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

Philadelphia Daily News had an article about the sad death of Harold Chapman, a vet who was allowed to wander away from Delaware Valley Veterans Home.   Chapman, diagnosed with dementia and work-related brain damage, wore only pajamas when he stepped past a manned security desk at 5:30 p.m. Dec. 31, 2007, and into the winter cold. Two hours later, a staffer reported that she could not find Chapman, a Korean War veteran, in his room or anywhere else.  Ten hours passed before Chapman's lifeless body was found a few yards from the state-run nursing home.  Details about Chapman's death emerged in a lawsuit his daughters filed against the state.  Evidence produced for the lawsuit includes surveillance tapes of the former policeman leaving the home.

Records from the Delaware Valley Veterans Home show that there were multiple failures by staffers, first by not monitoring Chapman's movements and, after he was belatedly discovered missing, by failing to immediately follow established emergency procedures. Staffers didn't notify the home's commander until after 9 p.m., more than three hours after Chapman disappeared. They didn't call police until 9:15 p.m.

Surveillance tapes show that Chapman left his restricted area by riding the elevator with an employee who was not authorized to be in the building at that time. One staffer, one of the last to be seen with Chapman, abruptly quit his job when told he would be questioned. Called "a person of interest" by investigators, the aide later was discovered to have a criminal record for stalking.

"If he were any closer, they would have tripped over him," his widow, Barbara Chapman, said in a recent interview.  "It was New Year's Eve, and everyone was getting ready for a party. He walked right by them," said Barbara Chapman, who viewed the tape. "He couldn't find his way back, and got lost. They told me it was painless, but I later found out it can be a very horrible death."

The Pittsburgh Tribune-Review has been investigating state veterans' homes and has found serious deficiencies at two of them, in Hollidaysburg and Scranton. The U.S. Department of Health and Human Services rated those facilities below average in meeting inspection requirements, giving them the lowest possible ranking: one star out of five, while other homes in the system fared better.

The 1,632-bed state veterans health system, dating to the Civil War era, costs $165 million a year to operate. It is separate from the federal Veterans Affairs. The state facilities include nursing-home beds, personal care facilities and locked dementia units, where many of the serious violations occurred.

• Email This
• Print
• Comments
• Trackbacks

The Star-Tribune had an interesting article about the massive stroke and death of a resident caused by a nursing home failing to give a medication despite a physician's order.  State investigators say a woman recovering from spine surgery died of a massive stroke in June after a nursing home in Faribault, Minn., failed to give her a medication prescribed to prevent blood clots.

The doctor's order was incorrectly transcribed by a nurse at Faribault Commons Nursing and Rehabilitation, and the home did not have adequate checks to spot the error, its administrator acknowledged Monday. The home was cited for neglect.

The report, made public last week by the department's Office of Health Facility Complaints, said this is what happened:

The unidentified patient was moved from a hospital to Faribault Commons on June 2 for rehabilitation therapy with orders for the daily Lovenox injection.  She was given the drug for three days, mistakenly did not get it on the weekend, then got it again for four days.  Then the treatment was stopped because a nurse mistakenly had written that it was to end on June 11, instead of July 11 as ordered.  The patient had a massive stroke on June 17 and was sent to the hospital, but returned to the nursing home two days later for end-of-life care. She died on June 24.

• Email This
• Print
• Comments
• Trackbacks

TriCities.com had an article about the case of Anne Brightwell.  She died in a hospice bed June 16 after months of screaming over a fractured left femur that would not heal.  Her upper leg bone shattered Feb. 6, when a hammock sling, used by Cambridge House nursing home staff to hoist her from a bed to a wheelchair, snapped. A medical examiner listed the broken femur as the cause of death on Brightwell’s death certificate.

The fall could have been prevented.  The nursing home had a history of using aging and tattered slings, but throwing newer equipment into use only when Tennessee Health Department inspectors arrived.  Three former Cambridge House employees say administrators hid daily-use equipment from inspectors, only to later pull it out after tucking away the newer items until the next state visit.

Cambridge House is part of a national chain of for profit nursing homes owned by AltaCare Corp., based in Alpharetta, Ga.  A letter faxed to the newspaper by Cambridge House confirmed “an incident involving use of clinical equipment, resulting in an injury that was treated in accordance with accepted clinical standards of practice.”
 
