Repeated unsupervised falls lead to lawsuit

The Madison Record had an article about a lawsuit against a nursing home that allowed a disabled elderly woman to fall and fracture both her hips. Hazel Timmons, guardian of River Reed, filed a suit against Stearns Nursing and Rehabilitation Center on May 21 in Madison County Circuit Court.  Reed lived in the Granite City nursing home from May 25, 2007, through July 7.

When Reed was admitted to the nursing home, employees were aware she suffered from Alzheimer's and dementia and was usually disoriented and confused.  Nevertheless, employees allowed Reed to wander unattended in the hallway during the middle of the night on May 29, 2007. During her unsupervised walk, Reed predictably fell and fractured her left hipYet again, on June 6, Reed was left unattended in a wheelchair and without a personal alarm. And, again, she injured herself when she fell out of the wheelchair.

Reed fractured her right hip after she was left unattended in her wheelchair with her tab alarm in the off position on June 15, 2007. During this incident, Reed attempted to walk unassisted when she was known to be non-weight bearing and at high risk for falling.

 

Silvercare Solutions and incontinence

The Tennessean had an interesting article about Silvercare, a company that has found a niche in the nursing home industry that improves the quality of care provided and the resident's quality of life.   Silvercare Solutions was started in February to capitalize on Medicare rules that required nursing homes to do more to ensure that residents are properly assessed for incontinence and provided with comprehensive care services.

Silvercare brings nurse practitioners to nursing homes to treat residents, relieving the homes of the need to hire specialized staff, find urologists to see the elderly residents in their clinics or transport residents there.   About a third of nursing home residents are incontinent, he said.

Silvercare got off to a fast start by acquiring the private practice of a geriatric nurse practitioner that delivered incontinence services to nursing homes in Philadelphia.  It is using the model of that practice to expand in Tennessee, Pennsylvania and New Jersey, where it operates in 48 homes.

Nina Monroe, director of nursing at client Bethany Healthcare Center here, said the nursing home already is seeing improvements in some residents since signing up with SilverCare about a month ago.  Previously, a gerontologist examined residents with incontinence, she said, adding that having specialized care helps to get to the source of conditions that cause the residents’ discomfort.

One of the founders of Silvercare, Frazer Buntin said he was motivated to launch Silvercare by personal experience; he lost his grandmother four months after she broke her hip hurrying to the
restroom at a Nashville nursing home.   This is a common problem in nursing homes.  Residents need to go to the bathroom; they hit the call bell for assistance. No one responds.  They risk falling by trying to get to the bathroom or they wet themselves and lose all dignity.  Many of the fall cases we handle resulted from the staff's failure to respond to call bells in a timely manner.


 

Lawsuit filed over preventable fall and death

Chicoer.com reported the filing of a lawsuit against Windsor Chico Creek Care and Rehabilitation Center for negligence and the wrongful death of a Geraldine Pavcik.  Pavcik was admitted to the facility on June 17 for short term rehab after a minor back injury.

Because Pavcik was at risk of falling, her doctor had ordered bed-rail restraints, a lowered bed, an alarm system, and that she be closely attended to.   All are standard preventative measures available in most nursing homes but they depend on proper supervision and a quick response time to call bells and alarms which, of course, depends on adequate staffing.  Most residents fall because the nursing home chose to be understaffed and that leads to falls.

These measure were not in place on "multiple occasions" while Pavcik was in the nursing home.  On July 3, Pavcik was left unattended and without bed rails and a bed alarm.  At 7 a.m. that day, she fell out of bed, severly fracturing her left hip.  Although her hip was X-rayed at the facility at 2:45 p.m., she wasn't transferred to an acute-care hospital until after 9 p.m.

Pavcik had surgery for her fractured hip, but the operation affected her mental condition, and she was no longer able to eat or drink effectively.   As a result, she contracted "aspiration pneumonia," a type of pneumonia that can develop in people who inhale liquid or bits of food. The woman died of respiratory failure as a result of pneumonia.

Among the accusations against the nursing home are that its administrators failed to hire enough staff to keep Pavcik safe, that her doctor's orders were not followed, that she wasn't transferred to an acute-care hospital when she needed to be, and that her doctor was not notified as her condition declined before she died.

