South Carolina Nursing Home Blog

South Carolina Nursing Home Blog

Nursing Home Information & Litigation

Staffing at 4.1 hours of nursing care per day per patient

Posted in Staffing

Illinois Citizens for Better Care  is a group dedicated to Improving the quality of life of Illinois long-term care residents.  They recently published the below are their website.

Both the federal government and Illinois require that nursing homes have enough staff to meet the needs of their residents.  The federal government does not enforce a minimum number for how much nursing staff a nursing home must have.  It does recommend that each resident who needs skilled care get at least 4.1 hours of nursing care every day, including 1.2 hours  (72 minutes) by a licensed nurse.  The federal government recommends that 45 minutes of the  1.2 hours be care by a registered nurse. In addition to the general requirement that nursing homes have enough staff to meet their residents’ needs, Illinois has always had an actual number for minimum nursing staff.  The 2010 Illinois nursing home reform law is increasing the minimum number; by January 1, 2014, it is scheduled to be one-and-a-half times what it was when the law was passed.

As of January 1, 2013, Illinois requires that a nursing home have enough staff to give each resident needing skilled care at least 3.4 hours of nursing care, including at least 51 minutes of licensed nurse care.  At least 21 minutes of the licensed nurse time must be care by a registered nurse.  For residents needing intermediate care, the numbers as of January 1, 2013, are 2.3 hours total nursing care, including at least 34 minutes licensed nurse time (14 minutes registered nurse time.)

Minimum staffing is scheduled to increase on January 1, 2014. The final numbers are supposed to be 3.8 hours total nursing time for residents needing skilled care, including 57 minutes licensed nurse time (23 minutes registered nurse time.)  For residents needing intermediate care, the numbers are scheduled to be 2.5 hours total time, 38 minutes total nursing time, (15 minutes registered nurse time.) The nursing staff counted in these numbers includes registered nurses, licensed practical nurses, and certified nursing assistants.  Under some circumstances, therapists and therapy aides may also be counted.  Other staff may be counted for residents who have a diagnosis of a serious mental illness.

Nursing homes are supposed to count as direct care staff, only people who are actually taking care of residents. They are not allowed to count time scheduled for breaks or training. You can see the staffing rule here. 

Nursing homes are required to post publicly, the names and job titles of the nursing staff working each shift.  Because nursing homes do not publicly post how many “skilled” and “intermediate” residents they have on each floor or unit, most of the time it will not be possible to tell automatically if the nursing home is meeting its minimum staffing requirements.  (If a unit obviously has all skilled residents – say,  on ventilators or oxygen – it is easier for an outsider to do a count.)  You can get some idea, however, from the staffing numbers that are posted, and – if you visit during different shifts – from talking to the staff as well as doing a head count.

All employees who examine or care for residents, are required to wear an identification badge with their first name, licensure status (if any,) and their job title or position. Regardless of the numbers, nursing homes are still required to meet their residents’ needs, even if this means they need more staff than the minimum numbers.

Video Footage Shows Neglect

Posted in Abuse and Neglect, Staffing

The Buffalo News reported that two employees of Erie County Medical Center’s skilled nursing facility were arrested following an investigation into their treatment of a nursing home resident.  The investigation relied on a hidden camera placed in the patient’s room and revealed an alleged pattern of neglect. Video footage appears to show that Donna Laury, 48, and Nakeia Green, 35, both certified nurse’s aides from Buffalo, violated the resident’s personal care plan by failing to use two people when performing incontinence care and failing to use a mechanical lift to transfer the resident. When the aides did use a mechanical lift, they failed to use two people to operate it. The aides then allegedly falsified documents in an effort to conceal their neglect.  The incidents took place in December 2012 in ECMC’s Skilled Nursing Facility, located in the hospital.

The victim was identified as a 79-year-old resident who suffers from Alzheimer’s disease and dementia. She is non-ambulatory and totally dependent on nursing staff of the facility for her care.  The aides were charged with felony counts of falsifying business records in the first degree and misdemeanor counts of endangering the welfare of an incompetent or physically disabled person and willful violation of public health laws.

