Nursing Homes Abuse Blog - By Jonathan Rosenfeld

The reported settlement of a nursing home negligence case in involving a medication mix-up caught my attention because of my perceived increase in the frequency with which medication errors are occurring at nursing homes across the country. 

Like many nursing home patients, the patient involved in this incident was a frail, elderly woman, who was dependent on the staff at the skilled nursing facility to provide her with the medications prescribed by her physician.

Also, similar to other errors involving nursing homes injuries-- such as deadful bed sores, the errors related to this incident are reflective of mistakes made by several employees providing care to the same patient. 

In this case, the original error was made by a pharmacy who mistakenly filled the physicians prescription with the wrong drug--- albeit similar in name. However, the error was then compounded when multiple nursing home employees administered the wrong medication to the patient over a course of 18 days.

Arguably, medication errors aside, the nursing home staff continued to provide inferior care when they failed to notice a rapid deterioration of the patient's strength. During the time that the wrong medication was administered, the woman lost a significant amount of weight and became visibly dehydrated.

Like other types of nursing home injuries, this medication error was not divulged until an autopsy was performed which indeed concluded that medication error contributed to existing kidney problems which eventually claimed the woman's life.

In response to a nursing home negligence lawsuit initiated by the deceased woman's family, both the nursing home and pharmacy involved in this sad course of events have agreed to contribute to a settlement.

My take:

As a lawyer who is regularly involved in the prosecution of nursing home negligence matters, I find episodes of injuries and deaths of patients resulting from compounded errors made by multiple staff members far too frequently.   Of course, the original pharmacy error is inexcusable as pharmacists have a duty to dispense proper medications.  However, the fact that different nursing home employees continued to administer the wrong medication over the span of 18 days is sickening--- particularly in light of the fact that the woman's body was obviously given indications that something was not right.

I truly hope the administration at this facility recognize the universal incompetence of their staff and implement a training program to help identify errors as their arise as opposed to simply paying out another settlement in the aftermath.

Related Nursing Homes Abuse Blog Entries:

Pharmacy Error Blamed For Death Of Nursing Home Patient After She Receives Incorrect Medication

'Significant Medication Errors' Discovered In Nursing Home Following Investigation Related To Patient Injury & Death

Wrongful Death Lawsuit Claims Nursing Home Negligently Administered Allergy Inducing Drugs To Patient

Who Should Manage Administration Of Medication?

Dehydration poses a major threat to the overall health of nursing home patients as the condition may exacerbate existing complications or cause other conditions to manifest themselves.  Dehydrated patients may be at risk for conditions such as kidney failure, low blood volume (hypovolemic shock), electrolyte imbalances, development of decubitus ulcers or death.

Consequently, nursing homes must appreciate the risk of patients becoming dehydrated and implement measures to ensure that patients remain well hydrated.  Depending on the person’s risk for dehydration, a nursing home may order fluid intake and output to be measured by staff either during a specific time period or over an extended period of time. 

Many nursing homes have adapted I & O monitoring for the following patient / conditions: tube feeding, catheterized patients, urinary tract infections, physician orders for increased / decreased fluids, patients receiving intravenous fluids or other medical conditions that put the patient at risk for fluid imbalance.

Commonly referred to as I and O, nursing home staff will monitor the amount of fluids a patient takes in compared with the amount of fluid a client puts out.  While it may be impossible to every form of fluid intake and output (such as fluid loss from perspiration or respiration) most measures of  I and O will simply measure the amount of fluid a patient drinks and voids by urinating, vomiting or through bowel movements.  If a patient received of artificial fluids in from feeding tubes, intravenous fluids and blood transfusions should be noted as well.

While the individual fluid needs of patients will vary depending on factors including their size, activity level and medication usage, most adults require approximately 2500 ml of fluids on a daily basis for their bodies to function optimally.  Staff should encourage patients to drink water and other fluids and keep them easily accessible so patients can access them easily. 

Rather than looking at fluid intake on a 24-hour basis, some nursing homes have broken patient fluid intake down by shift-related period to help staff more accurately measure if patients are receiving enough during more active parts of the day: ½ of total daily fluid goal, evening: 1/3 of total daily fluid goal and night: 1/6 of total daily fluid goal.