“Granddaughter Amy Shell noted in an interview that Brightwell lived through her twilight years without ever needing prescriptions for such common elderly ailments as high blood pressure or cholesterol.  Brightwell landed in a Cambridge House bed to rehabilitate an ankle she fractured at her Bristol, Tenn., home, where she lived alone, except for nightly visits from relatives.  Shell said Brightwell likely would have left the nursing home after rehab was complete.

Expectations changed the day the hammock sling snapped, with Brightwell awkwardly slamming to the floor on her left side.  Because of her age, the bone would not heal on its own. And, at her age, surgery to amputate the leg might have killed her.  The only option left for the aging matriarch was to rely on pain pills. Family members said it didn’t offer much help.  “Mom would lay in bed and say ‘Help me please, help me God, Jesus,’ and this would go on for hours,” Countiss said.

Former nursing aide Dickie Norris recalled in an interview the threadbare condition of the three hammock swings used at Cambridge House from last year until soon after Brightwell’s fall.
“They were frail ... like a worn out pair of jeans,” said Norris, who joined the nursing home in June 2008 and left in March.  The lifts remained in use until four weeks after Brightwell’s fall. Norris said he was lifting a patient out of bed and had him in midair when an administrator appeared and told him to get the patient down and hand over the sling.  “Then they ordered slings, but they wouldn’t work on the (pulley) machines,” Norris said. “We couldn’t get people up for physical therapy for weeks.”

Former nursing aide Brian Gross, who worked at the nursing home from May 2008 until October 2008, did not trust the slings.  “In those slings, I wouldn’t want to be lifted in it, and I weigh only 140 pounds,” he said.   Gross estimated that many of the nursing home’s patients weigh more than 200 pounds.  Gross recalled that the slings shown at inspection were slightly used, but in much better shape than the ones kept in daily circulation.

The hammock slings might have been discarded months earlier, had state inspectors seen them. Past nursing home employees said the Cambridge House administration went so far as to hide shabby equipment during health department inspections.  Former nursing aide Tony Apple, in a sworn deposition provided by lawyer Parke Morris, said that administrators pulled out newer equipment specifically for annual state inspections.  “Once the state inspection was over, the old slings came out,” Apple said in the deposition. 

Not only were the hammock slings in ill shape, said Shawna Caudill, a former Cambridge House nursing manager, but the bedsheets, towels and other linens showed considerable wear, too.
Caudill, who joined Cambridge House in April 2007 and left in November 2008, said the administration purposely overlooked the shabby quality of equipment.  “The faulty equipment was definitely brought up at many meetings, but it all boiled down to cost,” Caudill said.   One administrator’s “exact words were to put on my big-girl panties and deal with it.”

• Email This
• Print
• Comments
• Trackbacks

The Tracy Press out of California had an article about the death of a nursing home resident caused by the neglect and negligence of the nursing home.   New Hope Care Center which is owned by the for profit corporate owner Evergreen Healthcare Companies, LLC failed to properly monitor her medication and failed to check her into an emergency room fast enough when her brain started bleeding.  Caregivers failed to keep a close eye on the condition of the patient after a doctor ordered an increase in medication to prevent blood clots. A possible side effect of the medication is excessive bleeding. Because the nursing home staff didn’t monitor a change in the woman’s condition after the doctor upped her anticoagulant prescription, the state said they missed warning signs that could have saved the woman’s life.  Days after the doctor-ordered increase in her blood-thinning medication, the woman started slurring her words and complaining of a headache.  Even though the woman woke up just a couple hours earlier, she started nodding off, waking up only to vomit.

The facility was fined $100,000 after the nursing home ignored the worsening condition of a patient.  State investigators concluded that New Hope caregivers “failed to ensure that the resident’s medications were monitored and failed to fully assess the resident or promptly notify the physician when there was a change in the resident’s condition, which resulted in the resident’s death,” according to Al Lundeen, a spokesman for the state agency. The fine levied on the nursing home is the maximum penalty the agency can impose for a “AA” citation, the harshest assessment for hospitals and nursing homes in California.

The article mentions several other complaints and investigations into New Hope.

• Email This
• Print
• Comments
• Trackbacks

Minnesota state health officials investigated the death of a chaplain, Rev. Tim Vakoc,  who had been injured in Iraq.  The investigation revealed that the chaplain was neglected by nursing home employees after he fell and later died.  The priest was believed to be the first military chaplain wounded in Iraq.