 

Jury trial for resident who died as a result of numerous falls.

The Pittsburgh Tribune Review had an article about the recent jury trial against a nursing home in a wrongful death lawsuit in which the family of a woman claims the nursing home was negligent in her care and caused her death.  The family of Olive Shaffer contends she received inadequate care during her stay at Harmon House in Mt. Pleasant.   Shaffer fell several times while living in the nursing home and died July 22, 2003, from injuries she sustained in her falls.

Jurors were given evidence that workers at the nursing home falsified records, violated internal policies which make up the standard of care, and were negligent in supervising Shaffer.   The Shaffer family contends that Shaffer fell several times in the nursing home in June, and the staff made insufficient efforts to prevent her from taking more tumbles.

The nursing home had a management company (Grane Healthcare Co) that was responsible for implementing policies and procedures and training staff on fall prevention. In the lawsuit, the family said Shaffer fell twice on July 15, 2003, and she suffered catastrophic injuries, including brain swelling. She died from her injuries a week later, according to the suit.

The nursing home's defense is 1) Old people fall  2)  Falls happen and 3) Falls are not preventable. The only way to prevent it is to tie them up.

I hope the jury listens to the evidence and the defense's frivolous and misleading arguments and awards substantial damages.

 

Technology may help seniors stay home

John Leland of The NY Times wrote a great article about technologies helping people with health problems at home instead of in an institutional setting like a nursing home.

He writes that a flurry of new technologies are designed to enable the frail, elderly, or those who simply live alone to live independently and avoid expensive trips to the emergency room or nursing homes.   The article has several great examples.

Bertha Branch, 78, discovered the power of a system called eNeighbor when she fell to the floor late one night without her emergency alert pendant and could not phone for help.  A wireless sensor under Ms. Branch’s bed detected that she had gotten up. Motion detectors in her home registered that she had not left the area in her usual pattern and relayed that information to a central monitoring system, prompting a call to her telephone to ask if she was all right.   When she did not answer, that incited more calls — to a neighbor, to the building manager and finally to 911, which dispatched firefighters to break through her door. She had been on the floor less than an hour when they arrived.

Technologies like eNeighbor come with great promise of improved care at lower cost and the backing of large companies like Intel and General Electric.

But the devices are not usually covered by the government or private insurance plans.  Ms. Branch, who has severe diabetes and heart disease, said she could not live on her own without the system, built by a Minnesota company called Healthsense.

The cost for Ms. Branch’s basic system, supplied by a health care provider called New Courtland as part of a publicly financed program, is about $100 a month, far less than a nursing home, where the costs to taxpayers can exceed $200 a day. In the two years Mrs. Branch has had the system, she has fallen three times and been stuck once in the bathtub, each time unable to call for help without it.

Joseph Hayduk, 86, a retired Air Force lieutenant colonel, is greeted by a voice from a small box: “Good morning. It is now time to record your vital signs.” Mr. Hayduk has been using the device since 2006, after his second heart attack, through a program run by Meridian Health. The program asked him a series of questions regarding his medical condition and relays that information to Meridian Health.  There, a nurse calls all 18 patients in the program daily, starting with the ones whose data call for urgent attention. “This system’s invaluable to me, not only physically, but psychologically,” he said. “I don’t want to be in assisted living. That’s for people in wheelchairs and walkers.”

Philip Marshall, 85, another Meridian Health patient, uses a system tied to his cellphone to help him remember his medications. Mr. Marshall has high blood pressure and macular degeneration, and takes 10 pills a day. He cannot see a clock or work the buttons on most phones, so he uses a Jitterbug, a phone with big buttons and limited functions.

Drug compliance is one of the biggest problems for the elderly, especially those with memory loss. Until Mr. Marshall got Meridian’s Jitterbug system, his daughter Melanie, 55, said she had to leave work several times a month to help him with his drugs. “I’m answering the phone in meetings,” she said. “He’d forget whether he took a pill or whether he was supposed to take a pill.”

The system, which costs $20 a month, calls him after he is scheduled to take a pill and asks if he has taken it; if not, it asks him why not and sends automated alerts to his daughters.

