Medicare and the Bounce-Back Effect

Huffington Post had a great article about the Bounce-Back Effect and how acute care hospitals and nursing homes manipulate Medicare policy to increase profits.  There is a new phenomenon that has the interest of both the government and hospitals. Patients who bounce back. This refers to patients who are discharged from an acute care hospital and are readmitted within 30 days.

Patient re-admissions or bounce back is a serious financial and quality issue. A 2009 study published in the New England Journal of Medicine analyzed almost 12 million Medicare beneficiaries and found that approximately one-fifth were readmitted within 30 days of discharge and an even more alarming 34 percent were admitted in 90 days. If we look a year out from discharge they reported 67.1 percent who had been discharged for a medical condition had been readmitted or had died.

This revolving door is expensive and cost Medicare $17.4 billion dollars in 2004.  As a result, Medicare has already started to collect data on all hospitals and will keep a three-year running average of their readmission rates. Those hospitals having high rates will be financially penalized.  Some studies calculate 75 percent of re-admissions are preventable.   A study in the Journal of the American Geriatric Society noted a "greater risk of multiple complicated transitions (bounce back) in patients initially discharged to skilled nursing facilities" and "a lower risk of multiple complicated transitions for patients initially discharged to rehabilitation facilities."

Communication, or the lack thereof, appears to be the major factor for patient bounce back. One study interviewed acute care hospitals and the Skilled Nursing Facilities (SNFs) where they sent patients. Each blamed the other for not providing adequate information. Complete lists of medications were missing. Follow-up appointments were never made or communicated. Wound care or other instructions were confusing or never received. There was no official hand-off from one physician to another.

Certain patients are at a particularly high risk to end up back in the hospital within 30 days. You are more likely to end up in the hospital if you:

-Are older
-Are African American
-Are on Medicaid
-Are discharged to a Skilled Nursing Facility (SNF)

The data suggests that the first three have less access to follow-up and primary care. Discharge to a Skilled Nursing Facility -- what used to be called a nursing home -- is particularly worrisome. Medicare spent $21 billion dollars on Skilled Nursing Facilities, approximately one half of all of the dollars spent on post-acute care ( SNF, home health, rehabilitation facilities, skilled nursing facilities and long-term care).

 

THI Indicted in New Mexico

Finally an Attorney General has indicted THI entities for resident abuse and neglect.   It is about time.  Hopefully, this will open the flood gates for other state attorney generals to investigate and indict these entities who have shown a pattern of neglect and careless indifference to their residents. See indictments here and here.   The indictments have a lot of factual information showing the lack of care provided to a vulnerable adult. 

Murray Forman and Leonard Grunstein own and operate Fundamental Long Term Care Holdings which own, operate, and control the hundreds of THI facilities in the U.S. managed by Fundamental Clinical Consulting (the successor company to indicted THI of Baltimore Management).

The pattern of poor care and careless indifference by Fundamental in their THI facilities is well known in the nursing home industry.  Hopefully, these indictments will change their policies and procedures but it is doubtful.

 

 

Failure to Report and Investigate

Lexington Herald-Leader have been running a series of great articles on the failure of authorities to investigate complaints or for the facilities to report complaints and incidents.  See also article from WLWT.  The article uses the death of Ruby Goode as an example of lack of reporting, investigating, and prosecuting neglect and abuse of vulnerable adults.

The death of Ruby Ethel Goode in a nursing home was one of more than 100 incidents over three years in which Kentucky nursing homes were cited for violating state regulations. Few of those cases were prosecuted as crimes. When Brenda Goode Woitke learned that her 93-year-old mother had died in the Calvert City Convalescent Center, she assumed that she had died of natural causes.  But the death of Ruby Ethel Goode was far from natural or peaceful. She was found on the floor with her head stuck between the side rail of the bed and the mattress, her neck unnaturally stretched.

Not only did officials at the Western Kentucky nursing facility fail to tell Woitke how her mother died, but they intentionally hid the facts. A nurse told others "not to talk about this to anyone because they would all get in trouble," according to a state citation issued to the nursing home after Goode died.  "There was no evidence the family, the physician, the administrator, or the director of nursing were immediately notified" of how Goode, known as Ethel, died, according to a Type A citation, which is issued by state regulators when there is an immediate threat of death or injury to a nursing home resident.

Goode's own doctor said that if he had been told about the circumstances of his patient's death he would have contacted the coroner himself.  After a local newspaper reported how her mother had died, she walked into the office of Paducah lawyer Richard Walter and said: "I just want to know what really happened."

The civil lawsuit that was filed as a result has been settled for an undisclosed amount. Through the civil process, Woitke learned that the facility had not thoroughly assessed whether her mother — who had memory problems, was at a high risk of falls and frequently slid to the bottom of her bed — should be left alone with her bed rails up.

