McKnight’s had an article about end of life programs in nursing homes.  Fewer than one in five nursing homes provide end-of-life care services, according to new research from the American Association of Homes and Services for the Aging.   However, any expansion would have to deal with the "death panel" demagoguery.  These programs are necessary to assist residents and their families regarding their rights to end of life decisions.

As many as 25% of all deaths occur in the U.S. occur in a nursing home, according to the report from AAHSA’s Institute for the Future of Aging Services.  Despite this, less than 20% of nursing homes offer end-of-life programs. Nursing homes were more likely to participate in end-of-life programs if they also offered specialty programs for hospice, pain management or dementia care, according to the report.  

There is also a link between staff training in end-of-life care services and a facility’s participation in end-of life-programs, the report showed. Providing appropriate staff training may be the key to expanding program participation, according to Helaine Resnick, director of research at IFAS. The research was published in the online version of the American Journal of Hospice and Palliative Care Medicine.
 

Ohio’s Newsnet5.com had an article about their investigation into Ohio nursing homes.  Working with their partners at Scripps Howard News Service, NewsChannel5 spent three months researching care homes.   NewsChannel5 found poor ratings for a number of Cleveland-area nursing homes. In fact, a quarter of the facilities in Cuyahoga County rated just one star on Medicare’s five-star scale. Five other ManorCare properties in the area garnered just one star.

"There should be two kinds of nursing homes the excellent and non existent," said Larry Minnix, chief executive officer of the American Association of Homes and Services for the Aging.

Long-term care ombudsman, Gerald Kasunic, said, "If you smell urine or feces, or what I call the chemical hidden smell, something that may be a serious chemical odor, those are kind of bad signs."

According the SHNS and WEWS study of death records maintained by the Centers for Disease Control and Prevention, nearly 19,000 people died in area nursing homes in 2005 and 2006. Of those deaths, 651 people died of accidents, skin infections or other potentially avoidable causes.

 

NewJersey.com ran an editorial about the resident who was allowed to wander away from Preakness Healthcare Center in Wayne.  A resident with dementia wandered out of the nursing home and was found more than two hours later, roaming in the snow and ice and subfreezing weather. 68-year-old Vidal Mojica, was rescued by members of the Passaic County Sheriff’s Department. Mojica, who uses a walker to get around, was found behind the nursing home on Oldham Road wearing just a golf shirt, pants and shoes. Mojica was transported to St. Joseph’s Wayne Hospital, where he was being treated for exposure to the cold.

One Preakness employee said Mojica would have to have climbed unsupervised down three flights of stairs with his walker to leave the building. The employee also said Mojica is the second resident to wander away from the nursing home since it opened in October.

While we understand the need to protect the confidentiality of a patient, we are disturbed by the county’s stonewalling about the circumstances of his escape from the facility. This is an issue that concerns not just one Preakness resident and his family; it is an issue of deep concern to every county resident.

Numerous questions need to be answered:

How could a patient using a walker have escaped so easily? How could he have gotten so far so fast and remained unseen for more than two hours?

Is there some design flaw in the new building that makes it susceptible to such "escapes"? If so, what steps are being taken to correct them?

Finally, has this happened before, and how can we be assured it won’t happen again?

Such a lack of information about what appears to be a severe breach in security in a brand-new, $90 million facility that has already taken on the scorn of taxpayers is not something the county or facility administrators can afford to just slough off.

Perhaps there is a perfectly reasonable explanation of how a 68-year-old man using a walker was able to elude authorities for more than two hours. If so, we’d love to hear it.

Fox News ran a NY Post article on the verdict against a Brooklyn nursing home.  Brooklyn Queens Nursing Home will have to compensate the family of a 76-year-old patient neglected so badly that he left with more than 20 bedsores. The verdict of nearly $19 million, handed down by a jury, is the first in the state against a nursing home that includes punitive damages.

"It was horrible," said Margaret Whitehurst, who pulled her father, John Danzy, from the home after just nine months. "He walked in on two legs and a cane. He was 237 pounds. When we got him back, he was 148 pounds and he had holes all over his body."  She and her siblings moved Danzy, a retired truck driver and butcher, to another nursing home. He died as a result to an infection caused by the bedsores.

A Brooklyn jury deliberated two full days following the four-week trial before finding the Cypress Hills facility delivered substandard care.  The panel awarded $3.75 million for Danzy’s pain and suffering, but tacked on $15 million in punitive damages, based in part  that the home had doctored records to try to cover up the neglect.

An FBI expert testified that about 100 different skin-check notes showing "G" for "good" had been penned over to show "B" for "broken" — an effort by the home to claim it hadn’t missed the horrific sores.  "Someone went back and wrote B’s over the G’s to cover their tracks, so they falsified the records, he said. "We believe that once they found out they were being sued, they went back and said, ‘How could we have G’s here when they guy has 20 sores?’ "

The nursing home restrained the Alzheimer’s-stricken Danzy to keep him from wandering off, but left him alone for long periods.  Medical standards require that bedridden or restrained patients be moved every two hours to prevent such sores, but that Brooklyn-Queens only moved Danzy every four hours — if at all.