This is the ultimate goal of personal health monitoring — that people who know they are being watched may modify their behavior to better their health.

The future of these technologies, and the terabytes they gather, can involve unprecedented information about the whereabouts and well-being of older people. In a program with Intel, Dr. Kaye is combing motion data for patterns that indicate the onset of dementia, years before the decline shows up on cognitive tests.

 

State investigation of wandering death

This entry is a follow-up to the entry about a resident in Concord, N.C. who was allowed to wander away from the nursing home and fll off a loading dock.  A state investigation shows that a nursing home in Concord made several mistakes, which played a role in the death of a patient.  The 21-page report says that the staff and director of Five Oaks Manor knew that 87-year-old Annie Bell Scarboro was at risk for wandering because she had wandered off before.

State inspectors from the Department of Health and Human Services went into Five Oaks Manor in December after the Alzheimer's patient died. The report shows Scarboro got through three sets of doors unsupervised.

First, she went through the dining room doors. A worker says those doors hadn't locked properly for at least eight months. Then, Scarboro went through the kitchen doors and out a back door leading to the loading dock. The back door, according to the report, had no alarm.

Scarboro fell 4 feet off the loading dock .The "merry walker" chair she used to get around landed on top of her. A nurse who found Scarboro told inspectors, "I went out there and saw her blood was running everywhere."

A nursing assistant at Five Oaks told investigators, "Everyone knew that she wandered around. We all knew that she did that. She got out that kitchen door before."  The report shows that on May 22, 2008, Scarboro had exited the building through the same kitchen door.   The solution then was to check on her every 15 minutes.

The state investigation found the nursing home failed to meet several federal standards of care, meaning Five Oaks could be forced to pay a big fine and could lose their funding altogether.

NewsChannel 36 tried to get comment from the director, but he hung up on us.

To view the full 21-page report, click here.   The report does not mention the staffing levels at the time of the incident.
 

Fall outside nursing home results in death

News Channel 36 in Concord, North Carolina had a tragic story of a resident  who fell to her death at a nursing home.  State inspectors have launched an investigation at the Concord nursing home.

The 87-year-old woman was found with a massive head injury on the ground beside an outside loading dock.   The article mentions that a fence near the loading dock is brand new, clearly installed after the patient at Concords Five Oaks Manor Nursing Home was found on the ground.  She'd fallen 4 feet to the ground, hit her head and died after being rushed to the emergency room.

The nursing home administrator did not report the woman's fall or death to the state.  A state spokesman says someone else reported it to them. Concord police told News Channel 36 the same thing.

Just last week Medicare ranked Five Oaks among the worst nursing homes in the country with just one out of five stars. Two state inspections from this year showed deficiencies. One cites accident and supervision problems, with one example where a patient "was on the floor" and staff had to be "disciplined."   Another said a patient was "outside the building."

 Channel 36 had a follow up to this story here.  In the follow up article, the family expressed concern that someone else could die there. The family says she had gotten out of the facility before.

Her daughter, Rosemary Ritchie, said she is worried about other patients at Five Oaks Manor. Doctors told her that her 87-year-old mother was brain dead because of a fall that the nursing home could have prevented.

She says her mom somehow got through a kitchen door that didn't have an alarm or lock on it. That door led out to the back of the facility and a loading dock. "I put her there trusting they would keep her safe and then this happened. It's not right," Ritchie said.

News Channel 36 tried repeatedly to get in touch with management at the nursing home and were told they would not comment.

Prison time for nurse who covered up fall

Oregon Live.com had an article about a Portland judge who ordered the jailing of the former nursing director of a Northeast Portland nursing home where a 60-year-old woman cried in pain with broken legs for five days before staff called an ambulance.

Suzanne Kay Ruddell was found guilty of felony criminal mistreatment by a jury.  She must serve 19 months of prison time and three years probation for her role in the death of Linda Ober, who was dropped by aides while being moved into her bed.  The nursing home covered up the fal and failed to get x-rays or notify the family as required by law.

Ruddell waited five days before ordering X-rays for Ober despite multiple reports from different staffers that Ober was screaming or crying in pain. Ober died after a surgery to repair two shattered leg bones.

