss of consortium claim, the following elements must be established: the defendant must be liable for the spouse’s injury, the injured spouse and the claimant must be married, and there must exist proof of damages.

The statute of limitations for loss of consortium claims (735 ILCS 5/13-203) must be brought within the same time period allowed for the damages action for the injury. If the statute of limitations for the injury is extended, then the time to bring the loss of consortium claim can also be extended so they coincide. Any damages awarded for loss of consortium terminate upon remarriage.

A loss of consortium claim is an additional avenue to seek compensation and justice for the faults committed by the nursing home or care facility that was entrusted with the care of your loved one.

Sources:

McClain v. Owens-Corning (7th Cir. 1998)

735 ILCS 5/13-203

IL Farmers Insurance v. Hall

Resource:

Nursing Home Injury Laws

Comments

Fall From Bed Results In Death Of Newly Admitted Nursing Home Patient

Posted by Jonathan Rosenfeld on August 24, 2009

I've noticed a trend amongst many nursing home negligence cases-- injuries occur at a disproportionately high rate within the initial admission period. The most reasonable explanation for the heightened rate of nursing home injuries in during the initial admission period is most likely related with both the facilities unfamiliarity with the patient and vice versa.

Nonetheless, a facility that claims they were 'simply unfamiliar' with a patient is probably a poor defense if a negligence claim were pursued. Even before a care plan is developed, nursing homes must take reasonable steps to provide the highest feasible level of care for their new patients.

In order to facilitate a smooth and safe transition to the nursing home, caregivers and family should make the needs of their loved ones known to the staff at the facility. Providing the following information can be a valuable part of a transition:

Provide staff with realistic assessment of the individual of assistance
Let staff know about a sleeping and eating schedule
Provide the facility with a list of all medications
Provide staff with contact information for all physicians
Let facility know of specific health concerns

Along the lines of injuries shortly after an admission, on June 13, 2009, a resident fell out of bed and later died at Fejervary Health Care Center in Davenport, Iowa. This fall occurred within 24 hours of the resident being admitted to the nursing home.

Fejervary Health Care Center has a history of problems and has been fined several times by the Iowa Department of Inspections and Appeals. Last year, the nursing home was fined $7,500 for failing to ensure that each resident received adequate supervision to ensure against hazards from self, others, or environmental elements, and allowing a resident who was an elopement risk to elope from the facility.

According to the government’s Medicare website, the facility received one out of five stars, which is a much below average rating. In the past year, the nursing home had sixteen health deficiencies, which is eight more than the average number of health deficiencies in both Iowa and in the United States. Also, the number of health deficiencies in the past year is twice the number of deficiencies in the previous year.

Following the June 13 fall and death of the resident, the Iowa Department of Inspections and Appeals conducted a complaint inspection on June 29, resulting in a $6,000 fine. The inspection concluded that the nursing home facility failed to provide accurate assessments and timely intervention for a resident who experienced a fall and had a change in condition.

The resident was admitted to the nursing home on June 12 at 12:10 pm. During the initial interview with nursing home staff, both the resident and the resident’s spouse informed the staff that the resident had a recent history of falls at home. Nursing home staff established an individual care plan to help prevent falls. The plan included reminding the resident to use the call light, a bed alarm, and a body alarm. At 9:00 pm that night, the resident’s alarm sounded as the resident tried to get out of bed unassisted.

Then, in the early hours of June 13, an alarm was sounded and nursing home staff found the resident on the floor, wet with urine. The staff member who responded noted a skin tear on the back of the resident’s hand. After applying a dressing to the resident’s hand, the resident was helped back into bed and was under constant supervision for the rest of the shift.

In an interview with the Iowa Department of Inspections and Appeals, nursing home staff reported that the resident had fallen head first and hit their head. However, the staff member did not tell the nurse that the resident had hit their head. The staff members asked the resident whether the resident was hurt and checked mobility. The staff did not check the resident’s pupils or perform neurological checks and could not remember whether the resident had been asked about whether the resident had hit their head. Staff members did check the resident’s vitals, but only at the time of the fall.

Following the fall, the nursing home staff failed to inform the resident’s physician that the resident had suffered from a fall, even though the staff frequently contacted him for issues much less severe than a fall.

The staff reported that the resident seemed fine going about the day’s activities (eating breakfast, taking medication, talking with other residents, and using the restroom). Later that morning, the resident complained of hip pain and was given pain medication without an assessment. Shortly thereafter, the resident’s family members noted that the resident became agitated and complained of a headache. The resident then became unresponsive and was taken to the emergency room.

The doctor stated that the resident might not have been able to be saved even if the resident’s physician had been contacted at the time of the fall; however, the physician did not even have a chance to try to save the resident’s life since he was not contacted.

The hospital’s clinical summary documented the discharge diagnosis - severe subdural hematoma (bleeding in the brain), fever, hyponatremia (low sodium level in the blood), and microcytic anemia.