The state investigation refers to a patient who hit his head after he fell out of a mechanical lift while being moved by two staff members. He died at a hospital later that day. The investigation said the two employees, both nursing assistants, did not follow procedures for using the lift despite having been trained to do so. "Neglect did occur," the report states.

Vakoc was only 49 when he died. He was returning from celebrating a Mass with troops near Mosul on May 29, 2004, when he was struck by a bomb blast that severely injured his brain and cost him an eye.  He was hospitalized at both Walter Reed Army Medical Center in Washington and the Veterans Affairs Medical Center in Minneapolis, and underwent numerous surgeries. He had slowly started recognizing friends and families, and spoke again for the first time about three years ago.

• Email This
• Print
• Comments
• Trackbacks

The Cherokeean Herald had an article about the tragic and preventable death of a nursing home resident and the nursing home's attempt to cover it up.   Police and state Attorney General's office are investigating a death at Hillside Plaza Nursing Home.  At approximately 6 a.m., Edna May Sides was found dead outside the nursing home by staff members.

Nursing home staff contacted her family at approximately 10 a.m. the same day.  "Her family ended up notifying us," said Wells Police Chief Barry Starnes. "The nursing home treated it like a patient passing away and notified the family.  "The family thought it was a little strange, so they went to the Justice of the Peace in Alto and then called the Sheriff's Office and our department."

Chief Starnes says "I believe there was possible negligence, but I don't believe someone purposely did this."  "We're trying to get to the bottom of how this person got outside when she wasn't supposed to be," he said. "Hopefully, we're close to coming to a conclusion."
 

• Email This
• Print
• Comments
• Trackbacks

The St. Clair Record had an article about the recent lawsuit filed for a resident who died after the nursing home allowed the elderly woman to fall multiple times causing her death.  Dora Haskins-Bond lived at Eldercare Inc., doing business as Calvin Johnson Care Center, from December 2004 until July 31.   During her stay at the center, Haskins-Bond fell on July 7, sustaining fractures to her left femur and right knees.   Because Haskins-Bond had previously fallen several times while staying at Calvin Johnson, the home should have known of her susceptibility to falls and fractures and done something to prevent the falls.

The center and its owners failed to provide adequate resources and monitoring for Haskins-Bond to prevent her from falling.  Because of her fall, Haskins-Bond incurred substantial medical costs, endured substantial pain and suffering in her body and mind and suffered disability, disfigurement and an aggravation to her pre-existing health conditions.

In addition to Calvin Johnson, Eldercare's administrative manager, Steven Wolf, and Prudence Wolf, who had an ownership interest in the company, are included as defendants in the suit.

• Email This
• Print
• Comments
• Trackbacks

The Northwest Herald had an article about a lawsuit involving the neglect of a resident that led to a fall that caused her death.  The wrongful death lawsuit against a Chicago nursing home, Sacred Heart Home, states that the nursing home failed to prevent the fall that led to the resident’s death.

Kathleen Koch, died after suffering from a broken back, head injuries and paralysis after she fell in a stairwell at the nursing home. The fall happened Dec. 21, and she died eight months later at 61 years old.

The case alleges that staff should have better supervised Koch because they knew she had been diagnosed with bipolar disorder and schizophrenia and was at high risk for wandering and falls.  However, her room was not near a nurse’s station, and Koch was able to go into the stairwell unsupervised.

She was the type of resident that needs to be closely monitored and supervised which clearly was not done.  I am sure the nursing home will blame the resident and claim it was all her fault.

• Email This
• Print
• Comments (1)
• Trackbacks

The L.A. Times reported another story about a nursing home fined for allowing a resident to choke to death.  This is the third story about choking deaths in nursing homes in the last couple of weeks.  The nursing home was fined $80,000 after a 54-year-old schizophrenic patient choked on a meatball and died.

Raintree Convalescent Hospital had known the patient had problems swallowing.  The spaghetti meatball served to him needed to be chopped or sliced before being given to him.  Both the cook and the nursing assistant who served the meal failed to grind up the meatballs, as required. The cook failed to follow the directions for the patient's meal by not mashing up the meatball. He also said the nursing assistant failed to look at the meal card on the patient's tray -- which would have been a second chance to catch the error -- before serving the lunch. 
 