Sara Cunningham, one of Ober's five adult children, said the nursing home failed to notify them.  The family never got a chance to say goodbye.   "It wasn't until she'd endured five days of excruciating pain that my mom was taken to the hospital," she said. "This is inexcusable, especially for a nurse who's supposed to help people."

 

Injuries from falls are very complex

N.Y Times had a great article discussing the unpredictable impact of falls in the elderly population.  Because of the complex nature of the difficulties that can result from falls, there is a significant need for nursing homes to invest in adequate fall prevention which always includes hiring competent and caring nurses to supervise at risk residents. Residents who suffers falls sometimes never recover because of muscles atrophying or because of the increased lack of mobility causes pneumonia and other respiratory problems.

Once considered an inevitable part of aging, falls are now recognized as complex, preventable events with multiple causes and consequences, calling for a wide range of interventions, both psychological and physiological, that most patients never receive.

All falls need to be taken as seriously as diabetes because they can be a real warning sign that something serious is wrong.   In the article, Dr. Mary E. Tinetti, a falls expert at Yale University medical school, compared falls to strokes in their harmfulness.  Each year, 1.8 million Americans over age 65 are injured in falls, according to the Centers for Disease Control and Prevention. Some rebound as if the injury never happened. But for some, the fall sets off a downward spiral of physical and emotional problems — including pneumonia, depression, social isolation, infection and muscle loss — that become too much for their bodies to withstand.

Psychological factors can be as devastating as the physical trauma, Dr. Tinetti said. “It’s the fear of falling, the lost confidence. Good walkers stop walking, stop going to church. They become socially isolated and depressed.”

The period of immobility after a fall is particularly dangerous, said Dr. Gray-Miceli, whose research includes studying a group of patients after falls. “Being immobile, you’re not taking deep breaths, you’re more prone to orthostatic pneumonia, or older people can develop urinary incontinence. And that can have a whole cascade of emotional consequences as well as the physical consequences, such as skin breakdown, pressure sores, bladder infection, lung infection.

Patients’ pessimism can be self-fulfilling, because they may not walk to the extent they can. “Their stride becomes shorter,” Dr. Morrison said. “They don’t use their lungs.”

 

Importance of call lights

Northwest Arkansas Times had an article about a resident who died only 6 days after getting admitted to a nursing home. She was only 63 years old.  Why did they agree to accept her if they couldn't take care of her?

Donna Fay Snow dislodged her catheter line, entered the bathroom and fell. She bled to death while lying on the bathroom floor before she was found at 5: 35 a. m.   Many times the resident needs to go to the bathroom and hits the call light/bell but gets no response so they try to go to the bathroom without assistance.  In this case, the call light was not operating properly.

"It appears that the cord to her nursing call light was missing," the lawsuit states.

Snow had a port placement for dialysis in her upper left jugular vein that she was prone to pick, according to the complaint.  The nursing home and its staff knew about Snow's medical condition and should have taken steps to care for her needs, the lawsuit alleges.

 

Wandering a concern at adult homes

Times Record-Herald had an article about a resident who wandered away from an adult home and froze to death.  These kinds of incidents are preventable if the home has well-trained and competent number of staff members supervising the residents.  A death from wandering is a sure sign that understaffing, inadequate training, and a lack of supervision exists in that nursing home.

The article mentions that Karen Preston walked away from the Roscoe Manor Adult Home. She stumbled into the woods about a mile away. She fell repeatedly. She walked in circles. She curled up under a pine tree. And that's where police found her frozen body two days later - her socks next to her body, no shoes on her feet. A medical examiner ruled that she died of hypothermia.

Karen Preston was 54 years old and suffered from severe schizophrenia. She had lived in Roscoe Manor because she needed help with daily activities and supervion that an adult home is supposed to provide.

Preston's tragic death underscores the deplorable conditions at many nursing homes.  The Times Record-Herald reviewed inspections at 22 licensed adult homes in Ulster, Sullivan and Orange counties from 2001-07 and turned up 846 violations deemed to directly affect the safety or well-being of residents - with two-thirds of those citations recorded at the seven adult homes operated in Sullivan County.