The Iowa nursing home had an obligation to report any change in condition to the resident’s physician in order to help prevent further injury and even death as was the case here. In addition, the nursing home staff is responsible for providing accurate assessments of resident health, especially after a fall so proper care and treatment can be provided.

Sources:

Quad-City Times – Nursing Home Fined After Resident’s Death

Iowa Department of Inspections and Appeals – Fejervary Health Care Center

Iowa Department of Inspections and Appeals – 6/29/09 Inspection Report

Medicare – Fejervary Health Care Center

Related Nursing Homes Abuse Blog Entries:

Nursing Home Falls

Assisted Living Fall Leads To Wrongful Death Lawsuit

Lexington Care Center Named As Defendant In Case Involving Multiple Falls

Comments

Nursing Home Spotlight: St. Francis NSG & Rehab Center, Evanston, IL

Posted by Jonathan Rosenfeld on August 23, 2009

St. Francis NSG & Rehab Center is a larger 124 bed facility located in Evanston, IL a city just north of Chicago. According to the government’s Medicare website, the facility received three out of five stars, which is an average rating. In the past year, the nursing home had only three health deficiencies, which is five less than the average number of health deficiencies in Illinois and in the United States.

Each nursing home resident is entitled to receive the care and services necessary to maintain the highest quality of life possible. One survey noted that the facility failed to meet this requirement when it did not provide necessary care for a resident with insulin dependent diabetes mellitus.

On several dates, the staff did not give the resident the required insulin which resulted in high blood sugar (hyperglycemia). If blood sugar levels get high enough, a patient can develop diabetic ketoacidosis, where the body breaks down fat for energy which produces toxic acids (ketones). If left untreated, it can be a life-threatening condition.

In order to properly care for its residents, the nursing home is required to conduct a comprehensive and accurate assessment of each resident’s functional capacity, which must be updated periodically. The facility failed to have comprehensive assessments for two residents and failed to have accurate fall precaution assessments for four residents in the sample.

The facility is required to maintain a professional standard of care and services for all residents. This did not occur when the staff failed to follow the doctor’s order for a pressure sore and failed to properly document dressing changes.

The facility is obligated to prevent pressure sores and to treat existing pressure sores to prevent infection and promote healing. Pressure sores can be a very serious problem for nursing home residents who have limited mobility or are on prolonged bed rest. If not treated properly, pressure sores can worsen and affect more tissue, making treatment more difficult.

A patient suffering from Parkinson’s had a stage 4 pressure sore that was contaminated with urine and feces because no treatment dressing had been applied. The patient’s care plan required that the pressure sore be cleaned and a treatment dressing changed every two days. Another patient was also seen without proper treatment dressing on pressure sores.

The nursing home has an obligation to give proper treatment to residents with feeding tubes to prevent problems. During one survey, one resident with a feeding tube was not being fed at the rate prescribed by the doctor, and another patient received more fluids than ordered by his physician.

St. Francis Nursing Home received an average rating and has less health deficiencies than many facilities in the state, a closer inspection of the facility reals that serious problems can still occur even at facilities with a seemingly well respected record.

St. Francis Nursing Home is part of Resurrection Health Care. Resurrection operates seven nursing homes in the Chicago area.

Comments

Huge Nursing Home Verdict Tossed Out Because Parent Company Did Not Have Adequate Control Over The Facility

Posted by Jonathan Rosenfeld on August 20, 2009

Yesterday, we discussed the nursing-home-name-game, how large nursing home chains attempt to shield themselves from liability by creating a complex array of subsidiary companies and messy corporate structures.

Today, we are seeing the fall-out created by this complicated game of corporate re-organization-- how despite that fact that a large corporation makes decisions with respect to operation of a facility, and even derives profits from the facility, it can evade responsibility by re-arranging its corporate structure.

In 2007, a New Mexico jury rendered a large verdict ($53 million) against ManorCare after they heard how Barbara Boxer, a patient at a ManorCare subsidiary was ignored by staff as she suffered from gastrointestinal bleeding. The trial revealed that not only did employees at the nursing home fail to administer any treatment, but they attempted to cover up the situation by removing the bloody sheets-- with the tell tale signs that they had watched a lady bleed to death-- before notifying the ladies family.

Despite the fact that Boxer was a patient at a ManorCare subsidiary, a nursing home negligence lawsuit was brought against the parent company-- ManorCare exclusively.

In overturning the trial court verdict, the Appellate Court reasoned that the court erred in finding that ManorCare was the 'employer' of the nursing home's staff. The large damage award ($3.2 million compensatory damages and $50 million in punitive damages) was never even addressed by Appellate Court in its decision.

While we can simply say that the New Mexico Appellate Court made a bad ruling with respect to the rights of injured nursing home patients, this decision will only encourage nursing home giants to rearrange their companies into smaller subsidiaries-- only to protect the parent company from liability.

The family of Mrs. Boxer intends on bringing this case before the New Mexico Supreme Court.

Read more about this important nursing home decision here.

