South Carolina Nursing Home Blog : South Carolina Nursing Home Lawyer & Attorney : Poliakoff & Associates Law Firm : Elderly Care, Senior Care

Amarillo Globe News had an interesting article about new technologies at Texas long term care facilities to help care for Alzheimer's patients and give them more freedom.  The article mentions The Garden at Childers Place and its "plush accommodations".  The 20-bed "neighborhood," preferred over the term "unit," was built in 2007 and recently became a state-certified facility for Alzheimer's patients.

Childers Place is now one of four Amarillo facilities that are state-approved for Alzheimer's patients. The other three are: Ussery-Roan Texas State Veterans Home, Ware Memorial Care Center and Windflower Nursing, a part of Craig Methodist Retirement Community. All four combined have capacity for 155 patients.

Alzheimer's disease is a progressive and fatal brain disorder affecting 5.3 million Americans, the majority of which are 65 or older. The disease also is the most common cause of dementia, a mental disorder characterized by loss of memory and other intellectual abilities, according to the Alzheimer's Association. More than 80 percent of dementia cases are attributed to Alzheimer's.

Childers Place is operated by the Bivins Foundation. Residents living in one of the neighborhoods can move into The Garden if their condition deteriorates or they need more assistance. The layouts of the three communities are the same, allowing for as smooth a transition as possible.

The facility can only be entered by key-card access, required by the state. The wing is divided into two sections, with 10 rooms down each hallway. Each room has its own bathroom and shower, and residents are encouraged to outfit it with their own furniture.  Each section has its own communal living room, immaculately set with furniture and a fireplace. A communal kitchen also is available and equipped with staff-operated safety features to avoid any harm to residents.

The use of technology is likely the facility's greatest asset. Motion sensors in the room alert the nurses' station and pagers can notify staff members if a resident leaves a room. A resident who needs to use the restroom at night need only get out of bed, and a weight sensor placed in the bed gradually turns on lights in the room and bathroom. The lights turn off whenever the patient returns to bed. Residents who need help getting to the restroom are a fall risk, and staff members are quickly alerted so they can come to help.

"The smart-room technology keeps staff from hovering over a patient, and it gives them more freedom," Hendley said. "It really cuts down on (patient) anxiety."

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The Orange County Register had an article about the lawsuit filed on behalf of Oliver J. Shrock who was neglected at Kindred Healthcare Center of Orange.  The nursing home was fined $85,000 for their neglect and maltreatment.

Oliver J. Shrock's death on July 18, 2009 – four days after he suffered a fall and fatal head injuries  was labeled by the state as an "AA" citation – the worst violation that the state can issue against a skilled nursing facility.  The state concluded that the center disregarded Shrock's safety by not listening to the family's warnings, and not implementing safety measures, such as the use of a bed alarm.

Shrock's daughters, Kathleen S. Sakoguchi and Deborah Anne Whitman, sued the center and its former owner, Kentucky-based Kindred Healthcare Operating Inc.. Shrock's family told the center that Shrock – who was dependent on staff for most needs – was at high risk for falls, according to the lawsuit.

He fell soon after arriving at the center, but wasn't injured significantly. The center installed a bed alarm to help prevent future falls and placed mats on the floor to limit possible injuries.  But these measures weren't always in place when Sakoguchi visited her father, and she repeatedly had to tell staff to attach the bed alarm. The fall that caused his death happened on July 14, when Shrock was preparing to go home.

"A nurse assistant discovered Shrock on the floor bleeding from his head and she did not know how long he had been lying on the floor,'' according to the suit.  Shrock was taken to a hospital, and died four days later.

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The Las Vegas Sun had an article about a nursing home that was cited and fined $5,100 by the state for repeated health and safety violations and ordered not to accept new residents.  These violations are incredible.  The bureau said an “immediate jeopardy situation” was declared due to missing resident medications, failure to have criminal background checks, an ongoing cockroach infestation, a lack of a functioning auditory alarm system, poor care on a resident with a colostomy, tuberculosis testing and medication administration.

Eight of the deficiencies were repeats from previous inspections. The state Bureau of Health Care Quality and Compliance said there have been repeated violations dating back to February of 2007 at Best Care Facility which was fined $600 last year.  Surveys in 2007, 2008, 2009 and in February this year showed multiple violations. The bureau said the home was inspected Feb. 2 this year and received the grade of D when 30 violations were found.

