Nursing Homes Abuse Blog - By Jonathan Rosenfeld

At their most basic level, fines imposed against nursing homes for negligent care of patients serve to both punish facilities for situations that may have developed in the past and to serve as a way of prodding facilities to improve the care they dispense--- or else they will face similar sanctions again if the problems persist.

If all goes according to plan, facilities that receive a fine will stop, pause-- and think about the type of care that they provide to patients because the fine imposed against them remains enough of a sting for the facility to improve its patient care.

The trouble that I continually see with the overwhelming number of monetary fines imposed against nursing homes is that the fines are rarely commensurate with the degree of inadequate care provided.  Moreover, when the fines imposed against offending nursing homes are evaluated in the context of a facilities business operations, they amount to little more than the cost of doing business.

Poor care, meager fines

Perhaps a recent string of fines imposed the Connecticut Department of Health against several nursing homes in the state is about as good an example of these simply inadequate fines as one can find?

***According to a recent article in The Middletown Press, the DPH handed over the following fines.

• $650 to a Aurora Senior Living of Cromwell after a patient patient choked to death on marshmellows.  The patient was known to have dysphagia and the treating physician ordered that the patient was not to receive solid foods.
• $600 fine imposed The Apple Rehabilitation West Haven following a state investigation where 15 patients with various ailments were not given their prescribed medications for approximately one year.
• $510 to New London Rehabilitation and Care of Waterford after a patient was injured during a transfer with a Hoyer lift.
• $815 following a situation at Masonic Health Center of Wallingford involving two residents who were injured while being transported improperly in wheelchairs and for the drastic weight loss in two other patients.
• $510 when staff at Apple Rehabilitation Laurel Woods of East Haven transferred a patient in the bathroom with one staff member when their care plan indicated that they were to be transferred with two employees

From the perspective of acting as a deterrent, regulatory agencies and legislatures need begin flexing far more regulatory muscle--- or episodes of poor care such as this will always plague the industry. 

Maybe some of these state agencies need to confer with officials at the NBA, who seem quite capable of using fines to get players behavior in line with the leagues values?  Incidentally, no elderly people were neglected, abused or injured in relation to these incidents.

• $25,000 fine imposed a against a player who posted the photo of a scatily clad woman on Twitter.
• $35,000 fine to a player who was either licking blood off an injured finger or gesturing to the crowd
• $500,000 fine to the owner of an NBA team who issued a one sentence response to a fan during the NBA lockout
• $40,000 fine to Kobe Bryant for missing to appearences during and All-Star Game weekend

Related Nursing Homes Abuse Blog Entries:

Illinois Lawmaker Seeks To Tighten Reigns On Nursing Homes

What good are nursing home fines when they're not enforced?

Shouldn't Nursing Home Fines Be Reflective Of The Type Of Violation Committed?

How Much Do Nursing Home Need To Be Fined In Order To Clean Up Their Acts?

A jury in Michigan awarded $2.35 million in damages to the family of a deceased nursing home patient who choked to death on a meatball served to him during an admission to a skilled nursing facility.   The patient identified as 56-year-old Walter Polombski was a patient at Nightingale Nursing Center in Warren, Michigan-- a facility operated by Sava Senior Care when a meatball (he should have never been served) became stuck in his airway.

Even after Mr. Polombski's choking was identified by staff, there was a significant delay in the process of attempting to clear his airway.  In fact, evidence at the trial suggested that the facility waiting approximately 12 minutes from the time the choking was identified until they contacted paramedics.  The delay in obtaining care to clear the airway was alleged to have exacerbated the situation.

Choking is a disturbingly common type of injury that threatens the safety of nursing home patients-- particularly those who have sustained a stroke or other neurological injury.  In order to minimize a patient's risk of choking, facilities frequently utilize the skills of a speech therapist to conduct a swallowing test to determine what type of dietary modifications need to be made to the patient's food: served cut up, ground, chopped, pureed, or in another manner which meets the patients physical abilities.

In patients with extensive swallowing difficulties, restrictions may me implemented on the type of food or drink that the patient can have.  In extreme circumstances, a doctor may categorize the patient as "NPO".  NPO stands for Nothing Per Orem which means nothing by mouth. Doctors use this on orders when they do not want the patient to take in any type of food or liquid by mouth.