Comments

What's In A Name? Are Large Nursing Home Chains Intentionally Attempting To Deceive The Public When It Comes To Corporate Ownership?

Posted by Jonathan Rosenfeld on August 19, 2009

One of the things I do each morning is to look through my google reader account to see the new updates regarding nursing home news and information. Today, I glanced through the news stories to find another unfortunate report regarding the alleged abuse of a patient at an Ohio nursing home. You can read about this report of nursing abuse here.

As I read the article, where abuse was alleged to have occurred at Heartland Lansing Nursing Home, I realized how deceptive the names of nursing homes can be to the general public. In the case of Heartland, it is part of the nursing home behemoth, HCR Manor Care.

Yet by looking at the name alone most people, including most of the residents at the facility, likely have no idea that Heartland Lansing Nursing Home is actually owned by ManorCare. Further confusing the matter is that ManorCare operates nursing homes around the country under the Heartland, ManorCare and Alden Courts surnames.

Why don't large nursing home chains want to lend the parent companies name to individual facilities?

I am open to ideas, but I firmly believe large nursing home operators carefully name (and re-name) facilities with the intent of shielding the parent company from possible liability in the case of an injury or death. Additionally, these knock-off names are also used to give an appearance that many of the facilities are small mom-and-pop operations as opposed to being operated by a health care conglomerate controlled with decision makers thousands of miles away.

The name-game gets much more complicated when it comes to other national nursing home chains. For example, Kindred operates 14 nursing homes in Ohio all with different names and all without any signal to the pubic that Kindred owns and operates these facilities.

While I may be making a big deal about the names of nursing homes, the fact is that the names are crucial when it comes to naming responsible entities in a legal proceeding. In this respect, there can be little doubt that a number of lawsuits get dismissed or a parent company evades responsibility because the name of the facility where the alleged negligence occurred throws off the injured party.

The corporate ownership behind the names can be even more complex and confusing. Many corporate owners have split up all aspects of the daily operation of nursing homes into different entities and --- you guessed it--- all with different names. In some cases of corporately owned nursing homes, parent companies have successfully evaded responsibility for the actions of their employees by hiding under these shell companies.

All this is to say, is that many nursing home operators have become extremely sophisticated when it comes to using 'legal loopholes' to avoid responsibility for specific acts. Consequently, a thorough examination of each nursing home's corporate structure must be analyzed prior to initiating any legal proceeding.

Related Nursing Homes Abuse Blog Entries:

Golden Living Sells All Its Arkansas Nursing Homes

Investors To Gain From Increase In Elderly Population

Comments (3)

Make More Room. Nursing Home Population Set To Explode

Posted by Jonathan Rosenfeld on August 18, 2009

A recent study sponsored by the National Institute on Aging (NIA) and produced by the U.S. Census Bureau, “An Aging World: 2008”, predicts that by 2040, the 65-plus population worldwide will more than double, from about 506 million to 1.3 billion.

In the course of thirty years, the percentage of older people in the world will double from seven to fourteen percent of the entire world population. There is also an expected rise in the number of people 100 years or older (centenarians). The global aging trend is caused by a pattern that is seen across the globe; the world population has been growing, coupled with a rising life expectancy in most areas. This leads to increasingly large elderly population worldwide.

A growing elderly population means that the health care system needs to adapt to changing and increasing health care needs. In addition, more people are not having children (childlessness could soon reach 20% in the United States). This leaves more elderly people who don’t have families to help take care of them, leaving assisted nursing home facilities to provide additional services. In the next ten years, the number of people older than 65 might be more than the number of children under five for the first time ever.

The global aging trend presents both social and economic challenges for most areas of the world. The fastest growth of the older population is occurring in developing countries, where it has more than doubled the growth rate of the older population in developed countries. The older elderly (aged 80 and older) are the fastest growing portion of the total population in many countries.

The United States’ system of nursing home facilities is already strained. Many facilities provide inadequate or improper care to their residents. With increased nursing home populations, these problems and shortcomings might become worse as facilities struggle to provide basic care to all residents.

Resources:

Naples News - Study: Older Population Expected to Double as Life Expectancy Increases

NIH News - Unprecedented Global Aging Examined in New Census Bureau Report Commissioned by the National Institute on Aging

U.S. Census - An Aging World: 2008

Comments

Updates From Bed Sore FAQ. Top-Ten Most Visited Entries:

Posted by Jonathan Rosenfeld on August 17, 2009

Thousands of people visit Bed Sore FAQ each month to get information related to the care of bed sores (also referred to as decubitus ulcers, pressure ulcers or pressure sores) and to learn their legal rights after a bed sore develops during an admission to a nursing home, hospital, group home, assisted living facility, or residential care facility for the elderly.

Below are the 10 most popular Bed Sore FAQ's according to reader-generated traffic. If you have a question related to bed sores or are interested in discussing legal options, please fill out the contact form, and I will respond to your inquiry personally.