In addition to physically measuring fluid intake and output, nursing homes and other medical facilities should be aware of physical signs of dehydration in patients such as:

• Weight loss
• Dry skin
• Weak pulse
• Concentrated urine-  dark or foul smelling
• Loss of skin elasticity
• Cracked lips
• Sunken eyes

Related:

Jury Blames Manor Care Nursing Home For Dehydration Death Of Patient

The Burden and Outcomes Associated with Dehydration among US Elderly (pdf) American Journal of Public Health

Doctor Alleges Dehydration & Malnutrition In Nursing Home Lawsuit On Behalf Of Relative

DEHYDRATION IN THE ELDERLY- A SHORT REVIEW (pdf) JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 79, NO. 10, 1987

As is we need another statistic to confirm the extensive problems facing nursing home patients, here's some more fuel to add to the fire-- 35% to 85% of nursing home patients suffer from malnourishment according to a study published in Commonwealth Fund.

In response to this epidemic, an international group of nutrition experts has released new definitions to help medical professionals better equip themselves to identify and treat malnutrition.

According to the new guidelines, adult malnutrition can now be classified in one of three categories:

• Starvation-related
• Chronic disease-related
• Acute disease / injury-related.

The new guidelines were assembled in conjunction with input from the ESPEN (the European Society for Clinical Nutrition and Metabolism) and the American Society for Parenteral and Enteral Nutrition (ASPEN). The new definitions are being dually published in the journals Clinical Nutrition and JPEN, the official journals of ESPEN and ASPEN.

As a nursing home lawyer, I tend to see many cases involving the development of decubitus ulcers, urinary tract infections and other chronic medical problems trace their origins to situations involving malnutrition and dehydration over an extended period at a nursing home. 

Consequently, when evaluating most nursing home negligence cases, I always address the nutrition assessments in conjunction with nurses notes to see if there is a potential malnutrition component to the case as well.

Related Nursing Homes Abuse Blog Entries:

Doctor Alleges Dehydration & Malnutrition In Nursing Home Lawsuit On Behalf Of Relative

Dehydration & The Development Of Bed Sores In Nursing Home And Hospital Patients

Inadequate Nutrition & The Development Of Bed Sores In Nursing Home Patients

Grim Details Emerge Regarding Malnutrition In Kentucky Nursing Home

The California Department of Health has rendered its most severe citation (AA) and a $80,000 fine following an investigation into the death of an 86-year-old woman at Walnut Whitney Care Center (California).  An investigation determined that the woman was admitted to the facility in March, 2008 for medical care related to injuries she sustained in a fall.

Just five weeks after her initial admission, the woman was transferred to a hospital emergency room where she diagnosed as having septic shock.  Less than 24-hours after her hospital admission she died from resulting complications.

Specifically, the investigation determined that the nursing home failed to:

• Monitor the woman for developing a urinary tract infection
• Monitor the patient for dehydration
• Provide necessary fluids

Walnut Whitney is owned by Horizon West Healthcare.  Earlier this year, a jury awarded the family of a deceased nursing home patient $29.1 million in lawsuit premised upon elder abuse.

Related:

State levies fine $80,000 fine in Carmichael nursing home death The Modesto Bee November 20, 2010

Nursing Home Injury Laws: California

Nursing Home Abuse: Workers' Prank In Applying Grease To Dementia Patients In California Results In Criminal Charges

Failure To Follow Supervisory Guidelines Results In Substantial Fine For California Facility

Untreated Urinary Tract Infections In Nursing Home Patients May Result In Urosepsis

Some of my angriest clients contact me after a loved one was transferred from a nursing home to another nursing home or hospital only to learn of serious medical problems their loved one likely acquired during their original admission.  

Of course, breaking disappointing news is difficult for anyone to do.  Yet, in the case of nursing homes-- this is something they simply are required to do under the law.  Similarly, nursing homes must notify the patients doctor if their condition deteriorates.

I see many cases where there is no doubt an intention on the part of the original facility to cover up change in condition-- but also injuries related to situations involving improper care.

This situation of a dangerous condition being discovered only after the patient was transferred to a hospital was highlighted in a recent lawsuit filed against an Illinois Nursing Home, Alhambra Care Center.  Part of the lawsuit alleges that the patient lived that the nursing home with multiple health problems, but the staff at the facility failed to notify the family of the conditions including:

• Stage III decubitus ulcer
• Multiple stage I and II decubitus ulcers on the patients feet
• Dehydration
• Urinary tract infection

None of the conditions were disclosed to the family until after the patient was admitted to a local hospital.  

In cases such as these-- perhaps more alarming than not notifying the patients family as the various problems their loved one has developed-- is the fact that the facility allowed the conditions to develop in the first place.  My guess is that the facility was so ashamed of the condition they allowed their patient to get into that they failed to document the conditions during the patients stay at the facility either.

