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

The St. Louis American had an article about the prevalence of "hospital dumping" in St. Louis.  The article says that four times a week a nursing home resident calls in a panic because they were sent to the hospital for a medical or mental health condition. Then, when the hospital discharges the patients, the nursing homes won’t take them back.  This, of course, is against the law.  But the nursing homes don't care because the law is not enforced.

By law, skilled nursing facilities are required to give their residents a 30-day notice if they want them to leave the facility. 

If there is a reason why its staff can’t meet a resident’s medical needs, the facility should call the Missouri Department of Health and Senior Services.  However, the need is immediate and bureaucrats are busy.  Cheryl Wilson, director of the ombudsman services for the St. Louis Long-term Care Ombudsman Office, said the issue keeps her team running around in frantic circles all week, leaving them hardly any time to attend to other advocacy duties.

At Christian Hospital, in North St. Louis County, it happens “too many times not to be addressed by the State,” said Diana Tucker, social work case manager.

The State can’t quantify the number of cases because citations are not searchable by the type of violation.  The facilities say they would rather be cited by the State than take the resident back, Wilson said.

Both the ombudsman program and nursing homes are burdened with the surge in mental health patients. The State’s mental health care budget is dwindling every year. With psychiatric facilities closing, the patients are now moving into the nursing homes, Cheryl Wilson said.

This year, legislators severely slashed funds for the State’s two remaining psychiatric emergency rooms, as well as long-term care for people with mental illness and home care for the elderly.

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NY Times had a great article on the too common practice of overmedicating residents in nursing homes.  Nursing homes often chemically restrain residents because it is easier:  No complaints, no call bells, no requests.   Management can then staff less people on certain shifts especially at night.  Paula Spann wrote a great article.

Within three months of admission, a team of University of South Florida researchers determined, 71 percent of Medicaid residents in Florida nursing homes were receiving a psychoactive medication — an antidepressant or anti-psychotic, or dementia drugs — even though most were not taking such drugs in the months before they moved in and didn’t have psychiatric diagnoses. 15 percent of residents were taking four or more such medications.  Only 12 percent were getting nondrug treatments like behavioral therapy.

The article mentions Victor Molinari, a professor of aging at the University of South Florida and lead author of the study.  He wasn’t startled by those statistics. “They confirmed what I suspected,” he told me in an interview. “And people who work in nursing homes wouldn’t be surprised.  It seems the use of psychoactive medication is trumping the use of nondrug treatments,” Dr. Molinari said.   And given the possible interactions with the many other drugs most residents take, an average 10 or more prescriptions, “it could well be that we’re causing problems like falls, confusion and delirium, and hospitalizations,” he cautioned.

Nursing homes’ reliance on psychoactive drugs has troubled professionals in geriatrics for years.   In many states, residents being admitted directly from hospitals are exempt from screening.  As a result, federal data show, fewer than half of residents with major mental illnesses receive the mandated assessment.  Only half of nursing homes provide weekly patient consultations with psychiatrists, psychologists or other mental health experts; even fewer provide consultations with those who specialize in working with seniors. In addition, staffs are stretched thin and inadequately trained in mental health care. With a pill a quicker and simpler intervention than the alternatives, intentional overuse is the result.   If the aide had fewer patients to care for or if management increased staffing numbers, and more time to soothe one who was agitated, if she’d had better training in responding to behavioral problems, she might be able to handle behavioral issues.  

The Justice Department brought criminal charges against Eli Lilly, accusing the big pharmaceutical firm of illegally marketing its anti-psychotic Zyprexa to doctors who work in nursing homes and assisted living facilities, and encouraging them to prescribe it for sleep disorders and dementia. Its approved use is to treat schizophrenia and bipolar disorder. Lilly agreed to pay $1.4 billion in a related civil settlement.

“For years, I’ve had calls from family members saying, ‘Mom was completely lucid when she went into the nursing home, and a week later she no longer recognized us,’” said Janet Wells, public policy director of NCCNHR, formerly the National Citizens’ Coalition for Nursing Home Reform. “Families should question why drugs are prescribed, do some research. A lot of drugs are being used as restraints.”

Paula Span is the author of the recently published “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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ABC News reported a story about the deaths of residents caused by over medication and chemical restraint.  When residents at the Kern Valley Nursing Home complained or annoyed nursing director Gwen Hughes, prosecutors say she chemically restrained them with powerful anti-psychotic drugs. Her methods were so severe, three residents died.

