Nursing Homes Abuse Blog - By Jonathan Rosenfeld

A Connecticut nursing home has been cited by the Department of Health for discontinuing a dietary supplement without first consulting any doctors, dieticians or nurses.  The abrupt discontinuation is believed to be responsible for a sizable-- 11% weight loss in a patient at South Windsor Rehabilitation and Nursing Center.  When at the facility, state inspectors discovered another patient with a similarly drastic weight loss--- losing 22 pounds over the course of three months at the facility.

Incidentally, serious money troubles have plagued South Windsor over the past year and according to new reports the nursing home is now in receivership.  

As a nursing home lawyer who sees many facilities focused on their bottom lines at the expense of patient care, I find these reports to be completely disgusting.  My guess is that at some point an administrator at the facility elected to stop providing the dietary supplement as a cost cutting measure.

Thankfully, this incident was hopefully identified and remedied before either patient suffered any serious injury.  Nonetheless, when facilities unilaterally elect to change physician's orders they may be exposing themselves to liability in situations where the orders are not followed over extended periods and serious injuries insure.

Related:

Nursing Home Cited After patients Suffer Weight Loss, November 23, Courant.com

More Time Must Be Spent Feeding Alzheimer's Patients

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

Grim Details Emerge Regarding Malnutrition In Kentucky Nursing Home

A Kentucky jury is hearing evidence in wrongful death lawsuit against a nursing home that allegedly failed to provide sufficient nutrition and fluids which in turn contributed to her death. 

The lawsuit was initiated by a physician who is a relative of the deceased patient.  According to information contained in the lawsuit and remarks made by attorney’s during opening statements, the woman was admitted to Woodland Oaks from May 24, 2003 to June 30, 2003 for rehabilitation from a recent hip fracture. 

It was during her admission that staff failed to provide proper care and allowed her to become dehydration and malnourished. As a result of the dehydration and malnutrition, the woman developed a severe urinary tract infection amongst other medical problems that lead to her death on August 3, 2003.

Lawyers representing the woman’s estate were quick to identify facts that supported their allegation such as:

• The woman received only 600-700 cc of fluids per day despite an order for 1,770cc
• The woman’s weight dropped from 132 pounds to 116 pounds during her admission
• The nursing home identified the woman as having ‘fair’ potential to make significant improvement

Not surprisingly, lawyers representing the nursing home are quick to portray the woman was an elderly person who had a lot of medical problems and her complications were basically a manifestation of the inevitable.

Confused as to which story to believe?

So are other people.  This same case was tried on two prior occasions that resulted in mistrials.  As the jury hears the evidence in this trial they will be forced to decide if they should any--- or a portion of the $12 million sought by the the woman’s family.

Not surprisingly, these contrasting versions of events and patient quality of life arise in most nursing home negligence lawsuits.  While persuasive lawyers may be effective in presenting the evidence, many trials also utilize the expertise of retained experts to assist the jury in understanding some of the relatively complex medical issues that arise.

Of course the type of expert needs to be tailored to the specific type of case, but as a nursing home lawyer I frequently use the following experts on my cases:

• Orthopedic surgeons
• Nurses
• Geriatricians
• Infectious disease experts
• Economists
• Physiatrists
• Forensic accountants

Related:

Attorneys dispute care given to patient, Ironton Tribune December 1, 2010

Seems Like Common Sense, Yet Many Medical Facilities Continue To Ignore Patients Daily Hydration Needs

Meals: Nutrition vs. Neglect

Dehydration Death Costs Nursing Home $6.5M

Sad but true, many nursing home patients are suffering from malnutrition.  While we often associate malnutrition amongst the homeless or people living in a third-world country, some studies suggest that between 35% and 85% of nursing home patients are malnourished.

As attorney David Terry points out in his blog post, "How Does Poor Nutrition Affect the Development of Bed Sores in Nursing Homes?" the rampant malnutrition can be associated with an increased risk of developing bed sores.

Poor nutrition results in a deterioration of body functioning.  Over extended period of time, patients without adequate nutrition tend to have organs that begin to fail and critical body functions begin to deteriorate and lose effectiveness.

As the largest organ of the body, your skin is one of the first places where the consequences of inadequate nutrition may be visible.  Malnutrition can result in the deminished effectiveness of the skin's natural resiliance to pressure and other factions that contribute to the development of bed sores (similarly described as pressure sores, pressure ulcers, or decubitus ulcers).

In addition to malnutritions reduction in the effectiveness in the skins natural resilancy, malnourishment of nursing home patients may also lead to other medical problems that contribute to the development of bed sores:

Reduction in Energy Levels: Malnourished people have less energy and consequently are unable to move on their own– resulting in a more time spent in one position.

Reduction in the bodies natural cushioning: A long-term consequence of malnourishment is loss of fat, muscle and tissue– that provide necessary padding particularly in bed-bound patients, the less padding the more pressure that is put directly on the body– thereby resulting in increased rate of bed sores.

Inadequate Nutrition & Hinderance of The Bodies Natural Healing Properties

David makes a great point regarding the important role nutrition plays in not just bed sore prevention, but also healing bed sores.  One of the most overlooked aspects of bed sore treatment is assuring that facilities provide additional calories and protiien for patients with advanced bed sores.

