Withholding Records

Oklahoma News 9 reported on a troubling story involving the abuse of an elderly woman at the Quail Creek Nursing and Rehab Center in Oklahoma City. When daughters suspected that their mother, 96 year old Eyretha Mayberry, was suffering physical abuse at the hands of nursing home staff they took matters into their own hands by installing a secret camera in their mother’s room. Mayberry’s daughters caught nursing staff on film abusing 96 year old Mayberry. This video documentation led to the dismissal of staff members involved in the abuse, but the Quail Creek Center has refused to provide the family with medical records, and the investigation into the incident.  Sounds like someone is attempting to cover up the abuse.

Mayberry’s daughters have requested that Quail Creek Nursing and Rehab Center furnish their mother’s chart, which should document the injuries Mayberry sustained through staff abuse. However, the Quail Creek has failed to provide the requested medical paperwork after several requests; first claiming that the medical records had been sent to the "central office", and then stating that Mayberry’s daughters did not have the proper paperwork to request the records.

More disappointing still is the fact that the Department of Health has failed respond to Mayberry’s daughters’ request for further investigate into Mayberry’s case. When News 9 called the Department of Health to request a statement on the Mayberry abuse case, the Chief of Long Term Case responded that she “could not confirm or deny if an investigation is currently being done.”
 

Improper Transfer = Criminally Negligent

It was reported by both the Minnesota Public Radio News and the Minnesota Star Tribune that a Minnesota Department of Health investigation found two employees at the Castle Ridge Care Center in St. Paul to be criminally negligent in their care of an unnamed, elderly patient, going so far as to lie about a fall which directly led to the patient’s death back in January.  These two highly questionable characters tried to lift this elderly patient into a wheelchair using a mechanical lift, but they did not check to make sure that “‘all of the loops on the sling were properly attached to the lift.’”  As a result, the patient suffered a bad fall, which caused a lung to collapse and numerous bones to break. She was taken to a hospital for treatment, but sadly died three days later due to respiratory and renal failure, “complications from injuries caused by the fall.”

The employees neglected to report both the fall and their responsibility for it in an effort to cover it up.  They told a Castle Ridge nurse, who walked into the room just moments after the fall, that the patient had hit her head on a bar on the lift which caused a bump.  After viewing the patient’s X-rays which revealed broken bones, however, the nurse “asked the workers to re-enact the incident” and determined the practical impossibility of the bar hitting the patient’s head.

According to the director of the Office of Health Facility Complaints at the Minnesota Health Department, it seemed as though the negligent duo had deliberately attempted to cover up what they had done so people would not find out, and they would not get into trouble, and they later admitted as such.

"Attempted" Neglect?

An Ohio news station, NBC 4, reported that a local nursing supervisor have been found guilty of attempted neglect at a Woodsfield nursing home.  What the heck is "attempted" neglect?

Kathy Schwaben was employed at Monroe County Care Center when she neglected to assist an injured resident.  The resident was injured when she was a passenger in a MCCC van and the driver swerved recklessly, throwing the 81 year old out of her wheelchair.  An investigation discovered that the resident was not properly secured in her wheelchair at the time of the incident. There was no lap or shoulder restraint in use.  Instead ,she was crudely restrained by a bungee cord that was stretched across the arms of her chair. After the incident Schwaben failed to preform a physical assessment so the victim did not receive any immediate medical treatment following the incident. The elderly lady suffered several fractured bones as a result of the incident.

Schwaben was sentenced to a mere 10 day in jail that was suspended and only has to pay fines and court costs.  It is sad that the neglect of a family’s loved one is not taken more seriously and the punishment does not reflect the severity of the damage done.

Suspicions lead to Investigation

Wood TV 8 reported that a Wayland, Michigan nursing home is facing an investigation after Patricia Slornski began to question the suspicious circumstances surrounding her mother’s death.  Doris Robbins was resident of Laurels of Sandy Creek nursing home when she died suddenly.  The facility told Slornski that her mother had taken a afternoon nap and had simply never woken up.  When Slornski called the facility for more details she was put on hold for a lengthy amount of time and was then only allowed to speak to the facility’s lawyer.  This alerted Slornski to possible problems and motivated her to seek an investigation.

The report discovered that Robbins started to show signs of medical distress as early as ten o’clock the morning of her death. No one at the nursing home ever called a doctor and at 3:45 Robbins was discovered dead in her bed.

