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

Minnestoa Public Radio reported a story about a resident in a St. Anthony nursing home rwho fell, hit her head, and died four days later, after an employee failed to follow basic safety precautions, according to state health investigators.   An investigation by the Department of Health cited the employee for neglect.  The incident occurred after a nursing assistant at St. Anthony Health Center left the resident's room without setting a sensor alarm, lowering the bed, or placing a mat by the bed.

Her doctor ordered these precautions in the resident's care plan, after determining that the resident was at risk of injury from falls.  The resident suffered a fatal hematoma on her forehead from the fall. She appeared drowsy and weak after the incident.  Within two days, her condition had worsened, and included "periods of unresponsiveness and apnea," the report said.

The resident was admitted to hospice where she died.

Incredibly, the death certificate lists the cause of death as heart disease.

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The American Geriatric Society's website is a great resource for clinical best practices.  AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons is the one of the best.

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UPI had an interesting article about the health benefits of Vitamin D.  Falls, a leading cause of death and disability in the elderly, may be reduced by vitamin D supplementation in nursing homes, Australian researchers say.

Lead researcher Ian Cameron of the Sydney Medical School said older people living in nursing facilities or admitted to a hospital are at higher risk for falls than those living at home. Hip fractures, which can be deadly, occur in nursing facilities at a rate 10 times greater than elsewhere.

Cameron and colleagues conducted a meta-analysis of 41 studies involving 25,422 older people, mostly women. Five studies tested the effects of giving vitamin D to patients in nursing facilities, where it was found to be an effective measure for preventing falls although researchers are not sure why.

The researchers found multifacreted interventions -- which often incorporated exercise, medication or environmental factors including appropriate equipment -- reduced the risk of falls in hospitals. In nursing homes, the effects of multifactorial interventions were not significant overall.

However, the researchers concluded such approaches provided by multidisciplinary teams in these facilities may reduce the rate and risk of falls.

"In our review, we saw limited evidence that these combined interventions work, but we could more confidently recommend them if they were delivered by a multidisciplinary team," Cameron said.

The findings are published in the Cochrane Review.
 

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Miami Herald had a great article about how new technology is helping elderly people.  New devices monitor how well seniors are managing activities of daily living, aid with some tasks and help avoid any move to a nursing home.  Scientists, doctors, engineers and philosophers  gathered last month at a TEDMED (Technology, Entertainment, Design Medicine) conference to unveil solutions to some health care problems.

One of the devices that has been improved over the last few years is a pendant that can call 911 if the wearer falls.  Now the device can be programmed to answer the phone, reminders to take  medicine or alert to a fire, among other things.   It's one of several new products designed to help seniors stay in their homes.  At-home technology now can monitor senior citizens' movements, vital statistics, and sleep and bathroom patterns.  Many older people like having technology provide this extra layer of security because it doesn't require them to give up privacy.

The monitoring systems, which cost $150 to $200 a month, are more often prescribed to seniors for a limited time after a hospitalization or health issue. Some also are being used in assisted-living facilities where operators like the additional protections they offer.

Technology will allow seniors to avoid ``unnecessary early institutionalization'' because it will relieve the anxiety of loved ones. The ability to closely monitor a person's lifestyle also can help family members know when the older person is unable to remain home, said Katie Boyer, director of marketing for Home for Life Solutions, in Lee Summit.

Besides monitoring falls and daily activities, her company sells equipment that will turn off a stove if the user forgets. A built-in motion detector turns the appliance off if the user leaves the room and does not return in a specific time frame. As for managing medicine, systems exist that will dispense it at appropriate times and remind patients to take it. If the patient fails to take the medicine, the pills can move into a locked chamber to avoid an overdose.

GE has two products aimed at seniors: Health Guide allows users to check their blood pressure, sugar levels or heart rate daily. The information is sent to a medical provider who tracks it. If problems arise, the patient can have a teleconference with a nurse or schedule an appointment with their doctor.

The company also offers QuietCare, which uses sensors that learn daily activities and behaviors, and then watches for changes. The sensors will alert help if a person falls, goes to the bathroom at night and doesn't return to bed, or fails to get out of bed in the morning. Sensors also can be placed near the medicine cabinet or refrigerator, so monitors can track whether the person is taking their medicine and eating.