A year after Preston disappeared, another Roscoe Manor resident, Ella Maye, walked away from the home.  Maye, 78, had dementia and heart disease. State police believe she suffered a fatal heart arrhythmia while walking on Rockland Road early on Feb. 23. They believe she was trying to crawl back to Roscoe Manor when she collapsed on a neighbor's front lawn and died.

The adult home was supposed to do hourly bed checks, but Roscoe Manor owner Charles Benson said at the time that an employee had failed to do so.  No one noticed Ella Maye was missing.

Adult home inspection reports and history documented by state agencies make it clear: Residents of some Hudson Valley adult homes are at a significant risk of illness, injury or even death due to carelessness or negligence on the part of the homes' operators and staff.

Despite reforms over the past few years, state oversight has been ineffective in regulating these homes, which house a vulnerable population of the elderly, infirm and mentally ill. And anyone can end up in an adult home. All it takes is a medical crisis that renders someone unable to live on their own.

State documents paint a disturbing picture of homes where residents are left to sit in soiled clothing, are subjected to physically or verbally abusive staffers and repeated instances of mismanaged medications.

 

Bed-Rail Safety and Entrapment

William A. Hyman wrote an article in McKnight's Long Term Care News on July 24, 2008 about the dangers of bed rails and the problem with entrapment.

Bed-rail entrapments and deaths continue to occur in nursing homes, other facilities and in the home because rail and bed designs that are clearly dangerous continue to be used. Such rails may be in your inventory, or in the inventory of your rental supplier.

The U.S. Food and Drug Administration has recognized and reported on the problem of lethal entrapments for over 10 years, but it has not ordered recalls. Some manufacturers have designed safer rails yet not replaced those already in use. And despite the publicity efforts of the FDA, The Joint Commission published articles and others, there continues to be a lack of practical understanding of the nature of this hazard and how to recognize a dangerous bed.

The time to end lethal bed-rail entrapments is now, and the way to do it is to remove from the inventory those bed-rail systems that are unreasonably dangerous, and to insist that suppliers provide beds that at least meet current guidelines.

It is now 13 years since the FDA's Safety Alert on the dangers of entrapment in bed rails, and other parts of hospital and nursing home beds (1). This alert was directed to Home Healthcare Agencies, Hospices, and Nursing Homes, among others. It was based, in part, on already published work and reports to the FDA of deaths and injuries associated with beds and bed rails, the latter going back to publicly available data since 1985. The FDA alert triggered a number of related reports and announcements in the clinical literature (2- 4).

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Half of elderly falls result in brain injury and death

The Washington Post had a recent article about how falls in the elderly lead to death caused by brain injuries.  This is why it is so critical for nursing homes to have sufficient staff to supervise resdients, prevent falls, and have a fall prevention program.  Below are excerpts of the article.

The elderly fear breaking a hip when they fall, but a government study indicates that hitting their head can also have deadly consequences: Brain injuries account for half of all deaths from falls.

The study by the Centers for Disease Control and Prevention is the first comprehensive national look at the role brain injuries play in fatal elderly falls. It examined 16,000 deaths in 2005 that listed unintentional falls as an underlying cause of death.  CDC researchers found that slightly more than half of the deaths were attributed to brain injuries. The other deaths were due to a variety of causes including heart failure, strokes, infections and existing chronic conditions worsened by a broken hip or other injuries sustained in a fall.

"A lot of people don't think a fall is serious unless they broke a bone, they don't think it's serious unless they break a hip. They don't worry about their head," said Pat Flemming, a senior physical therapist and researcher at Vanderbilt University

Each year, one in three Americans age 65 and older fall. About 30 percent of such falls require medical treatment.   Previous CDC research showed that the U.S. death rate from falling has risen dramatically _ about 55 percent _ for the elderly since the 1990s.

As people age, veins and arteries can be more easily torn during a sudden blow or jolt to the head, said Marlena Wald, a CDC epidemiologist who co-authored the study.   That can cause a fatal brain bleed. Other factors can contribute, such as the use of blood-thinners, said Judy Stevens, another CDC researcher and co-author.