Once the dietary restrictions have been put into place, it is up to nursing home staff to carefully implement the orders and keep the dietary orders in place until they receive alternative orders from the patients physicians.  

However, even in circumstances where patients have dietary restrictions in place, it is important for staff to monitor all patients during meal times to help patients safely enjoy their food.  At all times, staff should always incorporated basic choking precautions:

• Encourage patients to sit upright
• Always keep a beverage within reach
• Don't rush patients while they eat
• Warn patients about food that may have bones or skin that may not be apparent
• Train staff on how to dislodge food / Heimlich maneuver

Related:

Dysphagia In Nursing Home Patients May Contribute To Medical Complications Such As: Choking, Pneumonia Or Death

Swallowing Therapy of Neurologic Patients- Correlation of Outcome with Pretreatment Variables and Therapeutic Methods (pdf) Dysphagia 10:1-5(1995)

Toothless Patient Chokes To Death After Nursing Home Staff Ignores Doctor's Order

Choking Death Just Latest Problem At California Nursing Home

Jury awards $2.35 million for death caused by choking on meatball in Warren nursing home Daily Tribune

One of the cruelest examples of nursing home negligence is when staff fail to adhere to physician's orders that pertain to patients' diets.  Similar to dispensing medication, when it comes to disabled patients, doctors are typically responsible for determining what types of food-- and just how much food-- patients should be eating.

Particularly, when its a situation involving a patient eating solid vs. soft foods, it is crucial that a doctor or professional with experience relating to patients swallowing and digestive abilities, carefully evaluate each patients individual needs. Further, it is crucial that staff at the nursing home strictly adhere to the orders set forth by the physician.

When staff fail to adhere to the physician orders relating to dietary restrictions, disaster may ensue.

An example of the problems associated with staff ignoring physician orders-- or just plain common sense-- happened at a California nursing home when a toothless patient choked to death on a pork chop.  Following an investigation into the incident at Goldstar Rehabilitation and Nursing Center, it was concluded that staff at the facility ignored physician orders specifying a soft-food diet, when they allowed the patient to consume a pork chop.

The incident resulted in a $100,000 fine.

Related:

Dysphagia In Nursing Home Patients May Contribute To Medical Complications Such As: Choking, Pneumonia Or Death

Failure To Follow Doctor's Orders Results In The Choking Death Of Hospital Patient

Choking Death Just Latest Problem At California Nursing Home

Nursing Home Injury Laws: California

Santa Monica nursing home fined 100K in death The Examiner

Who doesn’t remember the shock of their first time at the circus when the fire-eater or knife-swallower made their way to center ring to perform their stunts?  Surely, even when these trained performers make their way into the big top, there is always a risk of danger.

Certainly, not to make light out of a serious issue, there are similar swallowing-related dangers facing patients who may not be able to appreciate the dangers.  I have worked on a number of cases involving disabled patients who have swallowed foreign objects during admissions to nursing homes, hospitals and group homes. 

Most of these foreign-object cases involve patients with Alzheimer’s and other psychiatric conditions who remain unable to appreciate the dangers associated with swallowing materials that may be on hand in their rooms.

Commonly encountered swallowed foreign objects including:

• Plastic knives and forks
• Food packaging
• Sterile gloves
• Pens
• Toothbrushes
• Coins
• Razorblades
• Dental implants / dentures

What makes many of the foreign object ingestion cases particularly horrific for the patient is the fact that many of the foreign objects are extremely dangerous is the fact that many objects go undetected by staff until a problem manifests itself in the form of a severe medical complication -- such as choking or internal bleeding.

Given the prevalence in ingesting foreign materials or objects amongst Alzheimer’s, dementia and psychiatric patients, facilities need to be mindful of this real tendency and take steps toward minimizing the chances a patient can access these materials:

• Facilities should take steps towards identifying which patients have a history of ingesting foreign materials
• Medical devices should be kept under locked conditions
• Staff should remove non-edible food wrappers and coverings from meals prior to serving staff
• Staff should supervise patients with a swallowing proclivity

Due to the fact that many of these patients are simply unable to perceive the dangers associated with ingesting foreign objects, facilities need to be mindful of the inherent risks associated with keeping materials accessible to their patients and implement safeguards to prevent patients susceptible to this type of behavior from accessing materials.