John Cobb, CEO of Senior Lifestyle, started to install QuietCare in some of his company's 70 senior living facilities this summer because he thought it would make residents safer. With QuietCare, his staff can keep track of residents' whereabouts at night, he said.

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The third part in the series based on the Star-Tribune's excellent investigation into falls in nursing homes deals with prevention.  The key to prevention is proper staffing and training.  Inadequate staffing is a common complaint from nursing home workers, industry watchers and families with loved ones in nursing homes. More than 1,000 Minnesotans suffered fall-related deaths in nursing homes from 2002 through 2008, according to a Star Tribune analysis of death certificates.

Every night, after pulling on her scrubs and heading to work for the night shift, the nursing home aide would start to feel tense. Frail people's lives would soon be in her hands. Call lights would blink. Alarms would beep. Sometimes she felt too rushed to care for everyone properly.

"If there's one alarm going off in one hall and there's another one going off in the other hall in the other direction, which one do you go to first?" she said. "One of them you're going to save from falling. The other one is going to fall."

"I think it's really related to the inadequate staffing. Totally related. And, you know, the damage is untold," said Charlene Harrington, a professor emeritus of sociology and nursing at the University of California, San Francisco. She has done numerous studies on nursing home staffing. Though state and federal staffing standards are not precisely defined, 75 percent of Minnesota nursing homes reporting data are understaffed by one federal measure.

In interviews with the Star Tribune, 16 nurses aides at some homes with more than 10 fall-related deaths from 2002 through 2008 frequently complained of insufficient staffing. They requested anonymity, fearing for their ability to get jobs in the industry. The former night shift aide, who once worked at two metro area nursing homes, said it sometimes felt like chaos, even at 2 a.m.

Nurses aides help nursing home residents do the routine things others take for granted: Get out of bed, go to the bathroom, walk, eat.  Nursing homes have struggled to find good workers in the past, although the recession has widened the pool of candidates recently.  The average hourly wage for a nurses aide in Minnesota is $12.86, according to the state Department of Employment and Economic Development.

The impact of staffing can be profound. At St. Anthony Health Center, a frequent visitor told state inspectors doing a routine survey that she saw residents sit unattended for long periods, get out of chairs on their own and get agitated waiting for help to the bathroom. One nurses aide said she was concerned about residents' safety. Another said it was sometimes difficult to get to beeping alarms when they're busy with other residents. The survey the home for insufficient staffing, at the same time noting multiple falls.

The biggest roadblock to more staffing, by all accounts: greed for profits.

Nursing home care is already too expensive. The homes receive from $3,000 to almost $9,000 a month per resident in Minnesota, according to the state Department of Human Services. The average monthly cost is $4,858. About $1.35 billion was spent on nursing home care in Minnesota in 2007, according to the department. Medical Assistance paid for $813 million in fiscal year 2008.

At a minimum, Minnesota requires that homes provide two hours of nursing care per resident per day. Federal regulations say a nurse must be on duty 24 hours a day. Both say homes must have "a sufficient number of qualified nursing personnel on duty" to meet residents' needs, but give no number or ratio.

The federal Centers for Medicare & Medicaid Services (CMS) regulates nursing homes nationally and contracts with states to enforce the regulations. It calculates expected staffing levels for each nursing home, taking into account the severity of their residents' needs and time needed to care for them. Using those expected staffing levels, 278 of 371 Minnesota nursing homes are understaffed.

One federal study in 2001 found a high staffing ratio helps only to a point. For long-term residents, it found, staffing above 4.08 hours of care per resident each day didn't improve quality of care.

Little Sisters of the Poor nursing home in St. Paul is one of about 90 nursing homes in the state that has higher staffing than CMS expected.  Sister Theresa Robertson, the nursing home's administrator, said she believes there is a correlation between staffing and falls.  Higher staffing means residents can be watched more closely, she said. That may help the staff figure out when residents are acting differently and understand ways to help them and prevent falls, she and other administrators said.

Nursing home resident Jim Grant, who once lived at Rose of Sharon Manor in Roseville, said it took too long to get a response when he turned on his call light. Grant, a 73-year-old stroke victim, said that once when he needed to go to the bathroom, he got up by himself and fell and cracked bones in his right leg about a year ago.