“It has been determined that residents are not safe at this facility due to chronic, repeated non-compliance and that the facility is engaging in practices detrimental to the health and safety of the residents,” the bureau said.

A person named “Danny” at the nursing home answered the telephone. He said he would return a call later but he declined to give his last name.

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Houmatoday had an article about the tragic incident involving Etienne Adams, a 93-year-old nursing home resident.  His solo walk outdoors on a freezing night is the subject of a police investigation.  Luckily, the resident is in stable condition at Thibodaux Regional Medical Center after recovering from a fall outside Lafourche Home for the Aged and Infirm.  He is being treated for extended exposure to freezing temperatures. He was unconscious when police found him, and he has been unable to communicate since. Hypothermia had begun to set in.  His temperature dropped to around 83 degrees, while being exposed to outdoor temperatures in the high teens

Police investigators are trying to determine how Adams made it outside without any of the staff noticing and then stayed there without anyone noticing for hours. Officials are not certain how long he was outside of the home.

The nursing home has working security features available that include surveillance cameras, door alarms and a locked fence around the building.  Obviously either the security was not on or it was ignored by the staff.  There is also no video surveillance footage of Adams leaving his room. The nursing home's cameras capture only what it is happening in real time but do not record.

Adams left the facility and fell off of a ramp outside the facility.  There is no record of nursing-home employees looking for Adams outside once they realized he was not in his room.  After being dispatched to the nursing home on a missing-persons complaint, police found Adams on the ground near the back of the property.  Officer David Melancon’s report said “it was apparent that he had been lying on the ground for several hours.

 Here is a follow up article from the DailyComet on the investigation. 
 

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Edna Mae Sides' body was found in front of the Hillside Plaza Nursing Home by staff around 6 a.m.   Hillside Plaza Nursing Home staff found the body of Edna Mae Sides at 6 a.m. but for some reason did not call police for four hours at 10:15 a.m.   The time gap between when Sides' body was found by nursing home staff, and the time it took staff to call police, triggered an "intense investigation".

"The question always arises, cops are suspicious people, why did it take you four hours to call the police?" said Barry Starnes, Wells Chief of Police.   "The time difference and then finding a body outside one of the residence and bringing it back inside and cleaning it up and all this, to police is very suspicious," said Starnes. "To people who run nursing homes, that's standard practice."

Evidence suggests that the nursing home failed to supervise the demented resident and she wandered outside and apparently fell outside the nursing home.  Hopefully, the police will ask the right questions:  What was the staffing ratio?  Was the door alarm on?  Was it working? Did anyone respond to it?  Was a bed check done?  When was the last time she was seen?

Starnes said there are still several unanswered questions in this case. "Now, how she got out there, what procedures were not followed or what other things may be wrong, that's all still under investigation," he said.   "She fell on her face," said Starnes. He said she was unable to get up after the fall.

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Serita Cheryl Evans has filed a nursing home wrongful death lawsuit against a North Carolina facility, Primrose Retirement Villa IV,  that allowed her mother to wander out at night disoriented, fall into a ravine and die from a head injury.  The lawsuit was filed following the death of Carrie “Christine” Evans, whose body was found behind the facility on February 2.

Wandering from a long-term care facility, often referred to as nursing home elopement, can result in serious injuries like fractures from falls, heat stroke or hypothermia in extreme weather conditions. It is generally accepted that preventative measures by a nursing home can eliminate or greatly reduce the risk of serious injuries from nursing home wandering. Facilities can train staff, move high risk patients near the nurses stations, use door alarms and security cameras and lock sections of the nursing home where residents who are prone to wander are housed.

According to the complaint, Carrie Evans was diagnosed with bipolar disorder and hypertension, required medication to stay lucid and had problems sleeping that would increase the risk that she may attempt to wander from the nursing home. Primrose staff was well aware of her propensity to wander off, but did nothing to stop it.   There were no staff members on duty that evening to give Evans her medication, and a security system designed to residents from wandering off was broken and had not been inspected since 2005.