Still looking for more information? Bed Sore FAQ is updated frequently and we have many new entries in the works. Also, please check out our new sections including a Bed Sore Resource Section with comprehensive information on the following:

Comments

The Most Important Job In America.... Nursing Home Surveyors

Posted by Jonathan Rosenfeld on August 14, 2009

Firefighters, teachers and doctors are all important to the functioning of our society. Without the services they provide, people would suffer in many respects. But when it comes to jobs that are pivotal to the immediate safety, health and overall welfare of people-- especially the elderly, I nominate state and local nursing home inspectors as the most important job in America.

Go ahead email me about how 'wrong' I am. There can be no doubt that without this group of civil servants an untold number of our elderly would suffer serious injury or die needlessly.

Nursing home inspectors are on the front-lines of patient safety-- assuring all applicable laws our complied with. In the case of a patient injury, inspectors are there again to determine how the incident occurred and how similar incidents could be prevented in the future. Similarly, when a facility says it will take corrective action, nursing home inspectors are there to assure the plan is complied with.

Today's example of the vital role nursing home inspectors play in our society comes from Tennessee. After fielding complaints relating to poor patient care and conducting an annual survey, inspectors found multiple conditions at the Life Care Center of Chattanooga that posed a risk to patient safety. During the June / July inspections, inspectors (also referred to as surveyors) discovered safety violations in the following areas:

Administration
Performance Improvement
Physician Services
Nursing Services
Medical Records
Pharmaceutical Services

The conditions discovered by inspectors resulted in daily penalties, appointment of a special monitor at the facility, and suspension of new patients. Additionally, a copy of the order from the Tennessee Commissioner of Health that articulated the dangerous conditions and the resulting state and federal actions was posted on the entrance to the facility.

Nursing homes are heavily regulated by federal and state standards, not to make life more complicated for nursing staff, but because the regulations are crucial to provide quality patient care. If we did not have nursing home inspectors out and about in these nursing homes, who would ensure that the regulations are complied with and everything is done to protect our vulnerable seniors?

Read more about the suspension of new patient admissions at Life Care Center of Chattanooga here.

Related Nursing Homes Abuse Blog Entries

"Life Care Center" Permitted To Accept New Patients After State Finds Poor Living Conditions

State Inspectors Find Safety Violations In Indiana Nursing Home

Who Regulates Nursing Homes?

Comments

Reducing Decubitus Ulcers In Hospitals. How One Facility Managed To Reduce Hospital-Acquired Wounds By 63%

Posted by Jonathan Rosenfeld on August 13, 2009

Texas Arlington Memorial Hospital was recently recognized for implementing a systematic program to reduce the number of patients with hospital-acquired decubitus ulcers. The program resulted in a 63% reduction in pressure sores. This hospital accomplished this by taking the following steps:

Identifying decubitus ulcers on all new admissions
Reducing use of diapers amongst patients
Encouraging all staff to look for and document decubitus ulcers, even in their earliest stages
Paying extra attention to patients who are bed bound or who's skin comes into contact with medical equipment like oxygen masks or tubing
Implementing daily skin checks and intensive, hospital-wide skin checks on a quarterly basis to help the facility keep accurate tabs on how well its wound prevention program is working

Related Nursing Homes Abuse Blog Entries

Over 500,000 Adults Suffer From Bed Sores In Hospita ls

Pressure Sores In Hospitals On The Rise

In For Rehab. Out With Bedsores.

Proper Wound Documentation

Bed Sore Resources

Comments

Rather Than Do His Job, Nurse Would Rather 'Tie Down' Patient In New York Nursing Home

Posted by Jonathan Rosenfeld on August 12, 2009

I know some blog readers think that I just re-post the same entries about nursing home employees abusing their patients--- but I'm not. The reality is that nursing home abuse is a problem encountered by an untold number of patients in nursing homes across the country.

Out of New York, another case of abuse by a nurse's aide has recently made headlines when a nurses aide became irritated after a disabled patient repeatedly used a call light for assistance in the early morning hours in May, 2008. Rather than tend to the patient's needs, the aide chose to put an end to the calls by tying the patient to a wheelchair with a bed sheet and putting her into a darkened room.

The nursing home's video surveillance cameras captured the aide sleeping next to the forcibly restrained patient.

The aid involved in this incident pleaded guilty to violation of public health laws involving the abuse, neglect and mistreatment of a person. Additionally, the aide was required to surrender his nursing certificate and is banned from working as an aide for one year.

"Think about this individual being put in a dark room. This is not what you do to a human being," said Cynthia Rudder, Director of Special Projects for the Long Term Care Community Coalition. "How does and aide go into a common room, turn off the light and nobody notices?"

Good point Cynthia. Where were the other nursing home staff members (and I certainly hope there was other staff on duty) when this obvious abuse was occurring? I hope the the video surveillance is reviewed to determine the identities of the other individuals who did nothing to intervene in this situation involving obvious abuse.

Read more about this episode of improper use of restraints and abuse in a New York nursing home here.