Resources:

Intentional Swallowing of Foreign Bodies and Its Impact on the Cost of Health Care, Science Daily, November 4, 2010

Foreign body aspiration in dentistry- a review (PDF) The Journal Of The American Dental Association 1996;127;1224-1229 by SM Cameron, WL Whitlock and MS Tabor

CT Features of Esophageal Emergencies (PDF) Radiographics by Catherine A. Young, MD, JD • Christine O. Menias, MD • Sanjeev Bhalla, MD • Srinivasa R. Prasad, MD (2008)

 Milestone-Elmwood East is a small, 12-bed nursing home located in Rockford, Illinois. Milestone, Inc. is a private, not-for-profit corporation that provides “residential, developmental, vocational, and social support services for adults and children with mental retardation, autism, epilepsy, and cerebral palsy.” This facility committed serious violations that led to the choking death of one resident. (See Nursing Homes Abuse Blog: Topic – Choking)

This nursing home committed several serious 4^th quarter violations relating to the area of policy and procedure. (See “42 Illinois Nursing Homes Cited in 4^th Quarter of 2009 for Violations Related to Patient Care”) The Illinois Department of Public Health (IDPH) fined the nursing home $25,000 on November 17, 2009. The facility provides services for persons suffering from mental retardation. These residents require more care than average residents because of reduced mental capacities. 

First, the facility failed to conduct quarterly fire drills for the 2^nd shift personnel, which endangered the lives of all residents. In the case of an emergency, including fire emergency, staff members should be trained and prepared. As evidenced by the IDPH report, this did not occur with all personnel. 

The most serious of the violations involve the choking death of a 28-year old nonverbal male resident who was ambulatory (capable of walking), mentally retarded, and also suffered from autism and cerebral palsy. This resident died after choking on food unsupervised. (See “Failure to Follow Orders Results in Death of Patient & Hefty Fine”) The facility’s failures include: 

• Failure to implement policy on neglect
• Failure to ensure that resident’s behavior program was fully documented with certain behaviors of taking food from kitchen
• Failure to ensure that enough staff were available to manage and supervise resident in accordance with his behavior plan which allowed him to eat unsupervised

The violation report completed on September 17, 2009 notes that the facility’s own policy on abuse and neglect defines abuse/neglect as to include “any willful failure to respond to an individual’s obvious needs or to provide the appropriate supervision and care that the individual served should have.” The facility’s failure to provide adequate medical or personal care or maintenance for the resident resulted in physical injury. 

Before his death, the facility’s program charts (completed on May 7, 2009) had the resident on a program to ensure that he ate at a slower pace. To support this goal, a staff member sat next to him at meals to provide verbal cues and physical prompts to slow down. In the weeks before his death, staff members noticed that he was eating even more quickly and was stealing food, which suggested increased agitation. 

AT 7:00 AM, the Director of Nursing found the resident in the living room on his back with chewed up food next to him. The director of nursing called paramedics and performed CPR (cardio pulmonary resuscitation) until they arrived. Despite these measures, the resident died. The cause of death was asphyxiation caused by a sausage found lodged in his throat. It turns out that the resident had stolen a sausage wrap from the food that had been prepared for breakfast. A tray of food covered with foil was left on the kitchen counter. 

One of the direct service providers (DSP) even saw the resident walking out of the kitchen and noticed that the foil on the food had been disturbed. Even though the resident had no documented history of stealing food from the kitchen, he did have a history of stealing food from other residents. However, the facility personnel did not put together his presence near the kitchen, the disturbed food, and the history of stealing food. 

The facility’s assessment for the resident stated that he required 24-hour supervision including assistance with diet, portion control, and eating rate. The DSP who saw the resident coming from the kitchen admitted that it was not unusual to catch residents in the kitchen area. The DSP also stated that the resident had stolen food from the kitchen before but she failed to document this. 