Some of these situations may give way to a claim against the nursing home where the condition developed.  In addition to contacting an attorney to discuss your legal options, you should give serious consideration to locating another facility for your loved one following their discharge from the hospital.

Related:

Dehydration & The Development Of Bed Sores In Nursing Home And Hospital Patients

Untreated Urinary Tract Infections In Nursing Home Patients May Result In Urosepsis

Why do nursing homes describe pressure sores according to 'stages'?

Are bed sores on the heels common? Bed Sore FAQ

Next week attorney David Terry and I will be exchanging blog-posts on perhaps the most common-- yet under-appreciated medical condition effecting patients in nursing homes and hospital-- Bed Sores.

Used interchangeably with the terms: pressure sore, pressure ulcer or decubitus ulcer, most people have little appreciation of the real devastation that bed sores cause until they see one first hand. Few medical conditions are as graphically disturbing as an advanced bed sore on a human being.

To assist medical professionals in the assessment and treatment of wounds, a standardized 'staging system' has been developed. 

• Stage 1- Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In blacks, Hispanics and other people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved.

• Stage 2- At this point, some skin loss has already occurred — either in the epidermis, the outermost layer of skin, in the dermis, the skin’s deeper layer, or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, stage II sores usually heal fairly quickly.

• Stage 3- By the time a pressure ulcer reaches this stage, it has extended through all the skin layers down to the muscle, damaging or destroying the affected tissue and creating a deep, crater-like wound.

• Stage 4- In the most serious and advanced stage, a large-scale loss of skin occurs, along with damage to muscle, bone, and even supporting structures such as tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections. If you use a wheelchair, you’re most likely to develop a pressure sore on: Your tailbone or buttocks Your shoulder blades and spine The backs of your arms and legs where they rest against the chair When you’re bed-bound, pressure sores can occur in any of these areas: The back or sides of your head The rims of your ears Your shoulders or shoulder blades Your hip bones, lower back or tailbone The backs or sides of your knees, heels, ankles and toes.

• Unstageable- Is a term that generally refers to an extremely advanced wound where there is involvement of skin, muscle and bone.

Though commonly associated with the elderly, a bed sore can develop in patients of any age who are not properly cared for.  Put simply, bed sores are not a normal part of the aging process nor are they an inevitable part of life for patients in a long-term care setting.

Unlike many medical conditions that benefit from technological advances with respect to their prevention, bed sore prevention is low-tech and labor-intensive.  To minimize the development of bed sores, medical facility staff must pay attention to patient needs, utilize patience when caring for the patient and remain diligent when implementing care.  David and I will focus our attention on the most common contributing factors to the development of bed sores:

• Dehydration
• Nutrition
• Lack of pressure relieving devices
• Turning and repositioning of patients
• Contractures
• Incontinence / cleanliness

I look forward to this exchange and particularly to David's insights on these topics.  Follow our exchange on my Nursing Homes Abuse Blog or on David's Terry Law Firm Nursing Home Abuse Blog.

By the looks of many nursing home patients' physical appearance, you'd think they were living in the desert.  Rather than a weakened appearance due to trekking through the Sahara, most of these patients suffer the effects of dehydration due to improper care and general neglect. 

Dehydration occurs when the amount of water leaving the body is greater than the amount of water taken in. Water is routinely lost when a person breathes, sweats, urinates or has a bowel movement and as humidified air leaves the body. 

Dehydration is caused by too much water being lost, not enough water being taken in, or a combination of the two. Inadequate water consumption can be caused by an inability to drink fluids, which can be caused by a lack of strength to drink adequate amounts. The following can account for fluid loss:

• Diarrhea
• Vomiting
• Sweat
• Diabetes (elevated blood sugar levels cause sugar to spill into the urine with water following, causing frequent urination, which in turn can cause significant dehydration)
• Drainage from wounds and pressure sores

Common signs of dehydration are thirst (to increase water intake) and more concentrated urine (more yellow in color). The following symptoms might also occur:

• Dry mouth
• Fatigue
• Decreased urine output
• Few or no tears
• Body stops sweating
• Muscle weakness
• Electrolyte imbalances
• Muscle cramps
• Nausea and vomiting
• Heart palpitations
• Light-headedness

Severe dehydration can cause confusion and weakness, and if left untreated, even coma and organ failure. 

The main treatment for dehydration is fluid replacement. This can be accomplished by replacing fluids by mouth or intravenous fluid (IV). As treatment occurs, urine output increases. 