The severity of brain injuries isn't always immediately apparent, and some people may not lose consciousness. Wald noted a scenario seen in hospitals in which an elderly fall victim comes in alert and talking, but dies an hour or two later.

The study also found that deaths and hospitalization rates for fall-related brain injuries increased with age. Brain injuries accounted for about 8 percent of hospital stays for non-fatal falls.

There are several steps older Americans can take to try to prevent falls. Exercise can increase leg strength and balance. Glasses or other vision correction measures can help people avoid obstacles. And being careful with the use of drugs that can affect thinking and coordination _ such as tranquilizers and sleeping pills _ can also make a difference.

"Falls are not an inevitable consequence of aging. These head injuries are not inevitable, either," Wald said.

The research is being published in the June issue of a scientific publication, the Journal of Safety Research.

___

Nursing home appeals fine for allowing resident to fall 14 times

The Almanac News had an article about a nursing home appealing a fine after a resident's death caused by their inattentiveness and lack of supervision.

During her 10-month stay at Atherton Healthcare nursing home in Menlo Park last year, 51-year-old resident Debra Nickel fell 14 times, including a fall where she suffered a traumatic brain injury. She died several days later.  State investigators have determined that the nursing home staff is at fault for Ms. Nickel's death.  The facility was fined $100,000 for the neglect which is the most severe citation possible.

The Department of Public Health concluded that Atherton Healthcare staff was inattentive in caring for Ms. Nickel, who was known to be at risk for falls. The facility was hit with an "AA" citation the most severe citation under state standards.  "The facility failed to identify and continuously assess, evaluate and update the resident's needs and plan of care to prevent further falls and injuries," according to the report.

Nana Cocachvili, executive director of Atherton Healthcare, located at 1275 Crane St., said the nursing home is appealing the decision, and that Ms. Nickel's falls were "unavoidable."

Ms. Nickel died Dec. 1, a week after staff member noticed a "deep lacerated wound" on the patient's head most probably from an "unwitnessed fall," according to the report. The staff member informed a nursing home physician, who stated that Ms. Nickel "does not need to be sent out for stitches because scalp wounds heal easily," the report says.  The staff member notified a second physician, who recommended Ms. Nickel be taken to the emergency room, where she was admitted three hours later with high blood pressure and a heart rate of 128 beats per minute, the report says.

The San Mateo County Coroner's Office confirmed Ms. Nickel died Dec. 1 of swelling of the brain and brain hemorrhages caused by blunt trauma.

The citation linked to Ms. Nickel's death isn't the only Department of Public Health claim Atherton Healthcare is currently fighting.   In April, the state fined the nursing home $20,000 following an investigation into the Oct. 28 death of a 79-year-old man who fell backwards off a wheelchair lift.

The patient, Menlo Park resident Charles Ladeau, suffered major head trauma when he fell while being lifted into a van, and died shortly after the fall.  The incident exposed the fact that Atherton Healthcare was outsourcing the driving of patients to off-site appointments through a private company without a formal contract, and without "written standards how transportation services should be provided," according to the reports.

Ms. Cocachvili said Atherton Healthcare has appealed that decision too, and she argued the blame should lie on the transportation provider whose employee was supervising the patient when he fell, not the nursing home.   however, the nursing home cannot delegate care to a third party.  The nursing home is the health care provider who is ultimately responsible for the care provided to their residents.

In 2005, the facility changed ownership and was known as Canaan Healthcare. The current owners took over in early 2007 and the name switched to Atherton Healthcare.



Sedatives increase risk of falls in elderly

Journal of Clinical Nursing has an article about a recent study linking the use of sleeping pills containing benzodiazepines to increase falls in nursing homes.
Older patients taking benzodiazepines were 2.9 times more likely to fall   Obviously, patients who fall suffer severe injuries.   Some older patients have impaired cognitive function or limited functional ability and physical strength stemming from chronic physical ailments, increasing their risk of a fall, often when walking or being moved.

In addition, older patients are take multiple medications, whose side effects increase the patients' chances of a fall.  Physical restraints may be used to decrease the possibility of falling and being injured.

