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

PRWeb summarized a story from the NY Post about punitive damages against a nursing home in New York.   The New York Post reported that in December 2009, a Brooklyn nursing home was found guilty of negligence in the case of a patient who developed numerous and avoidable bedsores while under the home’s care. The jury awarded the patient’s family close to $4 million for pain and suffering, plus an additional $15 million as punishment for trying to cover up the poor patient care.

Elder abuse is prevalent in nursing homes around the country, and with serious consequences for patients. Older adults who are victims of elder abuse are more than twice as likely to die prematurely as are adults who are treated properly, according to a study published in the August 5, 2009 issue of the Journal of the American Medical Association.

Mistreatment can take many different forms, including physical, emotional, psychological or sexual abuse; neglect; withholding food and water; or denying visits from family and friends.  Family members and friends of nursing home residents must be vigilant in looking for signs of possible abuse or neglect.  These can include personality changes, depression, anxiety, unexplained or unusual bruises and injuries, rapid weight loss, poor grooming, and potentially unsafe conditions.
The National Center on Elder Abuse defines institutional elder abuse as “any of several forms of maltreatment of an older person by someone who has a special relationship with the elder (a spouse, a sibling, a child, a friend, or a caregiver)” that occur in residential facilities for older persons, including nursing homes. Its website, www.ncea.aoa.gov, explains that “perpetrators of institutional abuse usually are persons who have a legal or contractual obligation to provide elder victims with care and protection (e.g., paid caregivers, staff, professionals).

Looking exclusively at falls, the Centers for Disease Control and Prevention noted that an average nursing home with 100 beds reports 100 to 200 falls each year, representing up to 75 percent of residents. Many falls were caused by environmental hazards like wet floors, poor lighting, incorrect bed height and improper wheelchair use.

A November 2009 report from the University of California, San Francisco, stated that 26 percent of the nation’s nursing facilities were cited in 2008 for poor quality of care, 44 percent of nursing homes failed to ensure a safe environment for residents, 36 percent had food sanitation regulations violations and 33 percent of facilities received deficiencies for failure to meet quality standards.

 

 

 

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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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The second part of the Star-Tribune's investigation into fatal falls at nursing homes concentrate on the lack of sanctions.  Seventeen days after Agnes Johnson died, state investigators drove out to the White Community Hospital and Nursing Home to interview the staff.  An aide told them she had turned away momentarily while using a mechanical lift to maneuver Johnson from her bed to a wheelchair, and Johnson slipped from the device's sling to the floor, breaking her shoulder and thigh. The OHFC concluded that she died from neglect. It concluded that the aide violated the home's guidelines requiring two people to perform lifts, according to a report. It also determined the nursing home had not properly trained the aide to use the lift.  Despite the mistakes and Johnson's death, the OHFC did not cite the nursing home for violating state and federal regulations. The state found neglect in 17 cases statewide since 2004 where residents were seriously injured or died after falling out of lifts. It has issued citations for errors in only three cases.

When a Minnesota investigation finds that a nursing home was at fault, regulators require nothing more of the nursing home if it fired the worker involved or developed a corrective plan before investigators arrived. Minnesota rarely issues fines against nursing homes.  That is why some health care advocates question the OHFC's effectiveness in holding nursing homes accountable for abuse and neglect -- including falls.  They question a regulatory approach in which more than 1,000 Minnesota deaths were attributed to falls in nursing homes from 2002 through 2008, but the OHFC fully investigated only about 75 of those.

Federal officials audit the OHFC's process for evaluating reports of all types of incidents -- including falls -- and triaging them for possible investigation.  In the past two years, the OHFC has not met federal standards in how it selects cases to investigate.  Last year, federal auditors said that in a sample of complaints, OHFC triaged only 60 percent correctly.

In one of the sampled cases, the OHFC declined to do an on-site investigation into whether a nursing home was using mechanical lifts correctly and if the facility was following physician orders for medical checkups after injury. The auditors said the case should have been given the highest possible priority because other residents who were being moved with lifts were at risk.

