Nursing Homes Abuse Blog - By Jonathan Rosenfeld

Any environmentalist coming into my office would likely cringe at the heaps of medical records that I've accumulated from various nursing homes and hospitals on cases that I'm working on.  

I've really got nothing against beautiful trees, but in order to properly review and prosecute cases, medical records remain an incredibly important piece of the puzzle in terms of evaluating cases.

After all, medical records are objectively comprised documents that reflects the care provided by staff and the patient's condition throughout their entire stay at the facility.  Right?  

A recent article in the Sacramento Bee, "Woman's death raises questions about nursing home medical records," identified an ongoing problem in the nursing home industry--- doctored medical records.  The article documents the consistent inconsistencies betwee in a patient's chart during a short-term admission at El Dorado Care Center (California), formerly part of Horizon Healthcare.

Specifically, the article referenced the negligent care and subsequent lawsuit relating to the care provided to Johnnie Esco.  Like most nursing home patients, Mrs. Esco was admitted to the nursing home in order to receive medical care for several medical problems including chronic constipation. 

After initiating a nursing home negligence lawsuit, the family learned that in addition to not receiving proper care, the facilities inaccurate charting likely exacerbated her decline and subsequent death.

When compared with notes compiled by family members, medical records from other facilities and testimony from staff at the facility, it was quickly revealed that nothing in Mrs. Esco's medical chart was really truthful.  Discovered problems included:

• Documented assessment that were never really completed
• Rote charting- where staff filled in boxes identically to the day prior
• Late entries to the records that dramatically changed original entries
• Missing physician orders
• Drastic inconsistencies 
• Fraud

What soon developed was a situation where in a mere 13 days, Mrs. Esco went from an ongoing grandmother and great-grandmother into a terminally ill woman.  It turned out, that the chronic-constipation that Mrs. Esco and her family were readily controlling at home went completely unchecked and untreated during her short-term stay at El Dorado Care Center.

By the time she was transferred to a nearby hospital, Mrs. Esco had become completely bedridden and unresponsive.  A bowel obstruction had left her stomach distended and painful.  The extent of the fecal impaction was so extensive that doctor's suggested that even with surgery her chances of living a quality life were minimal.  On March 7, 2008 Mrs. Esco died.

Doctored Medical Record

As a nursing home lawyer, I'm always amazed at how frequently I come across inaccurate and altered medical records. Particularly in cases where a facility knows that it 'screwed up' I find especially important to secure a set of medical records as soon as feasible in order to preserve the condition of the records.

Federal law imposes a duty on nursing homes to accurately maintain patient records.  Under Medicare requirements for long term care facilities, nursing facilities are required to maintain records on each resident in accordance with accepted professional standards and practice (42 CFR §483.75(l) or Tag F-514).

Pursuant to F-tag 514, nursing homes must do the following:

• Maintain complete medical charts for patients
• Accurately document treatment provided
• Make sure the records are easily accessible
• Organize patient charts

Related Nursing Homes Abuse Blog Entries:

Nursing Home Administrator Pleads Guilty To Fraud After Lying About Genuineness Of Patient's Signature

Nursing Home Settles Lawsuit After Fraudulent Records Discovered

Is It Time For Nursing Homes To Embrace Electronic Medical Records?

Admissions Suspended At An Emeritus Assisted Living Facility Following The Discovery Of: Medication Errors, Bed Sores & Falsified Medical Records

Documentation Wake-Up Call- How To Prevent Documentation Deficiencies (pdf) AUTHORS: MARY C. MALONE, ESQUIRE and MARY P. CHILES, RN, RAC-CT

Most of the time a family contacts my office, it is due to an incident involving abuse or ongoing neglect. Although perhaps less obvious, after we investigate many of the cases, the underlying problem may be a complex medical condition that may ultimately prove important in successfully prosecuting the matter.

Here are some of the medical conditions we have discussed over the past year:

Clostridium Difficile / C. Diff

Clostridium difficile (also called C. difficile or C. diff) associated disease (“CDAD”) is a bacterial infection that can cause diarrhea and serious intestinal conditions (such as colitis - inflammation of the colon). CDAD is responsible for about three million cases of diarrhea and colitis annually in the United States.

Stevens Johnson Syndrome

Stevens-Johnson Syndrome (“SJS”) is a systemic disorder that affects the skin and mucous membranes, usually caused by a severe drug reaction. SJS often begins with flu-like symptoms (fever, sore throat, cough, burning eyes), then progresses to red or purple rashes and blisters (photos), especially around the mouth, nose, eyes. These symptoms eventually lead to skin sloughing (the shedding of the top layer of skin) because of cell death. Some patients with extreme cases of SJS appear as though they were severely burned due to the extensive skin loss.

Legionnaires Disease

Legionnaires disease is an infectious disease caused by the Legionella bacteria. There are two types of Legionnaires disease: Legion fever (where people generally develop pneumonia) and Pontiac Fever (symptoms similar to the flu).

Legionnaires disease got its name when a group from the American Legion conference all developed pneumonia. When scientists analyzed the group, they noticed that they all had the same bacterium called Legionella.

Subdural Hematoma

A subdural hematoma is a type of intracranial bleeding (hemorrhage), caused by head injury. Subdural hematomas occur when blood vessels burst in the space between the brain and the outermost membrane that covers the brain (dura mater). The collection of blood forms a hematoma, which puts pressure on the brain tissue.