"Even if no physical injury occurs, fall victims may develop a fear of falling again and thus reduce their activities as a result," the authors wrote. "This can lead to unnecessary dependency, loss of function, decreased socialization, and a poor quality of life."

The researchers found that use of sleeping pills containing benzodiazepines was significantly associated with fractures supporting the findings of most previous studies.

Patients using wheelchairs and bed rails were less likely to fall, but neither of the associations reached statistical significance. Nevertheless, "the use of these might be regarded as protective or preventative strategies," the researchers said.

Bed rails can cause injuries if patients climb over them, and physically restraining an already agitated individual can increase fear and worsen behavior, they said.   "In addition, restraints can lead to serious complications, including circulatory obstruction, skin tears, incontinence, fractures, and dislocations," they wrote. "These restraints should be used with care and consideration." 

The Study recognized that restraints cannot completely eliminate falls in nursing homes and that they may not be appropriate in every situation, but concluded that "our results support the hypothesis that they might be protective when used selectively together with fewer sedatives, especially benzodiazepines."

Primary source: Journal of Clinical Nursing
Source reference:
Fonad E, et al "Falls and fall risk among nursing home residents"J Clin Nurs 2008; 17: 126-134.


Nursing home covers up fracture caused by improper transfer

Here is another article about a nursing home's failure to prevent a resident from falling and then failing to intervene or inform the family. 

The family was never told that their 60-year-old mother had broken both legs in a fall and died of complications.  Eventually,  the family discovered the horrific details. Their mother, Linda Ober, had been dropped by staff at the nursing home where she lived and left to moan for help in her bed for five days.

Employees tried to cover up the injury by giving her pain medication and telling her that her memory of being dropped as they moved her out of her wheelchair was simply a bad dream.  The family is haunted by the thought that her mother spent her final hours wondering why her daughter didn't come to see her. According to the suit, the resident  told hospital staff that they didn't need to call her daughter, because nursing-home employees said they would. Cunningham, who lives a mile from the nursing home, said she was not told.

"I wasn't there to hold her hand," said Cunningham, breaking into tears. "All I needed was a phone call."

Thomas D'Amore, the attorney representing Cunningham and her siblings, said Ober's death was the result of having too few staff and not adequately training them to care for the center's residents. According to the U.S. Department of Health and Human Services, a review of the Gateway nursing home about the time of Ober's death found that the number of nurse-hours per resident was below the state average by 33 percent.

She was critically injured Oct. 29, 2006, when two employees dropped her after improperly wrapping a sling around her torso to move her from her wheelchair to her bed, according to the suit.   X-rays show Ober's badly broken legs. In one X-ray, her femur is jutting away from its normal position by 45 degrees. According to a summary of a state investigation that D'Amore provided, staff who treated Ober at Mount Hood Medical Center said Ober's pain was "off the scale" and that "you could feel the bones in her legs moving in your hands, and they were crunching."

Improper transfer causes resident's death

I read an article today about the death of a resident caused by the improper transfer by the nursing home staff.  Falls are always so dificult for the elderly to survive.  the injuries cause by falls can lead to immobility, pain, and demntia.  Preventing falls should be a high priority but often isn't.  Training and staffing are lacking in this area.

A Pennsylvania Coroner concluded a nursing home resident's death was caused by injuries she suffered after being dropped by staff from a mechanical lift.    Judith Bilger was dropped Aug. 9 and died three days later at the Laurel Crest Rehabilitation & Special Care Center.

Coroner Dennis Kwiatkowski says the 64-year-old woman died from internal injuries caused in the fall.   Among other things, she broke ribs and developed pneumonia from a lung contusion.

Proper staffing and education on proper use of mechanical lifts could have prevented the above incident and prevented this woman's death.

Top violations in nursing homes


Violations of "accident hazards" were the most frequently cited survey flaw across the nation in September, according to the Centers for Medicare & Medicaid Services. These hazards typically cause falls and injuries to occur.  The agency said 35.2% of the facilities cited were written up for F-tag 323.

Next on the list was a frequent No. 1 entry in the Top Ten list: F-tag 371 ("store, prepare, distribute and serve food") at 33.9%. This is very disturbing considering the importance of dietary and nutritional aspects for maintaining and improving the health of elderly residents especially to prevent or heal pressure ulcers.