Complications of dehydration may occur either because of the dehydration or because of underlying disease or situations. Dehydration can cause kidney failure; although, if treated early, it is often reversible. 

Electrolyte abnormalities may occur as important chemicals (sodium and potassium) are lost through sweat, vomiting, or diarrhea. Seizures can occur when the electrical discharges in the brain become disorganized.   

Hypotension (drop in blood pressure) can also occur, causing a patient to go into hypovolemic shock (insufficient blood flow through the body resulting in inadequate oxygen reaching tissues). A decreased blood supply to the brain can also cause coma, and if enough organs malfunction, death can occur.  

Older adults, people with chronic illnesses, and young children are most at risk for dehydration. As people age, the body’s ability to conserve water is reduced, the thirst sense becomes less acute, and persons become less able to respond to changes in temperature. Also, thirst is not a reliable gauge of the body’s need for water, especially for elderly persons. 

In older adults, the region of the brain that predicts how much water a person needs (the mid cingulated cortex) can malfunction, which helps explain why the elderly are more at risk for dehydration. In Chicago’s 1995 heat wave, more than 600 people died in their homes due to heat exposure. It is important that elderly persons be checked on during periods of high heat to ensure proper hydration. 

Dehydration can be easily prevented through proper hydration. However, some nursing home patients might be unable to drink adequate amounts of fluid because of forgetfulness, or illness. In addition, many nursing home residents suffer from diabetes, which is an increased risk factor for dehydration. Therefore, it is important that nursing home staff monitor residents to ensure proper hydration and urine output (dark yellow urine usually signals dehydration) in order to prevent serious complications caused by dehydration. 

Proper nutrition and proper hydration are essential elements of maintaining the highest possible health and well-being of nursing home residents. As discussed above, elderly nursing home residents are particularly susceptible to dehydration. The danger of pressure sores adds a further complication for nursing home residents at risk for dehydration. 

Dehydration is a risk factor for the actual development of pressure ulcers because dehydration can reduce blood volume, thus interrupting circulation and blood supply to the extremities. Maintaining tissue health is an important feature in pressure sore prevention; this includes proper nutrition and hydration, pressure relief and management, incontinence management, and wound care. In addition, the pressure sores can also be a major source of fluid loss as the sores drain, causing further dehydration. 

Therefore, nutritional intervention is an important element of pressure sore prevention and treatment. Nursing home staff must properly assess the resident’s nutritional needs, monitor the resident’s food and fluid intake, and make changes to the nutrition plan as changes in the resident’s health occur. Early intervention is important when a resident is not eating or drinking enough in order to prevent further health complications such as malnutrition, dehydration, and pressure sores. 

Resources:

Science Daily – Brain Malfunction Explains Dehydration in Elderly

Pressure Ulcer Management: The Importance of Nutrition

Dehydration Death Costs Nursing Home $6.5M

Autopsies May Help Families Determine If Their Loved One Was A Victim Of Nursing Home Neglect Or Abuse

Deciding whether to have an autopsy performed on a loved one is indeed a very personal decision for a family to make following a death.  

An autopsy can help a family get answers to not only the cause of death, and in the case of potential nursing home negligence, what-- if any, errors may have been made by a medical facility that may have caused the death.

After reading this news article about how a disabled nursing home patient may have 'choked to death' on his lunch I was reminded by how valuable autopsies can be where a death may occur in a nursing home or hospital setting that is insulated from the public.

What is an autopsy?

An autopsy is a detailed medical examination of the person's body and organs following death to establish the specific cause.  Autopsies are performed by a physician, a pathologist, who is trained to evaluate results from physical examinations and laboratory results from tissue and blood samples to determine the cause of death.

Once the examination and laboratory results have been evaluated, an autopsy report is rendered. The report notes the physical findings and states a cause(s) of death.  Because the report is rendered from an impartial author, it can be particularly useful in a litigation setting.  Similarly, just a the report may be useful in case against a nursing home or hospital, results may also absolve the facility of responsibility if the results do not substantiate poor care. 

In order to secure the most accurate results, most pathologists suggest performing an autopsy 24 to 48-hours after the death of a person.  Depending on where the death occurred  and the circumstances surrounding it, the autopsy may be performed by the state medical examiner or by a physician at a private hospital.

Is an autopsy called for in cases where nursing home neglect may have occurred?

In my opinion, particularly in cases involving the elderly, autopsies can be extremely helpful in rebutting arguments made by facilities who may argue that a death was the result of 'old age' or due to a 'variety complicated medical factors'.