There are no uniform regulations for timeliness in answering call lights. As Grant sat in his cramped room at Rose of Sharon, his bed surrounded by family photos and knickknacks, a woman down the hall bellowed in a hoarse voice, "I have to go to the bathroom! ... I've got to go. I've got to go ... I've got to go now." "She's got to go bad," Grant said. He noted that yelling to get a staff member's attention wasn't uncommon.

State health investigators and regulators rarely issue citations for staffing levels, data shows.  But nurses aides know that, even if they're working short-staffed, they're often the ones who take the blame for falls. In about 60 cases where records showed what happened to the nurses aide, homes fired aides about half the time. In 18 cases, homes issued suspensions or warnings or retrained the aides. In 11 instances, nurses aides quit.

One former nurses aide at Crest View Lutheran Home in Columbia Heights said she got frustrated by staffing levels when she worked there in 2007. She and other former Crest View workers described a lack of teamwork. At 4:30 on a Sunday afternoon this summer, the Crest View dining room came alive as staff members in colorful scrubs helped residents to dinner using wheelchairs, walkers and belts. One hallway was nearly deserted, except for one resident who talked on the phone in her room, another resident who sat near a room window, and a third who quietly ambled down the corridor. Throughout the hallway, a beep echoed repeatedly. There were no staff members in sight. The nurse's station sat empty. Crest View, which had at least 13 fall-related deaths from 2002 through 2008, was cited for insufficient staffing early this year as part of regular nursing home surveys.

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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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As discussed yesterday, here is an edited part one of the series of articles in the Star-Tribune about fatal falls in nursing homes.  There were 1,000 Minnesotans whose deaths were related to falls in nursing homes from 2002 through 2008, according to a Star Tribune analysis of death certificates. On average, one nursing home resident in the state dies every two days in circumstances stemming from a fall.  Less than 10 percent of fall-related deaths in nursing homes are fully investigated by the Minnesota Department of Health, which is charged with monitoring nursing home care.  Even when regulators discover that negligence or neglect caused the fall and death, they often do not cite nursing homes for violations of state and federal regulations.

Minnesotans in nursing homes fell after aides left them alone on toilets. They fell while being improperly  transferred -- such as from a bed to a wheelchair -- by one aide when two were needed. They fell when aides misused equipment for moving them and dropped them in the process.

Some died quickly, their fragile neck bones snapped or their aging bodies overwhelmed by internal bleeding caused by the fall and compounded by blood-thinning drugs. Others -- often still enjoying some quality of life -- were suddenly bed-ridden in excruciating pain from broken bones.  After a fall, a spiral of decline often begins in the elderly. Weakened by the ordeal, victims succumb to pneumonia or see their chronic health conditions erupt with a vengeance. The fall, medical experts say, sets off a deadly systemic chain reaction, hastening the end of life. 

More than a dozen former nursing aides who worked at Minnesota nursing homes that have had fall-related deaths cited staffing problems as a concern. By at least one federal measure, 75 percent of Minnesota nursing homes are understaffed, although both state and federal staffing standards are vague.

Advocates for the elderly say if more of the deaths related to falls were subject to a more rigorous regulatory microscope, it would reveal both overburdened staffs and mismanagement.

During its investigation at Crest View, the state found problems with falls there. In a single month -- April 2005 -- there were 48 falls involving 33 residents at the facility, the report shows. Although the facility "identified a concern" with an increased number of falls, it didn't revise its fall-prevention program, the report said. The state cited Crest View for flawed care, concluding that it violated three federal regulations. Under standard procedure, Crest View was given time to correct the deficiencies and avoid punishment.   Regulators took no further action.

But over the past few years, some nursing homes have launched fall-reduction efforts, using sophisticated equipment to pinpoint balance and gait weaknesses, providing strength training and beefing up internal investigations. Over the past two decades, changes in laws and a shift in nursing home philosophy aimed at increasing profits

Under federal rules, every nursing home resident must be assessed for fall risk. Over the past two years, small consortiums of Minnesota nursing homes have made fall-prevention a priority. Under a state incentive program, some get extra payments to improve their performance. One group, Empira, received $4.2 million last year for 16 participating nursing homes.  Part of Empira's strategy is changing how the homes try to prevent falls. Some homes are improving their investigations into what causes a particular resident to fall. A few turn to technology: St. Therese Home in New Hope bought expensive diagnostic equipment to pinpoint weaknesses when residents sit, stand and move.