The resident’s Individual Habilitation Plan states that the staff should report all issues of concern to their supervisor and/or the nurse. However, the DSP never reported seeing the resident stealing food from the kitchen. This failure resulted in the resident’s care plan not being updated to include measures to prevent him from stealing food, especially in light of his problems controlling how quickly he consumes food. The DSP also admitted that mornings at the facility were “hectic,” and the facility could benefit from additional staff. In addition, on the morning in question, the kitchen was left unsupervised even though there was food left out on the counter.

The facility’s failure to properly monitor the resident and update his care plan allowed him to steal food from the kitchen unsupervised and ultimately choke to death. Unfortunately, the fines assessed will do nothing to benefit this resident. However, hopefully, it will do something to change the behavior and procedures of the facility in the future in order to protect the other residents. 

Stories like this highlight the fact that there are problems with small nursing homes as well as large nursing homes. Even with fewer residents to care for, oversights and mistakes can occur, and these mistakes can be deadly. In this situation, Milestone-Elmwood East did not properly monitor and care for a young, 28 year-old resident. If you or a loved one have suffered injury at the hands of Milestone, Inc, you may be entitled to compensation. 

Sources:

Illinois Department of Public Health (IDPH); Milestone-Elmwood East

IDPH: Milestone-Elmwood East – 4^th Quarter Violations

IDPH: Nursing Homes in Illinois – Quarterly Report (October-December 2009)

Nursing Homes Abuse Blog: Failure to Follow Orders Results in Death of Patient & Hefty Fine

Nursing Homes Abuse Blog: Topic – Choking

Nursing Homes Abuse Blog: 42 Illinois Nursing Homes Cited in 4th Quarter of 2009 for Violations Related to Patient Care

I'm not sure if it's matter of inadequate staff training or simply a manifestation of inadequate staffing levels to meet patients needs, but the number if cases involving aspiration pneumonia is on the rise.

Aspiration pneumonia occurs when you aspirate foreign matter (usually food or vomit) into your lungs. Elderly adults are particularly susceptible to aspiration pneumonia because they are more likely to suffer from predisposing factors (including illness or disease that compromises the ability to swallow) or they might be too weak to cough, which can let foreign material enter the windpipe, allowing bacteria to enter the lungs. This can result in severe lung infections, which can require hospitalization, especially in older adults who are already weak because of age, illness, or disease.

Aspiration pneumonia can be caused by:

• stomach content entering your lungs after you throw up;
• a brain injury or other condition that affects your normal gag reflex;
• diseases such as ALS (amyotrophic lateral sclerosis), Parkinson’s disease or strokes, which can make swallowing difficult; or
• throwing up when passed out due to over-medication 

There are two types of aspiration pneumonia syndromes:

• Chemical pneumonia (CP) – aspiration of gastric acid
• Bacterial pneumonia (BP) – aspiration of bacteria from the mouth and throat
• Aspiration of gastric acid can cause acid burns when the stomach acid passes down the windpipe, which can leave lung tissue vulnerable to infection. 

Bacterial pneumonia occurs when a person suffers from an illness or condition that compromises their ability to cough or swallow (see causes above) and aspirates foreign material allowing bacteria to enter the lungs, resulting in infection. 

Chemical pneumonia usually has an acute onset, with symptoms occurring within a few minutes to two hours of the aspiration event. Symptoms include: respiratory distress, rapid breathing, wheezing, fever, and cough with pink or frothy sputum. Bacterial pneumonia, on the other hand, has a sub-acute onset, with symptoms occurring after a couple days to weeks after the aspiration event. Symptoms include: bad breath, putrid odor of sputum, fever, and weight loss. 

Aspiration pneumonia is a serious concern in the elderly. This is because swallowing is a complex activity, requiring coordinated opening and closing of the mouth and lips, chewing while inhaling and exhaling, mixing saliva with food, moving food to the back of the tongue, and having the swallow reflex send food down the esophagus. If any of these steps does not occur properly, you can be at risk of chocking, aspirating, or suffocating. 

The number of hospitalizations for aspiration pneumonia has been increasing, with the largest increase in the very old. From 1991 to 1996, the number of hospital discharges of Medicare patients, whose reason for admission was reported to be aspiration pneumonia, increased by 76% (while the number of elderly persons covered by Medicare grew by less than 7%). 