"It's not about the money," Woitke said. "The truth of the way my mother died was withheld from me deliberately. I don't want this to happen to another family."

But when prosecutors reviewed Goode's case, they said there was not enough evidence to charge anyone with a crime — even though regulators said the nursing home failed to adequately assess whether Goode should be placed in a bed with side rails. The citation even said that might have prevented her death.

A Herald-Leader examination of 107 Type A citations issued over a three-year period by the Kentucky Cabinet for Health and Family Services Office of Inspector General found a number of gaps in the system that mean few nursing home deaths are ever prosecuted as neglect or abuse. They include:

■ Police and coroners are rarely notified of nursing home deaths or serious injuries.

■ Although the state sends all of the most serious nursing home regulatory violations to the attorney general's office, that office can only prosecute with the permission of local prosecutors. And local prosecutors say they seldom hear about the cases.

■ The attorney general's office misplaced or never received at least five citations issued by the cabinet from December 2006 through 2009.

The responsibility for criminal prosecutions involving long-term care facilities is spread over several agencies, with no single authority as overseer. That results in confusion and finger pointing among officials who do not want their offices blamed for not protecting the elderly.

The inspector general says it's the attorney general's responsibility to review nursing home citations and determine whether a crime was committed. The attorney general says that the inspector general or Adult Protective Services office can notify local police or prosecutors when criminal activity is suspected.

The 107 citations involved 18 deaths and 30 hospitalizations. Seven of the type A citations resulted in criminal charges. Eight cases are still open.

Cases where no charges were filed included those at facilities where a man wandered away and froze to death; a patient who was not monitored lost 87 pounds in 19 days and was later hospitalized; and a patient who fell and broke her hip but did not receive medical attention for seven hours.

The examination also found that nursing home employees who are prosecuted seldom serve jail time.

Much of the problem, experts said, can be attributed to the lack of a central authority to oversee investigations and prosecutions of incidents at nursing homes.   Advocates for the elderly, family members and attorneys say that nursing home deaths and injuries are not often scrutinized as potential crimes because the victims are elderly and often have serious illnesses.

If many of the same things happened to children, there would be a public outrage, said Kathleen Quinn, the director of the National Adult Protective Services Association, a trade group for adult protection workers.

Most nursing home incidents "are not investigated at all," said Dr. Barbara Weakley-Jones, Jefferson County coroner and a former state medical examiner who first noted Kentucky's lack of attention to nursing home deaths in a 1991 study. "Unfortunately some nursing homes try to cover up what happened," she said.

Experts say criminal prosecutions in nursing home cases are difficult. Even if it seems clear that a crime was committed, it may not be certain which staff member or members did it. And elderly residents often cannot tell what happened.

Consider the case of Aden Owens, a construction worker who suffered a closed head injury at age 61 when a concrete slab collapsed. He entered Sunrise Manor Healthcare and Rehabilitation in Somerset in 1999. But his family became concerned about bruises he received — 114 injuries of unknown origin over seven years, the family alleged in a civil lawsuit.

Stephen O'Brien III, a Lexington attorney who represents Owens' son Bryan, said Owens' worker's compensation carrier required him to be at Sunrise Manor. The family spent several hours a day at the nursing home and in 2006 placed a hidden camera in his room.The videotape showed a nursing assistant pulling Owens' hair, twisting his fingers and striking his hands.  Another nurse's aide is seen striking him, jerking him by his neck and placing a knee on his chest while changing his diaper.   After Owens fell out of bed, an aide left him on the floor while changing his bed, the videotape shows.

Bryan Owens said he couldn't understand why his father's case wasn't prosecuted, while in another case, three nurse's aides caught on a hidden camera abusing an elderly woman at Madison Manor nursing home near Richmond in 2008 were prosecuted and convicted.

In the Madison Manor case, one aide was found guilty of abuse after she roughly handled 84-year-old Armeda Thomas. Another was convicted after she ate Thomas' food and said in records that Thomas ate it.

One key difference between the cases — Thomas' case received widespread media coverage. Owens' didn't.

 

Nurse Indicted for Neglect

WLKY out of Kentucky reported the indictment for neglect by nurse Elizabeth Toyse who was employed at Golden Livings Nursing Home.  Based on the records, Golden Living and Elizabeth Royse knew the resident was at risk of dehydration, but neglected to execute her duties which include monitoring the patients fluid intake and inadequately supervising the nursing assistants.

The neglect led the resident to become hospitalized.  The Cabinet of Health and Family Services conducted a survey in 2007 of the facility, where Golden Livings received a regulatory Type A citation.

 

Woman Drowns in Bathtub

Chicago Breaking News Center and Chicago Sun-Times had articles on the tragic case of Jean Engstrom who drowned in a bathtub while unsupervised at Warren Park Nursing Pavilion.  Chicago police are conducting a death investigation into the drowning. 