At St. Therese, in the midst of a heightened effort to prevent falls, a paralyzed, high-profile resident died after he was dropped as two nursing aides moved him from a wheelchair to bed last spring.

The Rev. Tim Vakoc, a 49-year-old Roman Catholic priest and Army chaplain, had suffered a devastating head injury in 2004 from a roadside bomb in Iraq.  On June 20, he died after falling to the floor and injuring his head, a state report determined. The state's investigation found no neglect by St. Therese nursing home, but blamed the two nursing assistants, saying they gave "incongruous" explanations of what happened as they tried to move Vakoc using an EZ Lift device.  Since 2004, at least 17 nursing home residents died or were injured across the state after being dropped from lifts.

Jeanette Lashinski doubts she ever would have filed a complaint about her mother's fall-related death in 2006. But her sister-in law, who worked in nursing home business offices much of her career, decided it was important to pursue. Lashinski's mother, Alice Kalas, was active into her late 70s, going dancing three times a week.   With arthritis and dementia, Kalas went to live at the Camilia Rose Care Center in Coon Rapids in early 2005. Nearly a year later, a nursing aide helped her to the bathroom and left her unattended. As the aide returned, she heard a crash and saw Kalas on the floor, head down. An X-ray scan showed her neck was broken. Kalas, 81, developed pneumonia and died 20 days later.

A state probe faulted the nursing home. The home failed to provide "supervision, assistance and on-going interventions" to reduce her risk, the state found. The state cited the nursing home for failing to prevent the accident. No fines were issued.  An alarm the staff had put on Kalas was removed with family'agreement because it agitated Kalas. Once it was removed, charts didn't list her as a fall risk anymore, and the staff thought it was safe to leave her alone in the bathroom.

Tania Rubin, 93, survived the Nazi advance in the Soviet Union, but a fall at Texas Terrace Care Center in St. Louis Park made her last days painful, her family said.  Early one morning, the staff found Rubin bleeding after hitting her face on an oxygen tank near her bed. She died a week later.  A hospital report after the fall said Rubin was suffering and dying, her chronic medical conditions no longer treatable. It is unclear whether a complaint was ever made to the state. A death certificate shows Rubin died of congestive heart failure, aortic stenosis and other natural causes. It does not mention her fall.

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The Star-Tribune had a series of articles based on their investigation into nursing home sin Minnesota.  Although the series concentrates on records from one state, it is persuasive as to what is going on nationally.  The first article "When Death comes without Dignity" discusses the investigation itself.

A Star Tribune report documents a troubling pattern in nursing homes based on death certificates.  They looked for patterns that might lead to a story, such as drug overdoses or medical errors. The death certificates noticed a number of deaths related to falls by patients in nursing homes.  More than 1,000 deaths related to falls in Minnesota nursing homes over the six-year period.

"As we worked on these stories these last several months, editors and reporters would literally shudder at some of the examples we had uncovered. Our minds would quickly flash forward to what would be in store for us when we grew old. Does anyone want to imagine being 90 years old, alone at night in a nursing home, struggling to get to the bathroom when no one is around to help?"

The Star-Tribune staff spent several months tracking down the families of those who had died from falls, exploring the conditions that led to an individual death, and talking to nursing homes in the hopes of explaining why so many of the elderly die in such a painful manner. One thing that became clear was how quickly the stability of a nursing home resident can change, "how one little incident can lead to the end."

The reporters also discovered some clear trouble spots: Reporters talked to nursing home aides who were at wit's end trying to keep up with the needs of their patients; to children who couldn't get a straight answer about how their parents had died, and to nursing home advocates who asked whether we just wanted them to tie up old people to make sure they don't hurt themselves. (Of
course not.)   The nursing homes' internal investigations are private, and the state does not require a complete review of every death by fall.

I will blog the next couple of days regarding this series of articles.

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Argus Leader had an interesting article written by Anna Bahney about a new invention that may help wheel chair bound residents.   Greg Johnson designed the wheel-chair to help his parents. Glenice Johnson spends her day in a wheelchair that her son developed, and Greg has turned over the wheelchair to a group of South Dakotans who work to find others who could benefit the way his mom has.