 

Memories of Neglect

Posted in Advocacy, Dementia Care, Medications

A nursing home resident with Alzheimer’s might forget receiving poor or negligent care, but the bad feelings created by ill treatment still could persist, University of Iowa researchers say.

Investigators showed sad and happy films to 17 Alzheimer’s patients and 17 people with healthy cognition, then assessed their memories of the movies and their emotional states. Those with Alzheimer’s quickly struggled to recall details of the films, or even that they had just seen a film. However, the feelings of sadness or happiness created by the movies lasted for up to half an hour.

“Quite strikingly, the less the patients remembered about the films, the longer their sadness lasted,” the university noted in a press release. “While sadness tended to last a little longer than happiness, both emotions far outlasted the memory of the films.”

The findings show that caregivers can have a powerful impact on residents’ well-being by doing “simple” things, said lead author Edmarie Guzman-Velez, a doctoral student in clinical psychology. These things might include serving favorite foods, interacting socially or joking with patients.

Full findings appear in Cognitive and Behavioral Neurology.

The Overmedicated Elderly

Posted in Medications

WRIC reported the problem of chemical restraints among nursing home residents.  There’s an unsuspecting problem lurking within the elderly population in America – overlapping prescription medications that put them at risk for adverse drug reactions and even overdosing.

According to some, the problem is an epidemic. “It’s the norm rather than the exception for sure that people are having problems they’re not even aware are medication related,” Keith Kittinger of Bremo Pharmacy in Richmond, Va. Said.

Pharmacists study their patient’s lists of drugs to see how they’ll interact, but they don’t always get it right, as Patti Moyer of Richmond knows. Three years ago Moyer learned she was taking twice her required dosage of blood pressure medications because she was prescribed two different pills.

Adverse drug reactions kill more than 100,000 people in the U.S. every year and can cause serious injury to more than two million. One thing contributing to the problem is that many of the symptoms that the medications are prescribed for, like dizziness, confusion and dementia, are actually symptoms of other medications that the individual is taking.

Speaking to the pharmacists and developing a relationship with them is Moyer’s advice for learning how to prevent drug reactions and overdoses, especially for older adults who are more at risk for them.

 

Extendicare Settlement with DOJ

Posted in Advocacy, Medicare, Trial themes

Extendicare Health Services Inc. (Extendicare) and its subsidiary Progressive Step Corporation (ProStep) have agreed to pay $38 million to the United States and eight states to resolve accusations that Extendicare billed Medicare and Medicaid for materially substandard nursing services that were so deficient that they were effectively worthless and billed Medicare for medically unreasonable and unnecessary rehabilitation therapy services, according to the the Justice Department and the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG).  A federal investigation into Extendicare Health Services Inc. accused the company of failing to provide appropriate care, follow safety protocols or maintain enough skilled nurses. Those lapses in some cases resulted in head injuries to residents, falls, bed sores and fractures and cases of malnutrition, dehydration and infection.  This resolution is the largest failure of care settlement with a chain-wide skilled nursing facility in the department’s history.

Between 2007 and 2013, in 33 of its skilled nursing homes in eight states, Extendicare billed Medicare and Medicaid for materially substandard skilled nursing services and failed to provide care to its residents that met federal and state standards of care and regulatory requirements.  The government alleges, for example, that Extendicare failed to have a sufficient number of skilled nurses to adequately care for its skilled nursing residents; failed to provide adequate catheter care to some of the residents and failed to follow the appropriate protocols to prevent pressure ulcers or falls.  Between 2007 and 2013, in 33 of its skilled nursing homes, Extendicare provided medically unreasonable and unnecessary rehabilitation therapy services to its Medicare Part A beneficiaries, particularly during the patients’ assessment reference periods, so that it could bill Medicare for those patients at the highest per diem rate possible.