Related Nursing Homes Abuse Blog Entries

'Dignity Training' Ordered For Staff In New York Nursing Home After They Humiliate Residents Who Need Assistance With Toileting

Caregivers Charged With Abusing Elderly In New York Nursing Homes

Nursing Home Worker Faces 25 Years In Jail Following Molestation Of Disabled Patient

Lawsuit Filed Against New York Nursing Home In Relation To Nun's Death

Comments

Assisted Living Employee Pleads Guilty To Manslaughter Charges After Resident Dies From Burn Injury

Posted by Jonathan Rosenfeld on August 11, 2009

Alvador Thompson, a nurses aide who poured scalding oatmeal into the mouth of a disabled patient has pleaded guilty in response to the involuntary manslaughter charges filed against her by the Montgomery County District Attorney.

This incident at an assisted living facility caught national attention not only due to the fact that an aide failed to check the temperature of the food she was serving to a disabled resident, but also due to the fact that despite the severe burns on the man's lips, tongue, mouth and throat, the facility waited almost half a day to get medical attention for the injured man. Also, Cambridge Brightfield, the Pennsylvania assisted living facility, failed to notify state officials of the resident's injury.

The elderly man received hospital treatment for his injuries, but was discharged back to Cambridge Brightfield where he died two weeks later.

In several months, Ms. Thompson will return to court for her sentencing. Pennsylvania categorizes involuntary manslaughter as a misdemeanor which carries a maximum penalty of 2 1/2 to 5 years in prison and a $10,000 fines.

Cambridge Brightfield's provisional license was revoked by the Department of Public Welfare after authorities learned of this burn injury and two other incidents where residents were found unresponsive and required hospitalization.

As far as I can tell, no fine or corrective changes were ordered by Pennsylvania officials. The fact that no severe penalties were ordered leaves me wondering, what real incentive is there for assisted living facilities to clean up their act? It is always easy to blame the individual involved in a particular incident, yet the reality is that the management and owners of this assisted living facility are the ones to blame as they typically fail to train many staff members to look out for situations such as this. As long as our society gives a mere 'slap on the wrist' to facilities that allow this type of treatment to exist we can expect more unfortunate situations such as this to continue.

Read more about this tragedy at a Pennsylvania assisted living facility here.

Related Nursing Homes Abuse Blog Entries:

Can Assisted Living Facilities Adequately Care For Alzheimer's Patients?

Criminal Charges Filed Against Assisted Living Employee In Relation To Resident Suffering Burns While Eating

Man Chokes To Death While Left Unattended At Nursing Home

Comments (2)

Even After Repeated Tragedies, Alden Wentworth Nursing Home Refuses To Hire Additional Staff To Assist Patients

Posted by Jonathan Rosenfeld on August 10, 2009

On May 4, 2009, Bennie Saxon, a veteran suffering from dementia who was a resident at the Alden Wentworth Rehabilitation and Health Care Center fell four stories to his death. The Alden facility is a large 300 bed, predominately black nursing home facility located in Chicago’s South Side.

According to the government’s Medicare website, the facility received only two out of five stars, which is a below average rating, receiving only one out of five stars for health inspections and one out of five stars for nursing home staffing. In the past year, the nursing home had 23 health deficiencies, which is fifteen more than the average number of health deficiencies in Illinois and in the United States. The number of health deficiencies is more than the health deficiencies in the past two years.

Alden Wentworth received only one out of five stars for its nursing home staffing, which is a much below average rating. The nursing home provides less licensed nurse staff hours per resident per day (42 minutes) than both the national average (1 hour 24 minutes) and the Illinois average (1 hour 12 minutes). The facility also provides less resident nurse hours per resident per day (16 minutes) than both the national and Illinois averages (36 minutes). The facility also offers less licensed practical nurse/licensed vocational nurse hours per resident per day (26 minutes) than the national average (48 minutes) and the Illinois average (36 minutes). The number of certified nurse aid hours per resident per day at Alden Wentworth (1 hour 20 minutes) is also less than the national average (2 hours 18 minutes) and the Illinois average (2 hours).

The Chicago Reporter conducted an investigation of the facility following Mr. Saxon’s death, and Chicago Now ran an update about the protests and meeting that occurred in response. The Alden Wentworth facility is owned by Floyd A. Schlossberg, who is one of Illinois’ largest owners of nursing homes, with ownership in twenty-nine homes. The Chicago Reporter reported that the Alden Wentworth facility provides residents with less than half of the time each day with staff than residents at a predominantly white facility in Evanston that is also owned by Mr. Schlossberg.

Following Mr. Saxon’s fall, the Senior Action Network staged two protests at the Alden facility. At the first protest, a Alden Wentworth employee threw a letter requesting a meeting with Mr. Schlossberg in the trash. At the second protest, Senator Jacqueline Collins, Representative Andre Thapedi, and Alderman Freddrenna Lyle were in attendance and also received rude treatment from the facility.