Filling out the top five were: F-309 (each resident must receive care for highest well-being) at 27.7%; F-281 (services must meet professional standards of quality) at 26.9%; and F-279 (Facility must develop comprehensive care plan with objectives/timetables.  

All information was culled from CMS' Online Survey, Certification and Reporting (OSCAR) data.


Lawsuit related to fall that led to death

 A wrongful death lawsuit was filed against a Menomonee Falls nursing home, contending that a resident died from complications caused by broken bones in both legs that she suffered during a fall that was not reported.

Dorismae Burgardt was dropped by a nursing assistant at Menomonee Falls Health Care Center using an improper technique. The incident was not reported to a registered nurse or the woman's physician. The first mention that something was amiss came the next day, when it was noted on her chart that Burgardt had "bruises" on both knees caused by being "lowered to the floor".

Three weeks later, Burgardt was dead. She was 81.

"This lawsuit is about dignity and safety," said attorney Jay Urban, who filed the lawsuit on behalf of Burgardt's estate and her husband, Allan Burgardt of Germantown. 

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Hip fractures

Hip Fractures Among Older Adults

More than 95% of hip fractures among adults ages 65 and older are caused by falls (Grisso et al. 1991). These injuries can cause severe health problems and lead to reduced quality of life and premature death (Wolinsky et al. 1997; Hall et al. 2000).

How big is the problem?

In 2003, there were more than 309,500 hospital admissions for hip fractures (NCHS 2006).
From 1993 to 2003, the number of hip fracture hospitalizations increased 19%, from 261,000 to 309,500 (NCHS 2006).
However, after adjusting for the increasing age of the U.S. population (U.S. Census Bureau 2006), the hip fracture rate decreased 14%, from 901 per 100,000 population in 1993 to 776 per 100,000 population in 2003 (NCHS 2006).
In 1990, researchers estimated that the number of hip fractures would exceed 500,000 by the year 2040 (Cummings et al. 1990).

What outcomes are linked to hip fractures?

As many as 20% of hip fracture patients die within a year of their injury (Leibson et al. 2002).
Most patients with hip fractures are hospitalized for about one week (Popovic 2001).
Up to 25% of adults who lived independently before their hip fracture have to stay in a nursing home for at least a year after their injury (Magaziner et al. 2000).
In 1991, Medicare costs for hip fractures were estimated to be $2.9 billion (CDC 1996).

 

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Problem of falls in nursing homes

Falls in Nursing Homes

How big is the problem?

In 2003, 1.5 million people 65 and older lived in nursing homes (National Center for Health Statistics 2005). If current rates continue, by 2030 this number will rise to about 3 million (Sahyoun et al. 2002).
Each year, a typical nursing home with 100 beds reports 100 to 200 falls. Many falls go unreported (Rubenstein 1997).
As many as 3 out of 4 people in nursing homes fall each year (Rubenstein et al. 1994). That's twice the rate of falls for older adults living in the community.
Patients often fall more than once. The average is 2.6 falls per person per year (Rubenstein et al. 1990).
About 35% of fall injuries occur among residents who cannot walk (Thapa et al. 1996).
About 5% of adults 65 and older live in nursing homes. But people in nursing homes account for about 20% of deaths from falls in this age group (Rubenstein 1997).


How serious are these falls?

About 1,800 people living in U.S. nursing homes die each year from falls (Rubenstein et al. 1988).
About 10% to 20% of nursing home falls cause serious injuries; 2% to 6% cause fractures (Rubenstein et al. 1988).
Falls can make it hard for a person to get around, cause disability, and reduce quality of life. Fear of falling can cause further loss of function, depression, feelings of helplessness, and social isolation (Rubenstein et al. 1994).


Why do falls occur more often in nursing homes?

Falling can be a sign of other health problems. People in nursing homes are generally more frail than older adults living in the community. They tend to be older, have more chronic illnesses, and have difficulty walking. They also tend to have problems with thinking or memory, to have difficulty with activities of daily living, and to need help getting around or taking care of themselves (Bedsine et al. 1996). All of these factors are linked to falling (Ejaz et al. 1994).

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