Extendicare has also been required to enter into a five year chain-wide Corporate Integrity Agreement with HHS-OIG.  OIG required Extendicare to agree to a Corporate Integrity Agreement under which Extendicare must have a comprehensive compliance program with systems to address the quality of resident care.  Extendicare’s compliance program must include, among other things, corporate-level committees to address compliance and quality, including a committee to assess staffing, and an internal audit program to assess the quality of care provided to its residents.  Extendicare must retain an independent monitor, selected by the OIG, who will regularly visit Extendicare’s facilities and report to the OIG.  In addition, an independent review organization will perform annual reviews of Extendicare’s claims to Medicare.

Extendicare is a Delaware corporation that, through its subsidiaries, operates 146 skilled nursing facilities in 11 states.  ProStep provides physical, speech, and occupational rehabilitation services.

Acting Associate Attorney General Stuart F. Delery said:  “It is critically important that we confront nursing home operators who put their own economic gain ahead of the needs of their residents.  Operators who bill Medicare and Medicaid while failing to provide essential services or bill for services so grossly substandard as to be effectively worthless will be pursued for false claims.”

 

Woman Receives 10 Years for Nursing Home Abuse

Posted in Abuse and Neglect

KOCO reported that Elizabeth Kibler, employee of Grace Living Center in Oklahoma City, was sentenced to 10 years, with a minimum of four years spent in custody, for abusing one of her elderly patients. The victim Anita Rich’s wounds included bruising around her mouth and on her arms, which were documented by videos her son made at the treatment center.

Her son, Christopher Rich, took the videos after noticing that his mother was scared all the time during her stay at the center and felt that he had no other options for improving her treatment. Videos of Kibler abusing the victim verbally as well as pouring water down her feeding tube were released by the district attorney’s office. The victim’s daughter, Melanie Rich said that the family hopes to see nursing home reform in the future so that no one else has to suffer what they did.

 

DOJ Settlement with Johnson & Johnson

Posted in Medicare, Medications

Global health care giant Johnson & Johnson (J&J) and its subsidiaries will pay more than $2.2 billion to resolve criminal and civil liability arising from allegations relating to the prescription drugs Risperdal, Invega and Natrecor, including promotion for uses not approved as safe and effective by the Food and Drug Administration (FDA) and payment of kickbacks to physicians and to the nation’s largest long-term care pharmacy provider.  The global resolution is one of the largest health care fraud settlements in U.S. history, including criminal fines and forfeiture totaling $485 million and civil settlements with the federal government and states totaling $1.72 billion.

In a criminal information filed today in the Eastern District of Pennsylvania, the government charged that, from March 3, 2002, through Dec. 31, 2003, Janssen Pharmaceuticals Inc., a J&J subsidiary, introduced the antipsychotic drug Risperdal into interstate commerce for an unapproved use, rendering the product misbranded.  For most of this time period, Risperdal was approved only to treat schizophrenia.  The information alleges that Janssen’s sales representatives promoted Risperdal to physicians and other prescribers who treated elderly dementia patients by urging the prescribers to use Risperdal to treat symptoms such as anxiety, agitation, depression, hostility and confusion.  The information alleges that the company created written sales aids for use by Janssen’s ElderCare sales force that emphasized symptoms and minimized any mention of the FDA-approved use, treatment of schizophrenia.  The company also provided incentives for off-label promotion and intended use by basing sales representatives’ bonuses on total sales of Risperdal in their sales areas, not just sales for FDA-approved uses.

In a related civil complaint filed in the Eastern District of Pennsylvania, the United States alleges that Janssen marketed Risperdal to control the behaviors and conduct of the nation’s most vulnerable patients: elderly nursing home residents, children and individuals with mental disabilities.  The government alleges that J&J and Janssen caused false claims to be submitted to federal health care programs by promoting Risperdal for off-label uses that federal health care programs did not cover, making false and misleading statements about the safety and efficacy of Risperdal and paying kickbacks to physicians to prescribe Risperdal.