Then, on July 24, 2009, the three elected officials mentioned above and leaders from the Illinois Department of Public Health met with a representative from the Alden facility. The Alden representative reported that changes had been made at the facility: a new administrator had been brought to the facility and staff assignments on the dementia floor were changed. However, the facility did not agree to hire additional staff.

Regarding a separate incident, the Illinois Department of Public Health conducted a complaint investigation of the Alden Wentworth facility on April 2, 2009.

The report revealed that the facility failed to provide the necessary care and services to attain or maintain the highest possible physical, mental, and psychosocial well-being of its residents. A resident who had a change in their breathing status was not evaluated by a physician in a timely manner, resulting in the resident being admitted to the hospital with Dyspnea (shortness of breath). The resident was suffering from a cold, temperature, and congestion. The doctor was not properly notified of the resident’s condition, which accounted for the delay in proper treatment. The facility’s response reported that nursing staff was alerted as to the proper procedure for what to do if the attending physician does not respond. The resident involved in the incident subsequently died.

Sources:

Chicago Now – The Background on Alden Nursing Home Meeting

The Chicago Reporter - Disparate Nursing Home Care

Medicare Website – Alden Wentworth Rehabilitation and Health Care Center

Illinois Department of Public Health – Alden Wentworth Rehab & HCC

Alden Wentworth Rehabilitation and Health Care Center

Mayo Clinic - Dementia

Comments

Choking Death Just Latest Problem At California Nursing Home

Posted by Jonathan Rosenfeld on August 07, 2009

Tustin Care Center, located in Orange County, California, was fined $50,000 by the California Department of Public Health for the choking death of one resident in March 2009. The California Department of Public Health concluded that the facility’s failure to assess the resident’s ability to eat was a direct cause of his death.

According to the government’s Medicare website, the Tustin Care Center received four out of five stars, which is an above average rating. In the past year, the nursing home had nine health deficiencies, which is three less than the average health deficiencies in California, and one more than the average number of health deficiencies in the United States.

The inspection report noted that one resident choked to death after eating lunch provided by the nursing home facility. In this case, the facility failed to conduct continuing assessments of the resident. Nursing homes are required to identify problems and develop an individual care plan for all residents based on initial and continuing assessments of resident needs. This requirement is in place to provide the best and most complete care and treatment to maintain the health and well-being of residents.

The resident was admitted to the facility on October 27, 2008 with hypertension, a lung mass, heart disease, and high cholesterol. The nurse’s assessment showed that the resident had both upper and lower dentures and was alert and able to feel himself. An individualized care plan was established, part of which was to monitor the patient’s diet tolerance.

Over the course of the resident’s stay at the facility, the nursing home staff noted that the resident was getting weaker and having difficulty moving around. However, there was no mention of an assessment by dietary or by the Interdisciplinary Team (IDT) of the resident’s swallowing ability or ability to tolerate a regular diet. The IDT notes from March 2, 2009 show that the resident had a change in condition caused by a decline in activities of daily living and a decline in mobility due to a five pound weight gain within a month. Still, the nursing home staff allowed the resident to eat regular meals on his own.

On March 14, 2009, the resident was served lunch in the dining room at noon. The resident ate twenty-percent of his lunch (Korean soup with rice). At 12:30 pm, the resident had difficulty breathing, and a licensed nurse performed the Heimlich maneuver but was unable to dislodge the food. The resident was then placed on the floor and given CPR before being transferred to the hospital. The resident did not have a pulse and did not regain consciousness. The hospital report indicated that the resident arrived at the emergency room in full arrest – he was flaccid and pale with a partially obstructed airway and no heartbeat. The hospital was unable to resuscitate the resident. The autopsy confirmed that the cause of death was asphyxia due to choking on food.

This unfortunate death could have been prevented had the facility taken better care to provide ongoing assessments of the resident’s ability to eat on his own.

Read more about this choking death in a California nursing home here.

Sources:

Mercury News - Tustin Nursing Home Fined $50,000 by State

Medicare – Tustin Care Center

California Department of Health: Nursing Home Citations – Tustin Care Center

Comments

Can Assisted Living Facilities Adequately Care For Alzheimer's Patients?

Posted by Jonathan Rosenfeld on August 06, 2009

Is it fair to expect an assisted living facility-- loosely regulated entities that help residents with daily living activities to care for a person with Alzheimer's?

Assisted living facilities (ALF's) are intended to provide a semi-structured environment to (primarily) elderly group. Meals are prepared and staff are intended to provide residents with daily living activities. Unlike nursing homes, ALF's are not intended to provide skilled nursing care.

In the case of Alzheimer's patients, many ALF's accept these people despite the fact that many offer no specialized care for them. Is this a case of corporate greed putting its quest for profits ahead of providing necessary care to its residents?

In the case of Ruby Larson (an Alzheimer's patient), I think the answer is a resounding 'yes'. On July 23, 2007 Larson wandered from Pheasant Pointe Retirement and Assisted Living Residence-- never to be heard from again. Last year a judge declared Larson to be legally dead as the search for her was fruitless.