An autopsy conducted determined that Jean Engstrom, 51, drowned according to the Cook County medical examiner's office. But officials could not indicate from the autopsy whether the woman's death was a homicide or an accident.   The woman was mentally ill and lived at the Warren Park Nursing Pavilion.  Police were called to the nursing home after staff members found the woman in a bathtub with the water running. They tried to revive her and called paramedics to the home who then took her to the hospital where she died.

Since the woman was mentally ill, she most likely needed supervision.  I wonder if a staff member started the bath (that is why the water was still running) and walked away.  I hope it was an accident.
 

Punitive Damage Verdict Against SavaSeniorCare

Congratulations to Jay Reinan who recieved a verdict and an Order allowing for punitive damages against SavaSeniorCare et al.  The case is Reigel v. SavaSeniorCare L.L.C and related companies.

On the claim of wrongful death, the jury awarded Plaintiff $75,000.00 in compensatory losses and $150,000.00 in punitive damages, for a total wrongful death verdict of $225,000.00. After reducing the punitive damages to the amount of the compensatory damages pursuant to the Court’s Order of June 16, 2010, the total wrongful death award is $150,000.00.  Total interest on the wrongful death claim is $51,151.71. The total judgment on the wrongful death claim is $201,151.71.

As to the extreme and outrageous conduct claim, the jury awarded $125,000.00 in compensatory damages and $100,000.00 in punitive damages.  Three years, four months and 24 days of pre-judgment interest on $225,000.00 at 9.0% per annum, compounded annually equals $76,727.56. The total judgment on the extreme and outrageous conduct claim is $301,727.56.

Total judgment in favor of the Plaintiff and against all Defendants shall enter in the amount of $502,879.26.

Neglect recorded on video

WCBSTV.com had an incredible story with a video showing a nursing home employee willfully neglecting a resident.  The video shows a nurse dumping an elderly woman in a wheelchair on the floor.   Nursing homes are supposed to be a safe place for the most vulnerable -- the elderly too sick and frail to care for themselves. But CBS 2 HD got an exclusive look at what happens when a nurse, instead of taking care of a patient, causes incredible harm. This is all too typical of the type of care provided at most nursing homes.

Criminal charges against nurse Jessie Joiner are based on the video recorded by a camera placed to protect patients and staff, by the William Benenson Rehabilitation Pavilion in Queens, N.Y.   Joiner is seen on video pushing a medication cart but suddenly abandons the cart and heads to the patient in the wheelchair. Joiner appears to jerk the chair sharply to the left and the woman, who is 85 years old and suffers from dementia, goes flying to the ground, a fall that breaks her hip.   No other staff intervened or assisted the resident.   The woman is seen lying alone on the floor for more than two minutes before another employee arrives on the scene. It appears he will help her, but with the patient still writhing on the floor, for over a minute he does nothing.

Nurse Joiner is seen walking right by the patient, who is now flailing on the ground with a broken hip. She does this not once but twice and then leaves the area.

According to the attorney general's complaint, Joiner admitted knocking the woman out of the wheelchair and not helping her. The complaint also alleges that she didn't report the incident until another staff member noticed the patient and later lied about it to the nursing home staff.

Joiner's attorney, Michaelangelo Matera, told a different story, saying that the patient herself caused her own fall.  Incredible.  Blame the victim.

Among the charges against Joiner are endangering the welfare of a vulnerable elderly person and willful violation of health laws. She has pleaded not guilty.


 

Duty to Report Incidents and to Investigate

The News-Gazette had an article about the state investigation of an incident in which a female patient at Champaign County Nursing Home suffered an injury that went undetected (or covered up) and died several days later.  The incident has led to a chain reaction of investigations, reports and findings that have resulted in $50,000 in fines against the nursing home, the loss of some Medicare and Medicaid funding and the potential loss of all Medicare and Medicaid funding.

Two other visits to the nursing home by public health inspectors – one on April 2 and another on April 29 – found more problems at the facility. In the April 2 inspection, it was determined that the nursing home did not follow its own policy in handling an allegation lodged against an employee.

Also that day, the inspector determined that the nursing home staff "failed to provide appropriate treatment and services to maintain or improve abilities in toileting and transfers" for four residents.

The April 29 inspection found that nursing home staff failed to use proper equipment when transferring three patients. In the most serious case a 91-year-old patient suffering from dementia broke her hip after she stood up from her wheelchair and fell. The woman was supposed to have had a personal safety alarm on her wheelchair.

In the incident which set off the series of investigations, a patient identified only as R7 slipped out of a chair while in a lounge area, but apparently was caught by a certified nurse aide.