Nursing home staff must take care to closely monitor the food given to residents who have difficulty swallowing. Usually, thicker, colder liquids are easier to swallow. Thin liquids, including water, can be dangerous because they are difficult to control within the mouth. Straws can help a person swallow by limiting the amount of liquid that can be taken at a time and directing the liquid to the back of the mouth. 

Nursing home facilities can also craft special menus for people with difficulty swallowing so that the food resembles normal food, but still has a soft pureed consistency (for example, chicken cooked and pureed with thickening agent and molded into a chicken leg shape, meatloaf, and casseroles). However, this would require the facility to design different meals for some residents, which would require additional time and efforts, which not all facilities are willing to undertake. 

Nursing home staff should consult the doctor if a resident has difficulty swallowing. The physician might recommend that the resident be placed on a liquid or pureed diet or even use a feeding tube in severe situations. Many residents would probably prefer a diet of solid foods because it is more pleasurable to eat and does not insult their pride by basically having them eat baby food. 

Staff can also have residents who have difficulty swallowing do a “dry swallow” (swallow without any food or liquid in their mouth) after taking a bite of food. However, this requires expensive supervision, which isn’t always possible at crowded nursing homes, where several residents might need monitoring during mealtimes. 

Aspiration pneumonia can result in serious lung infections in elderly nursing home residents. Many of these residents already suffer from underlying illness or disease, which makes it more difficult for them to fight infection. Infections can be dangerous and often require hospitalization. Therefore, nursing home staff should take extra precautions to prevent aspiration pneumonia in order to maintain the best possible health of residents. 

Sources:

Huntington Disease: Swallowing, Coughing, Choking, & Aspiration Pneumonia

Respiratory Reviews: Is Aspiration Pneumonia Epidemic in Elderly Americans?

eMedicine: Pneumonia, Aspiration

Health Resources: Guidelines Aspiration Pneumonia

In times of need, locating necessary information regarding the legal rights and resources for nursing home patients can be difficult and imposing.  In this respect, we are proud to introduce a new resource for patients, families and practitioners looking for a concise compilation of information regarding nursing home laws.  Nursing Home Injury Laws, provides every states':

• Nursing Home Laws
• Medical Malpractice Laws
• State Resources
• Applicable State Code
• Common Nursing Home Injuries
• Glossary
• Recognized Books & Journals
• Nursing Home FAQ

Additionally, we will be posting regular updates regarding important developments relevant to nursing home care within each state.  Here is a link to Nursing Home Injury Laws.

The Exceptional Care nursing home is a small 55 bed nursing home located in Burbank, IL. According to the government’s Medicare website, the facility received only one out of five stars, which is a much below average rating. The facility received only two out of five stars for health inspections, which is a below average rating.

Exceptional Care is not living up to its name.  In the past year, the nursing home had five health deficiencies, which is three less than the average number of health deficiencies in Illinois and in the United States. This is down from the twelve health deficiencies in the previous year.

Every nursing home has an obligation to provide a safe and secure facility for its residents and to provide proper care and supervision to achieve and maintain the highest level of well-being for its residents. Nursing homes must meet the Requirements for States and Long Term Care Facilities outlined in 42 CFR Part 483.

According to survey reports, Exceptional Care received violations for failing to:

• Provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident
• Provide or arrange services that meet professional standards of quality

According to survey reports, the facility failed to provide an ongoing program of activities as required under federal law. Many nursing home residents have activity care plans to help treat conditions, especially depression.

Several residents with activity care plans calling for one-on-one programs or group activity were never taken out of their rooms to attend group activity. In addition, the facility did not have adequate activities scheduled on several afternoons. Furthermore, several planned activities never occurred, had very low attendance, or had no staff to resident interaction.

The survey also revealed that the services provided or arranged by the facility did not meet professional standards of quality. Nursing home staff failed to properly administer medications as ordered for several residents and failed to clarify orders to provide proper treatment for residents.

The facility also failed to ensure a medication error rate of less than 5%. During the survey, 45 medication opportunities were observed, with four medication errors, resulting in a medication error rate of 8.88% for four of fourteen residents observed. The facility also failed to ensure that residents are free of any significant medication errors when staff failed to administer an ordered anti-psychotic medication for two weeks to a resident suffering from Bipolar disorder resulting in disruptive behavior.