California Attorney General Jerry Brown says that Hughes ordered one patient drugged just for glaring at her, and another for throwing a carton of milk. Some residents were left drooling, dehydrated, and dangerously thin.  According to Brown, "In a couple cases, elderly people were actually held down, restrained against their will, and given excessive amounts of medicine to keep them quiet."

Even more shocking -- Hughes had been fired for over-drugging once before, from a nursing home in nearby Fresno, Calif. The administrator of that nursing home said they told her next employer only the dates she worked there.

Three nursing home officials appeared at a hearing on charges of elder abuse at the Kern Valley facility from 2003 to 2007 -- Gwen Hughes, as well as administrator Pamela Ott and staff physician, Dr. Hoshang Pormir. The three defendants each face up to 11 years in prison, and all have pleaded not guilty. A preliminary hearing is set for March 9, 2010.

Additionally, a former pharmacist at the facility, Debbi Gayle Hayes, accepted a plea bargain on the condition that she testifies for the prosecution.

Experts say over-drugging is common nationwide, and the number of nursing home residents who are given these drugs is rising.   It has been estimated that nursing homes give anti-psychotics to one in every four patients. Some suggest that the drugs are replacing physical restraints, which are now illegal except as a last resort.

Toby Edelman, from the watchdog Center for Medicare Advocacy, says, "They're hiding the restraints. A physical restraint is visible, but a chemical restraint is not."

Using a chemical purely as a restraint is also illegal, but they are so widely used that the lawyer for Pormir, the doctor in the California case, plans to cite the drugs' widespread use as part of his defense.

His attorney, Dennis Thelen, says, "To suggest that using psychotropic medication is contrary to a patient's best interest is just flatly contradicted by what happens every day in the United States, yesterday, right now, and tomorrow."

A Food and Drug Administration official estimates that unnecessary anti-psychotics kill 15,000 nursing home patients each year, including Fannie Mae Brinkley.

There are steps you can take to make sure your loved one isn't at risk. Click the links below for more information.

Elder Justice Coalition http://www.elderjusticecoalition.gov

National Committee for the Prevention of Elder Abuse http://www.preventelderabuse.org

National Adult Protective Services Association http://www.apsnetwork.org/

National Center on Elder Abuse http://www.ncea.aoa.gov

National Association of State Units on Aging www.nasua.org

National Academy of Elder Law Attorneys www.naela.org

National Association of State Long-Term Care Ombudsman Programs http://www.nasop.org/

Nursing Home Comparison Tool from Medicare http://www.medicare.gov/NHCompare

Center for Medicare Advocacy www.medicareadvocacy.org

Directory of State Resources from the National Center on Elder Abuse http://www.ncea.aoa.gov/NCEAroot/Main_Site/Find_Help/State_Resources.aspx

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The Chicago Tribune had a good article about the use of anti-psychotic medications being overprescribed and over used in nursing homes.  Health advocates are calling for tough new rules on the use of anti-psychotic drugs in Illinois nursing homes, including tighter controls on doctors who prescribe the powerful medications. "Medical care should help you get better, not get worse," said Wendy Meltzer of Illinois Citizens for Better Care, an advocacy group for nursing home residents.

A Tribune investigation recently showed how many frail and vulnerable Illinois nursing home residents have been unnecessarily dosed with anti-psychotics, leading to harm and an increased risk of death. One psychiatrist, the Tribune found in a joint investigation with ProPublica, provided assembly-line care to thousands of mentally ill patients.

The FDA has approved anti-psychotic drugs to treat serious mental illnesses, such as schizophrenia, but doctors also prescribe them to geriatric patients with other conditions, such as dementia, in a common but controversial practice called "off-label" use. Meltzer said one way to stop nursing home doctors from using the drugs to "chemically restrain" residents is for the state to refuse to pay for certain medications.  Documents show that hundreds of nursing residents have been given psychotropics without their permission since 2001. 

Nursing homes, Meltzer said, should have a formal process of explaining the benefits and risks of taking psychotropics. Right now, she said, the goal of many nursing homes is to simply get residents to sign the forms as opposed to explain the options.

Advocates also said Illinois should require drugmakers to publicly disclose payments to doctors so that their patients can be aware of possible conflicts of interest. One pharmaceutical company gave Reinstein nearly $500,000 to promote a drug that Medicaid records suggest he prescribed 41,000 times.

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