There are three types of subdural hematomas: acute, sub-acute, and chronic. Acute subdural hematomas are the most dangerous and are usually caused by a severe head injury. With sub-acute hematomas, the signs and symptoms take longer to appear (days or weeks). Chronic hematomas can be caused by less severe head injuries, and symptoms can take weeks to appear because of slower bleeding.

Hypotension

Hypotension (low blood pressure) is a problem for many nursing home residents, causing dizziness and fainting. Blood pressure readings measure the pressure in arteries - systolic pressure (the top number in a reading) measures the pressure the heart generates when pumping blood out to the rest of the body and diastolic pressure (the bottom number in a reading) measures the amount of pressure between heartbeats. A systolic blood pressure of 90 millimeters of mercury or less or a diastolic blood pressure of 60 millimeters of mercury or less is considered low.

Sepsis

'Sepsis' is a bacterial infection in the bloodstream or body tissues, frequently found in patients with severe bed sores. In order to make a diagnosis of sepsis, at least two of the following must occur: a heart rate above 90 beats per minute, hyperventilation (more than 20 breaths per minute) and white blood cell count below below 4000 cells/mm.

Frequently, people use the term sepsis to describe 'severe sepsis' and 'septic shock.' Severe sepsis is used to describe people who have organ dysfunction following a diagnosis of sepsis. People diagnosed with septic shock have sepsis with hypo-tension (abnormally low blood pressure).

Amyloidosis

Elderly nursing home residents, especially those suffering from other diseases such as bed sores, have a higher risk of developing amyloidosis, a disease which can damage various tissues and organs. This can cause dangerous complications in residents who are already weak from advanced age or underlying disease.

Amyloidosis is a group of diseases caused by abnormal deposits of amyloid protein (usually produced by cells in bone marrow) in the body’s tissues and organs. The disease frequently affects the heart, kidneys, liver, spleen, nervous system, and gastrointestinal tract. The amyloid protein can deposit in a localized area (localized amyloidosis) or affect tissues throughout the body (systemic amyloidosis). Amyloidosis is diagnosed for testing for the amyloid protein in a biopsy of involved tissue.

Impacted Bowel

An impacted bowel is the condition where feces are trapped in the lower part of the large intestine, causing a waste obstruction. The stool collects in the bowel and becomes hardened. This hard stool can irritate the rectum, resulting in the production of mucus and fluid which can leak, causing fecal incontinence.

One of the most common symptoms is lack of appetite, caused by pressure on the abdomen. Hemorrhoids (a mass of dilated veins in swollen tissue around the anus) are a common sign of impacted bowels because it is more difficult to rid your body of fecal matter. Other symptoms include: a constant feeling of fullness; diarrhea; hardened feces; cramping and pain; vomiting; constipation; bad breathe; and bloating. If left untreated, the waste obstruction can cause a rectal infection that can lead to sepsis or death.

In addition to monitoring food and liquid intake of nursing home patients, staff need to pay attention to the elimination of the wastes.   When urine and feces are not produced on a regular basis, nursing home staff must bring these problems to the attention of physicians.

One of the more obvious cases of nursing home neglect my office is working on involves a patient who went at least 10 days without a bowel movement.  Shift after shift of nursing home staff tended to our client-- yet no one cared enough to look at his medical chart to see when the last bowel movement occurred.  It was not until the man was taken to a local hospital, was it determined that the man's bowel had become impacted with feces.  Within 24-hours of his admission to the hospital, the man died from complications related to sepsis.

What is an impacted bowel?

An impacted bowel is the condition where feces are trapped in the lower part of the large intestine, causing a waste obstruction. The stool collects in the bowel and becomes hardened. This hard stool can irritate the rectum, resulting in the production of mucus and fluid which can leak, causing fecal incontinence. 

One of the most common symptoms is lack of appetite, caused by pressure on the abdomen. Hemorrhoids (a mass of dilated veins in swollen tissue around the anus) are a common sign of impacted bowels because it is more difficult to rid your body of fecal matter. Other symptoms include: a constant feeling of fullness; diarrhea; hardened feces; cramping and pain; vomiting; constipation; bad breathe; and bloating. If left untreated, the waste obstruction can cause a rectal infection that can lead to sepsis (also referred to as: severe sepsis, sepsis infection, septic shock, severe sepsis, septicemia) or death. 

The most common cause of impacted bowel symptoms is Crohn’s disease.  In a nursing home setting, causes of impacted bowel include: not drinking enough water; not eating a diet with adequate fiber; lack of activity; certain prescription medications and generally unhealthy diet with high fat and processed foods.

When timely identified, impacted bowels can be treated with a higher fiber diet, increased hydration, exercise, laxatives, enemas, suppositories, or manually removing the hardened feces.

Unfortunately, many nursing home patients are highly susceptible to impacted bowels due to a combination of inattentive staff and an unhealthy lifestyle.  In order to minimize the chances of impacted bowels among patients, nursing homes should:  

• Provide the residents with proper nutrition (sufficient fiber, water, and healthy foods), the residents can suffer from painful constipation. 
• Provide as much physical activity as feasible for patients.
• Monitor each patients bowel movements (time, quantity, consistency)  
• Pay special attention to patients complaining of stomach pain or cramping

Resources:

Article Click - Fecal Impaction vs. Constipation

The association of fecal impaction and urinary retention in elderly nursing home patients

Annals of Internal Medicine – Incontinence in the Nursing Home