"CNA slid under (R7) and pulled her onto her lap ... (R7) denied pain .. did not hit head ... did not hit w/c (wheelchair) or w/c pedals. (R7) talking and laughing with staff ... able to move arms and legs without a problem or pain ... Body check done with no areas of redness noted," said a report identified as a "late entry," and dated Jan. 25. It is not clear whether the incident occurred that day or earlier. There was no other documentation of the fall before Jan. 25.

By Jan. 29, however, nurses noticed bruising on the woman's right leg and right hand. A physician ordered the woman be taken to an unidentified hospital. There, an emergency department attendant said the woman's "right leg has progressively increased in size with diffuse ecchymosis (bruising) ... It does appear (R7) struck her head." There was an "incredible amount of blood lost in the leg," an emergency department physician said. It "took a lot of fluid and blood to fix (R7's) anemia/shock which resulted in CHF (congestive heart failure)."

The woman died on Feb. 4. The Public Health investigation of the incident, dated Feb. 25, found the nursing home neglected to properly care for the patient in at least four ways:

– "By failing to implement existing policies on Falls, Lab and Diagnostic Test Results, Laboratory Testing, Orders for Anticoagulants, Anticoagulants and Change in Resident's Condition or Status;"

– "By failing to notify the physician in a timely manner of high laboratory values, neglected to identify a fall, to notify the Physician/Nursing staff of the fall and implement post fall monitoring;"

– "By failing to assess and monitor significant bruising as a side effect of anticoagulant therapy and a fall;" and

– Neglecting "to notify the Physician of the significant bruising in a timely manner, but continued to administer anticoagulants to R7."

The nursing home has allegedly instituted changes in response to the public health findings. For example, training will include special attention to reporting falls. "An episode where a resident lost his or her balance and would have fallen were it not for staff intervention, is a fall. In other words, an intercepted fall is still a fall," said a memo.

And when employees are accused of mistreatment of residents, a memo says they "will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator or designee. Employees accused of possible mistreatment shall not complete the shift."


 

Neglect leads to Wandering Death

MYFox9 had an article about the Minnesota Department of Health's investigation into the wandering death of a resident who froze to death.  The investigation revealed that the Jones-Harrison assisted living facility was guilty of neglect in the death of a patient who wandered outside last November.  The cause of the patient's death was listed as hypothermia from cold exposure.

Staff carelessly lost track of the woman with dementia on the evening of Nov. 21.  The family member said when she arrived at Jones-Harrison on the morning of Nov. 22, police had still not been called and the patient hadn't been seen inside the facility in 16 hours. Staff members were unable to locate the woman and were confused about her whereabouts before finding her around 10:30 a.m. the next morning frozen, with no pulse, near a parking garage. 

The report concluded that the resident walked through a gate door that was left open.  A maintenance worker leaving around 4 p.m. the day of the incident left the gate unlocked. The worker admitted to leaving it unlocked for his own convenience, using it to get to quickly get to his car in the cold weather.  There was no explanation why another staff member did not see that the gate was unlocked or how the resident was able to leave the facility without anyone noticing.

The nursing home did not effectively manage its resident register to keep tabs on patients, and staff did not initiate the missing persons protocol in a timely manner.


 

Neglect leads to choking death

The San Jose Mercury News had an article about an $80,000 fine against Homewood Care Center for failing "to provide the necessary services to prevent harm when staff failed to promptly respond to a life-threatening situation involving" a resident.  The facility was given a "AA" citation, the most severe penalty under state law, after a state investigation determined that a nurse's failure to perform the Heimlich maneuver on a patient resulted in his death.

According to the article, the man's medical record indicated that he was admitted to the facility with diagnoses including Alzheimer's and dysphagia, or difficulty swallowing.  The man was assessed as a high risk for aspiration (the entry of secretions into the trachea and lungs) due to difficulty of swallowing.  The facility was clearly on notice that the resident may choke.

At 5:30 p.m. on Aug. 24, 2009, a certified nurse assistant was feeding the man his dinner of puréed food when he began coughing. The man gasped for air and became distressed. Although staff members knew the man was choking on food, no immediate attempt was made to perform abdominal thrusts to clear his airway.

The facility also failed to promptly call 911. Though staff told investigators they called emergency dispatchers at 5:30 p.m., records indicate the call was received at 5:49 p.m., an unreasonable delay of about 19 minutes. The man was already dead when paramedics arrived. He was pronounced dead at 6:09 p.m.

Until January, Homewood Care Center was owned by Jack Easterday, who in 2007 was convicted of 107 felony counts of willful failure to pay employment taxes owed to the government. Easterday withheld more than $9.6 million in payroll taxes from employees' checks from 1998 to 2005.  He was sentenced to 21/2 years in federal prison and $8.71 million in restitution. Easterday was the sole shareholder of Westline Medical Management, which owns Homewood and seven other nursing homes in the state.

 

 

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