Ms. Larson, 75, was admitted to Pheasant Pointe in May, 2007 suffering from dementia, memory loss, and disorientation. During the three months Larson was a patient at Pheasant Pointe, she wandered from the facility three separate times.

Larson's family filed a lawsuit against Pheasant Point and its parent company, Spectrum Retirement Communities of Oregon claiming the staff failed to properly supervise Larson and that the companies should have known that Ms. Larson required care only a specialized Alzheimer's care unit could provide.

Unfortunately, Alzheimer's patients may encounter many problems while living in an assisted living environment. Of course, depending on the individual facility, the levels of care may be different. But most ALF's are horribly ill-equipped to care for Alzheimer's patient who typically require great care with meals, getting about, re-direction, medication as well as maximum assistance with daily living.

If a facility is unable to provide the level of care required, the facility should advise the family. Too often, ALF's never mention to the family that their loved one may be better off in a nursing home or alternative facility that specialized in Alzheimer's care.

Read more about this lawsuit against an assisted living facility here.

Related Nursing Homes Abuse Blog Entries

The Truth Revealed: Nursing Home Tries To Cover-up Fact That Resident Choked To Death On Tuna Sandwich

Nursing Homes For Alzheimer's Patients. What To Look For?

Woman Dies From Hypothermia After Wandering From Assisted Living Facility

Comments (5)

Fall In Nursing Home Claims The Life Patient-- Less Than 24-Hours After Admission

Posted by Jonathan Rosenfeld on August 05, 2009

On June 13, 2009, a nursing home patient fell out of bed and died at Fejervary Health Care Center in Davenport, Iowa. This fall occurred within 24 hours of the resident being admitted to the nursing home.

This was not an isolated event at Fejervary. Fejervary Health Care Center has a history of safety problems and has been fined several times by the Iowa Department of Inspections and Appeals.

Last year, the nursing home was fined $7,500 for failing to ensure that each resident received adequate supervision to ensure against hazards from self, others, or environmental elements, and allowing a resident who was an elopement risk to elope from the facility.

According to the government’s Medicare website, the facility received one out of five stars, which is a much below average rating. In the past year, the nursing home had sixteen health deficiencies, which is eight more than the average number of health deficiencies in both Iowa and in the United States. Also, the number of health deficiencies in the past year is twice the number of deficiencies in the previous year.

Following the June 13th fall and death of the resident, the Iowa Department of Inspections and Appeals conducted a complaint inspection on June 29, resulting in a $6,000 fine. The inspection concluded that the nursing home facility failed to provide accurate assessments and timely intervention for a resident who experienced a fall and had a change in condition.

The resident was admitted to the nursing home on June 12 at 12:10 pm. During the initial interview with nursing home staff, both the resident and the resident’s spouse informed the staff that the resident had a recent history of falls at home. Nursing home staff established an individual care plan to help prevent falls. The plan included reminding the resident to use the call light, a bed alarm, and a body alarm. At 9:00 pm that night, the resident’s alarm sounded as the resident tried to get out of bed unassisted.

Then, in the early hours of June 13th, an alarm was sounded and nursing home staff found the resident on the floor, wet with urine. The staff member who responded noted a skin tear on the back of the resident’s hand. After applying a dressing to the resident’s hand, the resident was helped back into bed and was under constant supervision for the rest of the shift.

In an interview with the Iowa Department of Inspections and Appeals, nursing home staff reported that the resident had fallen head first and hit their head. However, the staff member did not tell the nurse that the resident had hit their head. The staff members asked the resident whether the resident was hurt and checked mobility. The staff did not check the resident’s pupils or perform neurological checks and could not remember whether the resident had been asked about whether the resident had hit their head. Staff members did check the resident’s vitals, but only at the time of the fall.

Following the fall, the nursing home staff failed to inform the resident’s physician that the resident had suffered from a fall, even though the staff frequently contacted him for issues much less severe than a fall.

The staff reported that the resident seemed fine going about the day’s activities (eating breakfast, taking medication, talking with other residents, and using the restroom). Later that morning, the resident complained of hip pain and was given pain medication without an assessment. Shortly thereafter, the resident’s family members noted that the resident became agitated and complained of a headache. The resident then became unresponsive and was taken to the emergency room.

The doctor stated that the resident might not have been able to be saved even if the resident’s physician had been contacted at the time of the fall; however, the physician did not even have a chance to try to save the resident’s life since he was not contacted.

The hospital’s clinical summary documented the discharge diagnosis - severe subdural hematoma (bleeding in the brain), fever, hyponatremia (low sodium level in the blood), and microcytic anemia.

The nursing home had an obligation to report any change in condition to the resident’s physician in order to help prevent further injury and even death as was the case here. In addition, the nursing home staff is responsible for providing accurate assessments of resident health, especially after a fall so proper care and treatment can be provided.