But Minnesota's practice of not routinely issuing citations has a drawback, she acknowledged. To help consumers shop for nursing homes, the federal government developed a five-star quality rating that uses the number of citations issued against each home as part of the rating. That means that some substantiated cases of neglect are not reflected in the ratings for Minnesota homes.

In 2005, two nurses aides at Viewcrest Health Center were using a mechanical lift to move a resident from a wheelchair to bed. Without warning, the sling tore and the elderly woman fell to the floor.  The fall left her in great pain and her overall condition deteriorated. Six days later, she died. OHFC investigators discovered that Viewcrest was using a sling that had been patched to fix a broken strap, despite the manufacturer's recommendation to discard and not repair damaged slings. Despite the harm to the resident, the OHFC did not cite Viewcrest for violating government rules.

Viewcrest was found at fault in 2006, when the OHFC ruled that the nursing home didn't properly care for a resident, a known falls risk, who fell and broke her neck. The OHFC did issue citations in that case. Two years later, in 2008, the OHFC again cited Viewcrest because it didn't develop a care plan to help a resident who had fallen 11 times. But in the same year, the OHFC determined Viewcrest was at fault when a resident rolled off a bed and broke her leg while being cared for by a nurses aide. The state regulators said the facility did a poor job training the aide to care for the resident. No citations were issued. Then, in 2009, there was another fall-related incident at Viewcrest. The staff left a resident, who was at risk for falls, alone in his wheelchair and did not activate an alarm that would have sounded as he fell and cut his head. For a third time in four years, the OHFC declined to issue citations for mistakes the home made that resulted in falls.

Helen Fellerman, 93, had a rare disease that made her particularly prone to bleeding. She was also unsteady, forgetful and had a history of falls. So alarms were attached to her bed and wheelchair at Stillwater Good Samaritan Center so staff members would know when she was on the move. But when Fellerman tumbled from her wheelchair on the night of Aug. 31, 2005, the alarm did not go off, an OHFC report noted. She had been left alone for about 30 minutes. She died three days later. The fall had caused bleeding inside her skull, made worse by her medical condition.

 

 

 

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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 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.

 

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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.”

 

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Chicago's Daily Herald had an article about a million dollar settlement between a nursing home and the family of a resident who died after repeatedly falling at the nursing home in Libertyville.  The case, prompted by the 2005 death of 83-year-old Helen Menneke at Winchester House, was settled out of court after mediation.   Attorney Susan Novosad called the figure the largest nursing home negligence settlement in county history.

Menneke, formerly of Mundelein, was admitted to Winchester House in January 2004, suffering from dementia, Novosad said.   She fell several times over the course of the year, suffering a brain injury and broken bones, Novosad said.   Injuries from a final fall in December 2004 required surgery, and Menneke died in January 2005.

After Menneke's death, Winchester House instituted new policies requiring staff to more frequently check patients' wheelchair and bed alarms to ensure they're working properly, Novosad said.

"The family was outraged that this happened to their relative," Novosad said. "(They) didn't want this to happen to anybody else."
 

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Updated sentinel event statistics

The Joint Commission’s sentinel event statistics have been updated on The Joint Commission website. Since the sentinel event database was implemented in January 1995 through June 30, 2008, The Joint Commission has received 5,208 reports of sentinel events. A total of 5,336 patients were affected by these events, with 3,713, or 70 percent, resulting in patient death. The 10 most frequently reported sentinel events are:

Wrong-site surgery                                    691
Suicide                                                         641
Operative/post-operative complication  598
Medication error                                          470
Delay in treatment                                       390
Patient fall                                                     307
Assault, rape or homicide                         198
Patient death or injury in restraints         183
Unintended retention of foreign body*    175
Perinatal death or loss of function           159


* Added to reviewable events in June 2005; data represents events reviewed since that time.

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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.

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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.

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