Autopsies can be particularly helpful in the following wrongful death matters:

• Bed sores (also referred to as: decubitus ulcers, pressure sores or pressure ulcers)
• Malnutrition
• Dehydration
• Medication errors / overdoses
• Medical errors
• Falls with accompanying subdural hematoma

If you wish to have an autopsy performed on a loved one, you should contact your coroner or local hospital to get information about facilities that can perform one at your request.

Related Nursing Homes Abuse Blog Entries

Autopsy Confirms Man Was Murdered In Chicago Nursing Home

Medical Examiner Rules Tennessee Nursing Home Death A Homicide

Grandson Alleges Poor Nursing Care Results In Bed Sores "You Could Stick Your Fist" In

Bed Sore FAQ: Wrongful Death

Sometimes I'm amazed by the number of preventable situations that develop in nursing homes due to a facilities failure to provide basic care.  I mean, doesn't it seem obvious that facilities must provide food, water and a decent environment for their residents?  Am I oversimplifying nursing home care?  Perhaps, but the reality is that an overwhelming majority of nursing home injuries and deaths could be avoided if the facility were to provide this basic level of care.

The Columbus Dispatch reported on this type of preventable situation when it reported on the dehydration death of 61-year-old Peter Southard.  In 2005 Southard was admitted to Whetstone Gardens & Care Center in Columbus, Ohio for short-term nursing care to give his wife a break from her care-giving responsibilities.  Mrs. Southard was the primary caregiver for her husband since he suffered a stroke more than 20 years ago.  The stroke made it physically difficult for Southard to care for himself and realize when he was thirsty.  Unfortunately, the staff at Whetstone Gardens was unable to pick up on his special needs and he died shortly after his 15 day admission to the facility.  The cause of death was dehydration and kidney failure.

Southard's wife brought a wrongful death lawsuit against Whestone due to their failure to provide sufficient liquids to her husband.  Despite claims from the nursing home that the care they provided was sufficient and that Southard died due to dehydration from diarrhea, a jury recognized the facilities failure to provide basic care to this disabled man.  The Franklin County, Ohio jury awarded $500,000 for pain and suffering and $6 million to the wife and family for loss of society.

Dehydration Of Nursing Home Residents

Two out of five nursing home residents suffer from some form of dehydration.  Dehydration in nursing home residents can occur for a variety of reasons, including: diarrhea, the effects of medication, inability to perceive thirst, physical inability to drink or swallow and embarrassment related to incontinence.  Most of the the time, a resident's dehydration is due to inadequate care.  Common situations involving dehydration include:

• Failure of the nursing home to employ adequate staff, which results in the staff's inability to properly feed the residents
• Failure of the staff members to pay adequate attention to those residents needing assistance with eating
• Failure to properly educate the staff on nutrition and feeding methods
• Failure to provide proper supervision over those who provide nutritional services 

In addition to monitoring resident's intake of fluid, staff should be on the lookout for the following signs of dehydration:

• Dark yellow urine
• Sunken eyes
• Ashen skin
• Dry skin
• Bleeding gums
• Urinary tract infection
• Weight loss

Is it really too much to ask that nursing homes provide necessities such as water to their residents.  I guess that is what the Whetstone Gardens and Care Center is asking themselves now.

Related Nursing Homes Abuse Blog Posts

Medical Examiner Rules Tennessee Nursing Home Death A Homicide

Grim Details Emerge Regarding Malnutrition In Kentucky Nursing Home

We All Need Water

Dehydration is a common problem amongst nursing home residents.  Dehydration occurs when you do not drink adequate fluids or you lose fluids due to: sweating, vomiting or diarrhea.  If an elderly person becomes dehydrated they are susceptible to cramps, organ malfunction, pressure sores and even death.

Older people are particularly susceptible to dehydration because many elderly have the following conditions:

• Decreased thirst
• Kidneys that do not work well
• Choose to avoid liquids because of incontinence
• Have difficulty holding a glass
• Pain urinating
• Take medications decreasing urine output
• Inability to regulate body temperature
• Diabetes
• Inability to communicate

Signs of dehydration include:

• Dark yellow urine
• Sunken eyes
• Ashen skin
• Dry skin
• Bleeding gums
• Urinary tract infection
• Weight loss

It is the nursing home's responsibility to properly hydrate all residents.  Nursing home staff should monitor the amount of fluids consumed by each resident on a daily basis.  If a nursing home allows a resident to become dehydrated they are guilty of nursing home neglect.