A nutritional consultation should be brought in for patients with open wounds (stage 3 or 4 bed sores) so the specific nutritional needs can be tailored to the patient need. 

Caregiver tip:

As family and caregivers it is important to recognize the severity of the medical complications that accompany malnutrtion.  As with many medical conditions, it is far easier to prevent malnutrition than to teat the accompanying medical complications that tend to develop over time.

Caregivers should be on the lookout for the following: 

• Look out for physical signs of malnutrition: diarrhea, disorientation, drastic weight loss, reduced urine output or cracking skin
• Request a speech tharapist consult if your patient has difficulty swallowing 
• For bed bound patients, make sure meals are within reach of the patient and there is staff present to assist
• Ask about nutritional supplements for patients who are weak or have exhisting bed sores

Related Bed Sore FAQ's:

Can malnutrition cause bed sores?

Are the development of bed sores during a nursing home admission an indication of nursing home neglect?

Extra Calories Essential For Pressure Sore Patients To Heal Wounds

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

A nutritious, balanced, and appetizing diet is important for all nursing home residents.  But it becomes essential for those suffering from pressure sores.  This is because a person with pressure sores needs to consume more calories per day that their healthy counterparts. 

Facilities need to calculate each patient’s total energy expenditure (TEE) in order to meet their nutritional needs.  TEE is composed of three components:

• basal metabolism, that is the number of calories needed to maintain a body at rest, which depends on age, sex, and body size;
• voluntary activity such as exercise; and
• energy expended to consume and metabolize food.

In times of injuries and stress, a body’s metabolic rate may increase, which in turn requires additional calories to compensate.  The extra calories provide the energy for the body to react to the stress of injuries and heal wounds.  So, while a normal person may need only 25-30 kcals per kilogram per day, a person with moderate illness or injury needs 30-35 kcals/kg, and a person with critical injury or illness needs 35-40 kcals/kg.  

Proper treatment for pressure sores must involve an assessment by a qualified dietitian who can figure out how many calories the patient should be consuming in order to heal and the best way to help the patient get the necessary calories from a balanced and appetizing diet.

Many facilities overlook, this crucial component to healing pressure sores.  Using the above nutritional guidelines, patients with advanced pressure sores would require the following daily caloric intake:

• 100 lbs.: 1,587 - 1814 daily caloric intake
• 150 lbs.: 2,381 - 2,721 daily caloric intake
• 200 lbs.: 3,175 - 3,628 daily caloric intake

In most cases, facilities must provide additional snack and nutritional supplements in order for patients to achieve this level of calorie intake.  If facilities fail to provide adequate levels of nutrition, the pressure sores are like to to advance and additional complications may develop.

Source: Nancy Collins, PhD, Rd, LD/N, FAPWCA, Why Calories Count: Proper Nutrition Fuels the Wound Healing Process.

California nursing home regulators have fined El Dorado Care Center $21,000 for violations that led to the death of 86-year-old resident Donald Forseth.  In 2006, Mr. Forseth died within four months of his admission to this nursing home from complications related to dehydration. 

A complaint was filed against El Dorado Care Center by Foundation Aiding the Elderly, a patient advocacy group shortly after Mr. Forseth's death.  Almost two years after the report of nursing home neglect was made, the state Department of Health Services found that the facility failed to monitor the man's fluid intake, which led to severe dehydration, kidney failure and death. It also faulted the center for staffing deficiencies and other problems.

According to Carole Herman, president of Foundation Aiding the Elderly, "It took them almost two years to adjudicate this case," Herman said. "That is ridiculous and unacceptable.  The state is not doing its mandated monitoring of nursing homes in a timely manner, which causes many more abuses to occur."

During the course of the state investigation Herman said that Forseth's widow, Patricia, received a settlement from the civil case against El Dorado Care Center in the.  Read more about this incident involving dehydration here.

Dehydration is a common problem amongst elderly in nursing homes.  Elderly are susceptible to dehydration for several reasons including:

• Failure to detect thirst
• Inability to control body temperature
• Embarrassment over using the toilet
• Medications that act as diuretics

It is the responsibility of the nursing home to ensure that residents remain properly hydrated.  Most situations involving dehydration are preventable with simple monitoring of fluid intake.  If the facility fails to monitor fluid intake and dehydration ensues, they are responsible for nursing home neglect.

Related:

Nursing Home Injury Laws: California

Today my office was contacted a Chicago-area woman whose mother lost 30 pounds within three months of her admission to a nursing home.  She explained how her 87 year old mother suffered from dementia and needed assistance with most daily living activities including help with meals.  The woman went on to explain that the entire reason she brought her mother to the facility was because she was assured that the facility was capable of meeting her daily nutritional needs.

The case above illustrates a common problem at many nursing homes and long-term care facilities--the neglect of residents.  Neglect related to the nutritional needs of nursing home residents is perhaps one of the more dramatic areas of neglect.

A drastic weight loss or gain can be indicative of poor care.  This article from the FDA discuses the nutritional problems encountered by many elderly.  Paul Kerschner, vice president of the National Council on Aging discusses how "seniors tend to be at a disproportionate risk of poor nutrition that can adversely affect their health."  Kerschner estimates that 15 to 50% of the elderly population are affected by poor nutrition.

Poor nutrition typically plays a role in most injury related nursing home maladies such as: bedsores, falls, decline in cognitive function, and an overall decline in quality of life.