In its complaint, the government alleges that the FDA repeatedly advised Janssen that marketing Risperdal as safe and effective for the elderly would be “misleading.”  The FDA cautioned Janssen that behavioral disturbances in elderly dementia patients were not necessarily manifestations of psychotic disorders and might even be “appropriate responses to the deplorable conditions under which some demented patients are housed, thus raising an ethical question regarding the use of an antipsychotic medication for inappropriate behavioral control.”

The complaint further alleges that J&J and Janssen were aware that Risperdal posed serious health risks for the elderly, including an increased risk of strokes, but that the companies downplayed these risks. The complaint alleges that, despite the FDA warnings and increased health risks, from 1999 through 2005, Janssen aggressively marketed Risperdal to control behavioral disturbances in dementia patients through an “ElderCare sales force” designed to target nursing homes and doctors who treated the elderly.

The government’s complaint also contains allegations that Janssen paid speaker fees to doctors to influence them to write prescriptions for Risperdal.  Sales representatives allegedly told these doctors that if they wanted to receive payments for speaking, they needed to increase their Risperdal prescriptions.

The civil settlement also resolves allegations that, in furtherance of their efforts to target elderly dementia patients in nursing homes, J&J and Janssen paid kickbacks to Omnicare Inc., the nation’s largest pharmacy specializing in dispensing drugs to nursing home patients.  In a complaint filed in the District of Massachusetts in January 2010, the United States alleged that J&J paid millions of dollars in kickbacks to Omnicare under the guise of market share rebate payments, data-purchase agreements, “grants” and “educational funding.”  These kickbacks were intended to induce Omnicare and its hundreds of consultant pharmacists to engage in “active intervention programs” to promote the use of Risperdal and other J&J drugs in nursing homes.  Omnicare’s consultant pharmacists regularly reviewed nursing home patients’ medical charts and made recommendations to physicians on what drugs should be prescribed for those patients.  Although consultant pharmacists purported to provide “independent” recommendations based on their clinical judgment, J&J viewed the pharmacists as an “extension of [J&J’s] sales force.”

J&J and Janssen have agreed to pay $149 million to resolve the government’s contention that these kickbacks caused Omnicare to submit false claims to federal health care programs.

The civil settlements described above resolve multiple lawsuits filed under the qui tam, or whistleblower, provisions of the False Claims Act, which allow private citizens to bring civil actions on behalf of the government and to share in any recovery.

Hospice Care in Nursing Homes

Posted in Advocacy, Trial themes

Senior Housing News reported that care experiences are typically worse in the nursing home setting, according to the latest results of a Hospice_Field_Test_Report_2014 by the Centers for Medicare & Medicaid Services (CMS).  The Hospice Experience of Care Survey measured experiences of patients and their caregivers in three hospice settings: nursing home (including both skilled and regular nursing facilities), home care (including assisted living facilities) and inpatient care (acute care hospitals and freestanding hospice IPUs).

While average overall rating of hospice care scored 93 out of 100 in the survey, nursing home care received a score of 90.2.  Using a number of criteria, respondents ranked nursing home care, which for the most part scored lower than other care settings. The composite, Understanding the Side Effects of Pain Medication, ranked lowest in nursing home setting satisfaction, with a score of 71.1. In comparison, that score for home care was 89.5, for acute care hospitals was 73.7 and for hospice IPUs was 81.  Other nursing home composite scores ranged from 86.2 for Getting Help for Symptoms and 88.5 for Hospice Team Communication to 95.2 for Providing Support for Religious and Spiritual Beliefs and 95.3 for Treating Your Family with Respect.

 

Importance of Communication

Posted in Advocacy, Trial themes

Dr. Jeffrey Levine on his website recently wrote an interesting article about the importance of communication among health care providers using the Ebola case in Texas as an example.  Below is the article in full.

A simple lapse in communication in a Texas hospital resulted in a patient with a deadly contagious disease being discharged home. The information regarding the patient’s travel history was recorded into the electronic medical record (EMR) by a nurse but not transmitted to the doctor who made the decision to discharge him. Such an error seems difficult to comprehend, but this type of communication mishap happens frequently with pressure ulcers.