Robbins had previously put into writing her wish for doctors to do everything they could keep her alive. However, the facility ignored Robbins’ wish to be kept alive.  In addition to not calling a doctor for medical attention, the facility also did not preform CPR, call an ambulance, or notify police of the death.  Slornski is speaking out in hopes of getting answers for her mother’s death and preventing similar incidents from happening to other families’ loved ones.  “It’s not just about my mother because there are people like her that have a face, that are in jeopardy when rules and regulations are not followed.”

Billion dollar Fine for Risperdal

The L.A. Times reported the $1.1 billion fine imposed by a federal judge in Arkansas litigation against Johnson & Johnson after a jury found that the companies downplayed and covered up risks associated with taking the antipsychotic drug Risperdal.  Circuit Judge Tim Fox determined that Johnson & Johnson and subsidiary Janssen Pharmaceuticals Inc. committed nearly 240,000 violations of the state's Medicaid fraud law — or one for each Risperdal prescription issued to state Medicaid patients over a 31/2-year period.  Each violation carried a $5,000 fine, the state's mandatory minimum amount, bringing the total to more than $1.1 billion. Fox issued an additional $11 million fine for more than 4,500 violations under the state's deceptive practices act, but he rejected the state's request to levy fines in excess of the $5,000 minimum for the Medicaid violations.

Arkansas was one of several states to sue over Risperdal. A South Caroline judge upheld a $327-million civil penalty against J&J and Janssen in December 2011.  Meanwhile, Texas reached a $158-million settlement with the companies in January in which they didn't admit fault.

 

Assault Between Residents

The Chicago Tribune reported the suspicious death of a resident after a fatal altercation with another resident at Oak Park Healthcare Center.  The nursing home failed to report the altercation to the health department for further investigation. Anibal Calderon, 80, died of head injuries after an alleged fight that took place.  Calderon's death was ruled a homicide by the Cook County medical examiner's office. The Illinois Department of Public Health is now investigating.

Under state law, the nursing home should have reported the incident immediately to the health department as well as to the family of the victim and local police. Federal regulations require that nursing home residents involved in violent incidents be removed from the facility if necessary for their safety and the safety of others.  State officials have no record that Oak Park Healthcare notified the health department, said spokeswoman Melaney Arnold.  The for-profit nursing home has 204 beds and an occupancy rate of about 75 percent, according to the state. 

Nursing homes are also required to make available for public inspection the five most recent years of survey materials that would list possible violations, according to the IDPH website. But the Tribune reporter was escorted out of the Oak Park facility after requesting to look at the documents.

 

$8 Million Verdict in Improper Transfer Case

The Louisville Courier Jornal reported the jury's verdict in a recent two week nursing home neglect trial against Treyton Oak Towers.  The jury awarded $8 million in damages to the estate of a retired surgeon whose legs were broken becuase of neglect.  Dr. David Griffin died less than two months after he was improperly transferred from a chair into his bed causing fractures.  The plaintiffs claimed Griffin was transferred without a lift and by only one nursing assistant, in violation of the nursing home’s care plan, which required two assistants.

The worse part is that Defendants tried to cover up what happened.  Employees were ordered to change medical records to cover the incident up.  This happens all the time in nursing homes. 

The verdict was returned after the jury deliberated for about two hours and included $2 million for pain and suffering, $1 million for violating the state nursing home statute and $5 million in punitive damages.
 

Crime and Cover Up

Kansas City's KCTV5 reported the lawsuit filed about the alleged crime and cover-up at Brandon Woods at Alvamar.  Predictably, Defendants say there is no merit to the lawsuit, but the allegations in a 32-page court document are detailed and disturbing.  The suit was filed by the family of Jean Allen who was living at Brandon Woods at Alvamar in hospice care with dementia and almost entirely immobile.

The report of a possible sexual assault by a nursing aide was upsetting to the family, but the outrage stems from how the facility responsible for Allen's care handled that report.

"The lawsuit against the owners and staff says the daughter of Allen's roommate called the head of nursing on Oct. 21, 2010.  "The telephone message starts out, 'Something awful may have happened,'" said Skepnek.  Skepnek says the head of nursing, Sharon Mulqueen, did not contact Allen's family, did not suspend the nursing aide, did not call police and did not send Allen to the hospital. The next day, he says, Mulqueen suspended the aide and sent Allen to Lawrence Memorial Hospital - not for a sexual assault exam, but for a routine Medicare exam."

