Nursing Homes Abuse Blog - By Jonathan Rosenfeld

Recognizing that staff may lack training in certain areas essential to patient care, many nursing homes have begun to implement training programs at their facilities to help teach proper protocols-- and hopefully improve patient care.  While the training can be quite effective in terms of improving the satisfaction of patients and prevention of medical errors, no amount of training will suffice in order to prevent situations involving harm to patients stemming from a basic lack of common sense or carelessness.

I began thinking about how many common errors involving injuries to patients in nursing homes derive not from improper medical care-- but from an even more alarming situation--- when staff fail to utilize some of their basic sensible skills that they (hopefully) have accumulated over the course of their lives.  

After seeing a news blurb about the death of a patient at a California nursing home--- I truly wonder how some people not just obtained advanced degrees--- but made it past the fourth grade!

While I'm certain there are many, many, deaths at nursing homes every day, I strongly doubt that there many deaths as senseless as one involving the passing of an 81-year-old patient at Seton Medical Center who died from suffocation when a nurse tending to her left the cap on breathing tube that was placed into the woman's trachea.  

Following an investigation into the incident by the California Department of Public Health, the agency determined that at the time of the incident, the nursing home did not have a policy in effect for properly inserting the breathing tube--- commonly known as a 't-piece'. 

Policies are great when it comes to complex issues or discretionary acts, but remembering to remove the cap on a patient's breathing tube? Come on, if the staff member involved in this incident can't remember to remove the cap to a breathing tube, do we really want to given him / her another shot caring for disabled patients after they have had an opportunity to review a policy?

Related Nursing Homes Abuse Blog Entries:

What Good Is Medical Technology When It Is Not Used Properly?

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

Failure To Clean Trach Tube Leads To Lawsuit

Nursing Home With History Of Problems Now Faces Wrongful Death Lawsuit Related To Poor Care of Patient With Tracheostomy Tube

With all of the great strides we have seen in the field of medicine, one can only hope that patients in medical facilities are better off today than their peers were in the past.  However, as will all types of patient care, technologies have little use when not in the hands of properly trained and skilled workers.

A reminder of just how crucial staff training is to the patient care experience comes from the headlines in California when staff at Community Hospital of San Bernardino elected to disconnect an alarm on a ventilator needed by a patient with breathing difficulties.

According to a report from the California Department of Public Health, the California Nursing Home made multiple errors related to the death of the who requiring breathing assistance.  The investigation revealed that:

• An alarm on the ventilator machine used to detect abnormal readings was intentionally turned down by staff members, making the alarm inaudible
• The facility failed to train staff on how to care for ventilator patients
• Staff failed to check on the patient every four hours as required under the facilities protocols
• Even after staff noted a change in the patient's respiration rate, they failed to monitor any changes

The errors with respect to the care of this ventilator patient resulted in a AA citation and an $80,000 fine.  Read more about this incident at a California Nursing Home here.

Related Nursing Homes Abuse Blog Entries:

Nurse Facing Criminal Charges After Intentionally Neglecting Ventilator Patient

Elderly Patients Are At Higher Risk For Developing Aspiration Pneumonia When Facilities Fail To Account For Patient Needs

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

Perhaps Abiodun Oke should be shoveling asphalt or a similar occupation where a person's compassionate side is not necessarily crucial to the job?

On the other hand, as a licensed practical nurse (such as Mr. Oke)--- or really any profession responsible for caring for the elderly-- I would suggest have substantial dose of compassion as they are the ones who are responsible for providing the daily care necessary for some of the most fragile members of society.

The reason I suggest that Mr. Oke look for a more physical type of work is that he faces criminal charges relating to the neglect of an 81-year-old Pennsylvania nursing home patient.  In addition to suffering from dementia and pneumonia, the patient was also ventilator dependent.

Specifically, it is alleged that on August 13, 2009, Mr. Oke intentionally walked out of the room of a ventilator patient he was responsible for caring for and refused to re-attatched her ventilator tube.

The incident was reported to authorities and nursing home management by a respiratory therapist at the facility who witnessed the incident and stepped in to reattach the patient to the respirator.  When confronted by the respiratory therapist, Oke said, "I connected her twice, now I want to see her suffer" as the patient began to turn blue from the lack of oxygen.

In addition to the testimony from the respiratory therapist, prosecutors also have a video showing Mr. Oke in the hall of the facility.

Surely, criminal issues aside, the world would be better off without people like Mr. Oke responsible for providing hands-on care to such a vulnerable group.

Related:

Nursing Home Fined For Negligent Care Of Resident On Ventilator

Elderly Patients Are At Higher Risk For Developing Aspiration Pneumonia When Facilities Fail To Account For Patient Needs

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

Nurse charged with neglect, By Keith Phucas Times Herald, January 24, 2011

Nursing Home Injury Laws: Pennsylvania

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 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.

 Who really likes to think about sputum or mucus?  Well, Thomas Sharon, R.N. at legalnurseconsultanttom.com points out that sputum color is an important factor to look at when evaluating the quality of breathing tube care.  Breathing tubes such as tracheostomies and ventilators are a common medical medical conditions for nurisng home and long-term care residents.  

Obviously, these medical condions require ongoing nursing care which is beyond the common knowledge of many nursing home residents and their families.  As nurse Tom discusses in his recent post, nurses must reposition and clean the breathing tube in order to prevent infection and medical complications.  There are many preventable medical complications in respiratory patients that may be easily identified by a family member or friend with common sense.  

Nurse Tom points out that the color and consistency of the sputum is frequently indicative of the quality of nursing care and may be used to identify potiential medical complications such as infection or suffocation.  Futher, the breathing noises are important to pay attention to as well, as congested raspy breathing noises usually demand immediate nursing attention.  

Below is the chart from Nurse Tom's site, demonstrating how to identify respiratory problems from the color and consistency of secretions.