The chair, called the Dignity200, is the first wheelchair on the market that allows what the makers call "self-toileting."  The user pushes a lever that drops a center panel from the seat. The person backs the chair over the commode, readjusts clothing and urinates or allows for a bowel movement as if sitting on a toilet seat. Once clean, and after adjusting clothing, the user moves the chair away from the commode and the panel is returned to place.

"If I'm here by myself, I can take care of what I need to," Glenice said. "Mentally and emotionally, it is a tremendous plus. It makes all the difference in me being at home."

The adjustable, custom-built chair, available at Kreisers medical supply store in Sioux Falls and a growing number of similar stores, costs $2,950.   It is an expensive chair, Greg admits. But chair effectively pays for itself every three weeks, considering that a month's stay in a long-term care facility can run at least $5,000.

But the greatest benefit might be a wheelchair-bound person staying home as long as possible.

Greg said he was able to figure out how to remove the understructure from beneath the wheelchair but couldn't work out the drop-down panel.  He called up a rancher friend with a background in engineering to pick his brain.   Together, they began to work on prototypes. The hardest part, Greg said, was "making sure the seat cushion would be of a quality that allows her to stay in the seat all day. If that didn't work, it wouldn't be possible."

The Dignity200 now is approved by the Federal Drug Administration and is in testing for applications outside the home. According to the Centers for Disease Control and Prevention, health care workers who routinely lift and move patients have a higher risk of injuries than workers in most other occupations, and the number of those injuries are increasing.

In September, the chair became part of a risk prevention study overseen by the University of South Dakota medical school in partnership with the Good Samaritan Society.

"The lifting and transferring from chair to commode and so forth for residents whose conditions tend to be frail, that's a significant issue and a significant source of injury to residents and staff," said Bill Kubat, vice president for resident community and quality service at the Good Samaritan Society.

A trial of the chairs at a Good Samaritan facility helped the chair get where it is now. Stories emerged, including staff who felt the chair made their work safer and a woman who had not used the bathroom on her own for four years and cried when the chair had to be returned at the end of the trial.

But the longest test case has been Greg's mom, who has been in the chair for two years.

"For my mom, she can feel like she's on her own a little more again," Greg said. "And my dad doesn't have to be home. He's got a lot more freedom and he's doing a lot less lifting. It has changed their life."

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We are pleased to have Hannah Watson write a guest blog today on how to protect your loved one in a nursing home.

While there are some truly great, caring nursing homes out there, the reality is that many older Americans are at risk of abuse in these long term care facilities. In fact, according to the American Psychological Association, every year an estimated 2.1 Million older Americans are victims of physical, psychological or other forms of abuse and neglect. If you want to learn to keep your loved one safe then follow these tips to help ensure they get the help and support they need to stay well-cared for and happy.

1. Research the nursing home before placement. Before you ever place a loved on into a nursing home make sure that it’s going to be a good environment for them. Research others’ experiences, go to see the facility yourself and spend some time getting background on it to make sure you won’t regret your decision.

2. Monitor your loved one for injuries. One of the most obvious signs that abuse or neglect is taking place is physical injuries. While these can sometimes occur in less than sinister situations, it’s important to find out where they can from and if staff can provide reasonable explanations for them.
3. Visit often and unexpectedly. Perhaps one of the best ways to prevent abuse of your loved ones is to visit them often and vary the times at which you visit. If someone was harming your loved one, it would make it much more difficult for them to do so. Plus, you’ll be better able to monitor your loved one’s health if you see them regularly.

4. Talk to the staff at all levels. Developing relationships with the caregivers at the facility where you are housing your loved one can also be one way to not only find out just how your loved one is cared for but also help establish relationships of appreciation that can change caregivers’ attitudes.

5. Ask for all the information on your loved one’s care. It’s important to know just how much your loved one is eating, what medications they are on and the details of their daily care. After all, signs of malnutrition and other forms of abuse are much harder to spot.

6. Just ask. One of the easiest ways to find out if your loved one is being cared for properly is to ask them themselves. Assure them that you want to guarantee their safety and if you feel it’s at risk remove them from the facility as soon as possible. If they can’t talk, learn the signs of elder abuse and make sure to follow through on any suspicions.

This post was contributed by Hannah Watson, who writes about the nursing school online. She welcomes your feedback at HannahWatson84@ yahoo.com
 

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