Sources:

Quad-City Times – Nursing Home Fined After Resident’s Death

Iowa Department of Inspections and Appeals – Fejervary Health Care Center

Iowa Department of Inspections and Appeals – 6/29/09 Inspection Report

Medicare – Fejervary Health Care Center

Comments (3)

PA Nursing Home Lawsuit Claims Facility Failed To Supervise & Implement Wheelchair Precautions

Posted by Jonathan Rosenfeld on August 04, 2009

A nursing home negligence lawsuit has been filed against the Village at Luther Square Nursing Home after Edward O'Neil died from injuries allegedly sustained due to a fall from his wheelchair. According the the facts alleged in the lawsuit, staff at Village at Luther Square left O'Neil unattended in his wheelchair for several hours on July 5, 2008.

During the unsupervised time, Mr. O'Neil's wheelchair tipped over onto him causing him to suffer a brain bleed and fractured neck.

The lawsuit brought by Mr. O'Neil's estate, claims that staff at the nursing home failed to: provide visual checks, utilize appropriate restraints and implement 'anti-tipping' precautions on the wheelchair. Mr. O'Neil died two days after the incident from 'natural causes'.

Mr. O'Neil's death accentuates many problems at Luther Square that were recorded by nursing home inspectors. Following the death of Mr. O'Neil and another resident who died from a similar fall-related incident, the Pennsylvania Department of Health downgraded Luther Villages nursing home license. Similarly, in June, 2008 state inspectors fined the Erie, PA nursing home $7,000 after finding 21 violations relating to patient care and building conditions.

This case is pending Erie County Court. Read more about this Pennsylvania nursing home lawsuit here.

The Importance Of Nursing Home Inspections

If anything, this case highlights the importance of getting inspectors (also referred to as 'surveyors') from your state's department of health involved in the investigation process following a incident involving injury or death. Despite a large workload and a frequently inhospitable work environment, department of health employees provide a vital service for injured residents and their families.

Nursing home inspectors have access to documents and witnesses that would frequently be unavailable outside of a litigation setting. Moreover, their access in the days, weeks and months following an incident or period of neglect helps assure important facts are documented in a timely manor.

While the reports generated by nursing home inspections are usually considered to be inadmissible in court, the specific facts can be crucial to the success of nursing home lawsuits. Perhaps, equally beneficial to both the resident and the the facility, the findings in the report may reveal the facilities appropriate actions relating to an incident. In these circumstances, the findings may prevent a disappointing outcome for an injured party years down the road.

Related Nursing Homes Abuse Blog Entries

2 Resi dents Fall From Wheelchairs With 2 Days At Nursing Home

Fall Leaves Veteran With Broken Neck In Illinois Nursing Home

Big Verdicts Against Nursing Homes

Comments

How can nursing home ombudsmen help with problems encountered in a long-term care facility?

Posted by Jonathan Rosenfeld on August 03, 2009

"How can nursing home ombudsmen help with problems encountered in a long-term care facility?"

-Carol, Beachwood, Ohio

Every state is required to have a long-term care ombudsmen program as set forth by the Federal Older Americans Act. In the long-term care setting, ombudsmen act as patient advocates to help families find facilities that meet resident needs, address problems encountered in long-term settings and inform patients of their legal rights.

Most people utilizes ombudsmen services when they encounter a problem at a facility such as a resident injury resulting from abuse or neglect. In this context, an ombudsman can help in the investigation of the incident and resolve problems with the facility.

In many cases, the information provided by a nursing home ombudsman may substantiate an episode of poor care. This information may be helpful in determining how an incident occurred and if the matter should be pursued as a nursing home negligence lawsuit. Even in cases where there are findings of improper care, most jurisdictions prohibit ombudsmen reports from being introduced into civil lawsuit.

If you have a question regarding nursing home care or seek more information regarding a nursing home injury, the ombudsmen program is a great resource to help provide you with more information. Unless you give ombudsmen specific permission to share your information with the facility, all personal information will be kept confidential.

Resource:

National Long Term Care Ombudsman Resource Center- provides contact information for ombudsman in every state.

Comments (2)

Nursing Home Employee Charged With The Financial Exploitation Of Elderly Patient

Posted by Jonathan Rosenfeld on August 02, 2009

A Chicago nursing home worker faces financial exploitation and aggravated identification theft charges for allegedly stealing $4,008 from a patient at The Moorings, a nursing home in Arlington Heights, IL. Police were tipped off to the theft by the victims family who noticed that money was consistently being electronically withdrawn from their family member's bank account over a period of several months.

Nelson remains free on bail and no longer works at the Moorings. Authorities acknowledge that Nelson has a previous criminal conviction for forgery. Read more about this exploitation of a nursing home patient here.

The Moorings is part of Presbyterian Homes, a company that operates several nursing homes and assisted living facilities in the Arlington Heights, Evanston and Lake Forest, IL.

Comments

Contact Jonathan at: (888) 424-5757

Topics

Recent Updates

Links

LexBlog Network

About Jonathan Rosenfeld

Stay Connected

Subscribe

Concerned about a loved one? Talk with an attorney today.

Bed Sore FAQs

Rosenfeld Legl Network