"I just did not think to chop up his meat that day," the nursing assistant told state investigators.   The facility was probably understaffed which did not allow her time to do her job properly.

The man stumbled out of his room, pale and unable to speak. After a nurse unsuccessfully attempted the Heimlich maneuver, paramedics were able to suction the meatball out of the man's airway, but he was pronounced dead at a hospital emergency room.

• Email This
• Print
• Comments (1)
• Trackbacks

Mark N. Geller is a Memphis attorney with Nahon, Saharovich & Trotz PLC. He leads the firm's nursing home practice group. He wrote the following column which can be found here:

The federal government's Medicare program recently released a rating system that ranks the quality of care for residents in nursing homes. Among our nation's 50 states, Tennessee ranked third from the bottom in its percentage of nursing homes that received the report's highest five-star rating -- ahead of only Louisiana and Georgia.

According to this rating system, Tennessee also had the fourth-highest percentage of poor-performing nursing homes in the nation (those that received the lowest possible rating of one star), behind Louisiana, Georgia and Virginia.

On the surface, these results are bad enough for Tennessee's elderly population and their families. Unfortunately, though, the Medicare Nursing Home Compare report fails to capture the true extent of how poorly our fellow Tennesseans who live in nursing homes are being cared for right now.

In fairness to the nursing home community, four nursing homes within 50 miles of Memphis were given the highest ranking by Medicare's report, and they stand out among the best in the country. (To view the full report, go to medicare.gov.)

As an attorney who practices in the area of nursing home litigation, I witness almost daily the substandard level of care many elderly Tennesseans must endure. I have seen the wide range of poor nursing home care across this state; poor care that sometimes includes leaving people in their own excrement for long periods of time, which results in bed sores and even death. There are cases -- and they're not uncommon -- in which elderly nursing home residents have been left begging for food and water, but have been ignored. Or cases -- including one recently in Memphis -- where elderly residents have wandered out of their nursing facility unsupervised and were severely injured.

Even this bare recitation of facts pales next to actually hearing a family's story. Family members have spoken about how they begged and pleaded for care that never came. They have talked about the heartrending suffering their loved ones go through in their last days of life.

Despite these stories and the objective data ranking Tennessee among the worst in the nation for nursing home care, Tennessee legislators recently sponsored bills (HB2243 and SB2160) to reform lawsuits against the nursing home industry by putting a monetary value on human life.

The bills set the price of a human life at $300,000. If they become law, that would be the maximum amount of noneconomic damages that could be awarded to plaintiffs in lawsuits against a nursing home. In addition, if a jury concludes that the nursing home's actions were so wrong that they warrant the award of punitive damages, that amount would be limited as well, by a formula that uses calculations provided by the nursing home itself relating to its level of patient care.

These proposals, which are under review in legislative committees, are bad bills that are primarily focused on limiting the compensation that a family can recover if a jury finds that a nursing home acted improperly. They would protect nursing homes from liability. Nothing in them would protect nursing home residents.

There is no serious measure within these bills that sets out minimum standards for proper care of nursing home residents. The proposals fail to provide measures to protect the residents from negligent or improper care. They have no provisions to require nursing homes to maintain proper staffing levels or even treat their residents well.

Tennessee's low ranking in the nursing home industry is easy to understand. Typically, nursing homes are operated by multibillion-dollar, multistate corporations whose main purpose is to make as much money as possible for their shareholders. Of course, there's nothing wrong with making money. What is wrong is that many nursing home chains too often cut operational costs to increase profits. Such cuts are unconscionable when they are done at the expense of their stated business goals: the comfort and well-being of the elderly.

When a nursing home's budget is cut, the nursing home must function with less supplies, equipment and staff. Less staff means fewer people to provide care to the residents. Eventually, it reaches a point at which the staff, no matter how caring or qualified they may be, are simply unable to meet the needs of the residents.

Life is precious and should be treasured. Every human being deserves to be treated with dignity and respect.

Making money is perfectly acceptable so long as you are doing your job first. Here, the primary job should be to provide skilled and humane care to the residents of Tennessee's nursing homes and to make sure their needs are being met.

The state should legislate serious standards of care for nursing homes. And nursing home operators should be held accountable if they fail to live up to those standards.
 

• Email This
• Print
• Comments
• Trackbacks