The nursing home staff refused to file a police report until hospital staff threatened to do so themselves.  In the interim, the nursing home staff had bathed Allen and washed her clothes, destroying whatever DNA evidence might have been available.  As for Allen's exam, the suit says a specialized sexual assault nurse reported cuts and scrapes that left her with "no doubt" that Allen had been sexually abused.

 

Burying the Truth

ProPublica, in collaboration with PBS “Frontline” and NPR, took an in-depth look at the nation’s 2,300 coroner and medical examiner offices and found a deeply dysfunctional system that quite literally buries its mistakes.   ProPublica and PBS "Frontline" have identified more than three-dozen cases in which the alleged neglect, abuse or even murder of seniors eluded authorities. But for the intervention of whistleblowers, concerned relatives and others, the truth about these deaths might never have come to light.  Below are excerpts of the report:

When it comes to the elderly, the system errs by omission. If a senior like Shepter dies under suspicious circumstances, there's no guarantee anyone will ever investigate. Catherine Hawes, a Texas A&M health-policy researcher who has studied elder abuse for the U.S. Department of Justice, described the issue as "a hidden national scandal."

 

Because of gaps in government data, it's impossible to say how many suspicious cases have been written off as natural fatalities. However, the limited evidence available points to a significant problem: When investigators in one jurisdiction comprehensively reviewed deaths of older people, they discovered scores of cases in which elders suffered mistreatment.

An array of systemic flaws has led to case after case being overlooked:

•When treating physicians report that a death is natural, coroners and medical examiners almost never investigate. But doctors often get it wrong. In one 2008 study, nearly half the doctors surveyed failed to identify the correct cause of death for an elderly patient with a brain injury caused by a fall.
•In most states, doctors can fill out a death certificate without ever seeing the body. That explains how a Pennsylvania physician said her 83-year-old patient had died of natural causes when, in fact, he'd been beaten to death by an aide. The doctor never saw the 16-inch bruise that covered the man's left side.
•Autopsies of seniors have become increasingly rare even as the population age 65 or older has grown. Between 1972 and 2007, a government analysis [2] found, the share of U.S. autopsies performed on seniors dropped from 37 percent to 17 percent.
 

In a 2008 study, 225 physicians were asked to determine what killed an elderly man who had fallen and suffered a severe head injury. Just over half of the doctors correctly identified bleeding of the brain as the primary cause of death. Nearly two-thirds didn't list the fall as a contributing factor.Erroneous death certificates and faulty reporting practices are partially responsible for few senior deaths being investigated. But there's another factor: Many coroners and medical examiners resist looking into these cases.

Of the 1.8 million seniors who died in 2008, post-mortem exams were performed on just 2 percent. The rate is even lower -- less than 1 percent -- for elders who passed away in nursing homes or care facilities.

 

 

Admitting Nursing Errors

The website MedicalXpress had an article discussing the new study called, "Nurses' Perceptions of Error Reporting and Disclosure in Nursing Homes," published in the January 2012 issue of the Journal of Nursing Care Quality.   The majority of registered nurses who responded said error disclosures are difficult to process in nursing homes.   In NHs, nurses more routinely interact with patients with complex needs, which in turn increases the chance of errors occurring. Nursing errors refer to a nurse's action that adversely affected, or could have adversely affected, a patient's safety, quality of care, or both. Examples of nursing errors include lack of prevention (eg, breach of infection control precautions), inappropriate judgment or attentiveness, misinterpreting a physician's order, or documentation errors.

NYUCN Assistant Professor of Nursing, Laura M. Wagner, PhD, RN, GNP-BC said  "Our research highlights the need for nursing homes to improve communication processes and policies, ultimately rendering a culture of safety in nursing homes."  The authors found that multiple barriers exist that might inhibit disclosure; almost one-third of the respondents were less likely to disclose if they believed they might be sued or reprimanded.

"Although there is increasing attention to disclosing harmful events, there is a significant gap between what is expected and what actually occurs in current practice. The process of disclosing is an ethical and legal obligation that provides essential information to patients and families."

The cover up is always worse than the initial mistake made by the caregiver.