The oversight occurred at Texas Presbyterian Hospital in Dallas which is a large and busy place. According to US News and World Report this non-profit 609 bed hospital had over 83,000 ER visits and 24,000 admissions in a recent year. The hospital is highly rated, with 74% of patients giving this hospital either 9 or 10 out of 10, the best possible score. Texas Presbyterian uses an EMR called Epic, a market leader in health information technology that is used by some of the nation’s largest and most prestigious health care systems. According to an article in Healthcare Economics, 40% of Americans have their healthcare information stored on Epic.

The hospital initially blamed the slip-up on a flaw in the EMR, but later reversed its position. Apparently the information that recorded the patient’s travel history was correctly entered, but because of “separate physician and nursing workflows” the information did not get to the doctors who discharged the patient home. The result was a potential epidemiological disaster, with many people unnecessarily exposed to a highly contagious and deadly disease and a patient who was left untreated for several days.

This phenomenon of “separate physician and nursing workflows” is unfortunately common in the care of pressure ulcers. Many nurses work hard at assessing skin, but often the physician doesn’t get the information and the wound goes inadequately documented and treated. There are many reasons for this. Wound care is not well represented in medical education, and despite the evolving standard that requires physician documentation and treatment orders, many doctors see wound care as a low priority. Pressure ulcers often go unexamined and poorly incorporated into the physician’s plan of care.

Quality pressure ulcer care entails examination and documentation, but too often we encounter the barrier of “separate physician and nursing workflows” that inhibits communication and proper transfer of information. When a patient is admitted with a wound, the physician needs to know about it and examine it. When a patient gets a new wound in the hospital, the same applies. But for the nurse, simply entering the information into the record with the assumption that the physician will read it is not enough.

According to a landmark report on medical mishaps by the Institute of Medicine, errors represent places where the system failed and the breakdown resulted in harm.  For Thomas Duncan who died of Ebola in Texas, the system failed. The nurse who entered the information into the EMR could simply have spoken directly to the doctor to communicate the critical travel history in addition to typing it into the computer.  This principle works both ways, and doctors need to listen to the information and incorporate it into their assessment and plan. The same applies to a patient who is admitted to the hospital with a pressure ulcer, gets a new one during the hospital stay, or has a wound that is deteriorating.

Any EMR that reinforces professional silos is basically flawed, and entry of data into a computer should never be a substitute for direct communication – the most basic element of interdisciplinary collaboration that is an essential component of pressure ulcer care.

Staffing for High Acuity

Posted in Staffing

Below is from an IDC Health Insights Go-to-Market Services publication called IDC Insights – Staffing LTC to Meet the Demands of Increasing Acuity (1).

For provider organizations, staffing presents a challenge regardless of the care setting in question, but long-term care providers are faced with a growing number of considerations because of changes in regulations, accreditation and quality initiatives, and the patient population. By 2030, the number of
Americans over the age of 65 is expected to nearly double, and this growing aging population places demand on long-term care providers and their staff.

This growing over-65 population has a high burden of chronic disease, resulting in increasing acuity levels among patients seeking long-term care. For long-term care providers, labor is the top source of operating costs, and managing these costs while striving to staff facililities with the best mix of people and skills to deliver high-quality care appropriate to the acuity levels of the resident remains a challenge.

These issues make effective workforce management applications that allow providers to staff specific to acuity levels a critical issue. At the same time the population is aging, so is the workforce. There is a shortage of skilled, experienced care providers, and turnover is high, driving the need among long-term care organizations to more efficiently manage their workforce. It’s not just a matter of reducing costs; providers need to better manage the existing workforce and equip workers with tools to improve employee satisfaction, simplify time and attendance functions, create efficient scheduling and payroll processes, and maintain a competitive environment in which they can compete with their local counterparts for the best workforce available to deliver the quality of care needed.