The facility also failed to thoroughly investigate unwitnessed and unknown injuries for a resident who was found with bruises on multiple areas of the body. Nursing home staff failed to conduct an investigation into the cause of the bruises.

Nursing homes are charged with providing the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of its residents. The facility failed to meet this requirement by failing to follow swallow precautions for a resident who was identified with a high risk of choking.

Exceptional Care received only one out of five stars for nursing home staffing. The facility has 37 total residents, compared to the national average of 94.7 and the Illinois average of 103.9. Each resident received 59 minutes of nursing home staff time per day, which is less than the Illinois average (1 hour 12 minutes) and less than the national average (1 hour 24 minutes).

This two-star rated facility has many deficiencies, which might be a troubling sign that nursing home residents might not be receiving the proper care and attention they need and deserve.

Sources:
Medicare website
IDPH website

Related:

When Bruises Can't Speak For Themselves: The Difficulty Proving Abuse Of Disabled Nursing Home Residents 

Who Should Manage Administration Of Medication?

Welcome To The Nursing Home. Let's Begin Our Assessment and Care Planning

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A nursing home cook and nursing assistant have been fired following the death of a 54-year-old schizophrenic patient at a California nursing home.  The incident took place at the Raintree Convalescent Hospital.  Despite the fact that Raintree documented the patient's swallowing problems and ordered all food to be sliced or pureed to accommodate his swallowing problems, the man was served whole meatballs.

According to a an investigation by the California Department of Public Health, the man stumbled out of his room, pale and unable to speak after he was served whole meatballs.  A nurses attempt to do the Heimlich maneuver on the man was unsuccessful and he was pronounced dead a short time later at an area hospital.

This is a case where the facility admits that its staff failed to follow standing orders with this patient.  According to Antonio Sandoval, assistant administrator at Raintree Convalescent Center, the cook and the nursing assistant ignored the residents care plan when they served whole meatballs to the man for lunch.  "Neither of them did their job." he said.

This incident resulted in an $80,000 fine against the facility.  Further, this reinforces Raintree's poor Medicare rating.  Raintree received just one out of five stars according the Federal nursing home rating system.

Related Nursing Homes Abuse Blog Posts

Nursing Home Resident Chokes To Death On Dinner

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

What Is It Like To Live In A 1-Starred Nursing Home?

The Centers for Medicare & Medicaid Services has fined The Crossings, a New York nursing home $13,300 for failing to provide emergency medical treatment to a choking resident.  The fine involves an October 15, 2007 incident where an 89-year-old woman was left unattended by a nurse as she ate her dinner.  

The nurse returned to the woman's room to find the woman with her mouth open, not breathing and here lips were blue.  The nurse failed to call a 'code blue' to the situation and woman died.  A 'code blue' alerts the nursing home staff to a dangerous situation and summons them to help with medical assistance.  Code blue's also instruct the nursing home staff to call 911.

An investigation into the incident demonstrated the nursing home staff lacked training on 'code blue' drills that resulted in potential harm to all residents of the facility.  Amazingly, this nursing home was not shut down immediately by nursing home inspectors.  

As we have discussed before in the Nursing Homes Abuse Blog, many of the errors made in nursing homes do not involve complicated medicine. Why a nursing home employee, or any person, for that matter would not pick up the phone to call 911 reaches far beyond an error into into criminal territory.  Read more about this situation involving nursing home abuse at a New York nursing home here.

A coroner determined that a 77-year-old nursing home resident choked to death on his dinner, according to an Australian newspaper. The victim suffered from advanced dementia necessitating assistance with meals. Investigators determined that the nursing home attendant assigned to supervise him left the man unattended as he was eating his dinner.

The link to the full article is here.

Choking injuries and asphyxiation are real dangers amongst the elderly. Many nursing home residents suffer from dementia, impaired judgment, difficulty swallowing, and problems chewing food. It is the responsibility of the nursing home staff to identify those who may be at risk for choking.

If a nursing home resident has difficulty swallowing, the nursing home staff should provide soft foods, cut all food into small pieces and make sure the resident is in an upright position while eating. Most importantly, the nursing home staff must carefully monitor residents during mealtimes to prevent choking. Choking incidents may result in injury, medical complications and even death.

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