Following Evans’ death, the Harnett County Department of Social Services has levied fines against the Primrose facility for multiple safety violations, including a fine for not properly supervising residents in a situation that leads to severe injury, and for not correcting care quality issues that the state has identified within a reasonable amount of time.

The agency’s inspectors also noted a lack of training for non-licensed staff at the facility on several occasions, and the state has felt the need to conduct 28 investigations on Primrose in the last two years, compared to the state standard of four investigations per year.

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SignonSandiego had an article about another California nursing home being hit with the most severe citation – and the maximum fine of $100,000 – in connection with a patient who died from a preventable fall.   I wish more States including apathetic South Carolina would investigate, enforce, and fine nursing home incidents like California.

The patient, who was not identified, was recovering from hip surgery at Aviara Healthcare Center on Regal Road in Encinitas.  He was admitted to the facility in April for physical therapy and was a known risk for falls.  He fell twice there within 24 hours between May 9 and 10.  After the first fall, the Aviara staff put an alarm on the patient's gown. Despite the alarm sounding, no staff member responded when the patient got out of bed and walked into the hallway.   This probably took several minutes but no employee came in to check on him or assist him. alarms are only as good as the people responding to them.

 The wall in that area lacked a handrail, so when the man began stumbling, he grabbed a large mechanical device used to lift residents out of bed.   He fell and pulled the equipment down to the floor with him, and his head hit the metal frame of the lift, according to a report by the California Department of Public Health. The patient was hospitalized and died from the blunt-force trauma.

Seven Aviara employees said the lift was supposed to be kept in a shower room and not the hallway. Even after the man's death, a state health investigator found the lift still stored in the same hallway location.

Aviara also was fined $16,000 because it failed to closely monitor a patient who wandered away from the facility three times within nine hours last month.
 

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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 hip.  Yet 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.

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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.

 

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The Chicago Tribune has had a series of articles about the tragic death of a nursing home resident who was unsupervised and allowed to wander away from the facility.  The articles are good although many questions remain unanswered.  See articles here, here, here, and here.  Below is a summary of what I believe has been found out thus far.

Sarah Wentworth -- who suffered from dementia -- was found in a snowbank outside The Arbor of Itasca the cold morning of Feb. 5.  She had been exposed to the elements for at least 90 minutes and more likely 5 hours. Wentworth was unable to leave her bed without assistance.   No one is sure how she could have left her room and the building without being noticed by staff.  Staff are required to do a bed check every two hours.  She was known by staff to be a wanderer and wore an ankle bracelet that reminded the staff.

Wentworth was wearing only a hospital gown when police arrived at the nursing home.  She had on an ankle bracelet that should have (and may have) triggered an alarm at the facility's nursing station when she passed through the first of two exit doors.   Inside the nursing station at The Arbor of Itasca is a handwritten note reminding staff that "if this buzzer sounds, staff must go out to the courtyard to check for a resident."

Nursing home staff members told Itasca police they checked the door to the courtyard when the alarm went off, but did not see anyone.   No mention of a polygraph test was noted.

Neglect and obstruction of justice charges may be filed against as many as four employees. Heidi Leon, a 23-year-old staff member on duty the night of the incident, was watching TV in a room adjacent to the nursing station when Wentworth exited a door and triggered the alarm.  She watched three straight episodes of "Dog The Bounty Hunter" and "shrugged off " an alarm that indicated a resident had wandered outside into near-zero conditions.  Instead of checking the courtyard as instructed, the staff member assumed someone "stepped outside to have a cigarette" and turned the alarm off "so it didn't distract her television program."

Tom Hendrix, an attorney for the nursing home, did not respond directly to the allegations but said that "policies and procedures were in place for the supervision and safety of residents, including an alarm system which was in working order." Hendrix did admit that some employees had been suspended.

Mr. Hendrix nor the nursing home employees can explain how she got outside.   She was unable to get out of bed on her own.  Although an alarm sounded at a secure door during the middle of the night when Wentworth left the building, no nursing home employee checked on her.   The outside temperature that morning was about 1 degree.

Heidi Leon was charged Tuesday with criminal neglect of a long-term-care facility resident, criminal neglect of an elderly person and obstruction of justice. If convicted, she faces up to 7 years in prison.

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