 

The Intelligencer had an article about dog therapy in nursing homes.  Therapy dogs walk the halls and sit at the feet of residents of nursing homes and hospital patients, putting smiles on faces. In addition, they visit assisted living facilities, children’s reading programs and libraries, assist with stress relief, do home visits, visit hospices, schools and shelters throughout the year.

At Mound View Health Care in Moundsville, in addition to resident facility bulldog Betsy, therapy dogs have been visiting for several years. Connie Smith of Moundsville and her dog, Shadow Dancer, have been visiting the facility for more than four years.  Shadow Dancer, a Shetland sheepdog is now semi-retired after making about 150 regular visits, but the dog still makes an occasional return. Smith said she now has a younger dog that is making the visits.

Randy Moore of St. Clairsville and his boxer mix, Sierra, have made more than 200 visits at different facilities around the Ohio Valley.

"There are not enough therapy dogs," he noted. "I think every place needs therapy dogs. It’s amazing what they can do. They can actually help bring someone’s blood pressure down and reduce stress."

Therapy Dogs International is an organization that provides therapy dogs for hospitals and other facilities. "The dogs need to be trained," he noted. They have to be able to pass a 16-part test.  Most hospitals require dogs to have TDI certification before they are allowed to visit.   It ensures the dogs have the right temperament and meet insurance requirements.

Smith said anyone who might want to get involved with TDI and bring a dog for training can call her at 304-845-7829. Moore suggested looking at the TDI Web site www.TDI-dog.org.

I read an interesting article from the Oakland Tribune about how nurses move to avoid the consequences of misconduct. There is a dangerous gap in the way states regulate, license, supervise, and sanction nurses: They fail to effectively tell each other what they know.   As a result, caregivers with troubled records can cross state lines and work without restriction, an investigation by the nonprofit news organization ProPublica and The Los Angeles Times found.

Using public databases and state disciplinary reports, reporters found hundreds of cases in which registered nurses held clear licenses in some states after they’d been sanctioned in others, often for serious misdeeds. In California alone, a months-long review of its 350,000 active nurses found at least 177 whose licenses had been revoked, surrendered, suspended or denied elsewhere.

State regulators aren’t using their powers to seek out this information, or act on what they find, the investigation found.

By simply typing a nurse’s name into a national database, state officials can often find out within seconds whether the nurse has been sanctioned anywhere in the country and why. But some states don’t check regularly or at all. The failure to act quickly in such cases has grave implications: Hospitals and other health care employers depend on state nursing boards to vouch for nurses’ fitness to practice.

Because there is no federal licensing of nurses, each state sets its own standards on punishable behavior. In general, states can discipline a nurse based solely on the actions taken by another state. But they vary widely in how quickly — or harshly — they act on this information, according to interviews with regulators in 14 states.

Delays in several states left Craig Smart free to practice. In 2000, he surrendered his license in Florida after testing positive for cocaine and flunking a treatment program. It took eight years for five other states in which he was licensed to respond to Florida’s action. California was the last to revoke his license, in 2008, after he had practiced here for several years.

Even when states share borders, they sometimes fail to heed each other’s disciplinary actions. At least 10 nurses, for example, hold clear licenses in Massachusetts despite being disciplined next door in Rhode Island, including suspensions for drug thefts and violence.

There is ample information available for states to identify nurses disciplined by other jurisdictions. Two separate databases attempt to track disciplinary actions from every state. States are required to report to one, run by the federal government, within 30 days of taking an action. Reporting to the other, operated by the National Council of State Boards of Nursing, is voluntary.

Each database can be programmed to alert a state whenever a nurse it has licensed runs into trouble in another state.  When checking a nurse’s record, nursing officials say they almost uniformly use the council’s database; it’s free and the government’s is not. In fact, federal statistics show that nursing boards accessed the government database fewer than 300 times total in 2007 and 2008.

In addition, ProPublica and The Los Angeles Times found that the federal database is incomplete, despite the requirement that all states report discipline to it. Many actions appeared to be missing when reporters tried to match known cases by date of discipline to a version of the database in which confidential information had been removed.

The council cannot force states to submit names, and states have a financial incentive not to: They make money by charging nurses to verify their licenses, test scores and training to authorities in other states. For example, a nurse licensed in California who wants credentials to practice in Arizona must pay California $60 to confirm her background. Those sorts of checks netted California nearly $1 million in fiscal 2009. New York, which charges $20 a check, earns more than $250,000 a year.

When states turn over their lists of licensed nurses to the national council, that group earns such verification fees. "The decision to join is a revenue loss for them," said Kathy Apple, the council’s chief executive officer. "That’s difficult for some states."

Reporters went further, checking the full roster of 350,000 licensed nurses against a public version of the council database. They found that at least 643 California nurses had sanctions elsewhere, including the 177 whose licenses had been revoked, suspended, denied or surrendered.

Jose Martinez, who surrendered his license in Texas in July 2008 after being accused of performing a rectal exam on an 11-year-old girl without a doctor’s order or a witness present. In a letter to the Texas board, Martinez acknowledged his misconduct. "Yes, I made a mistake and, yes, I am guilty. After 4 years as a tech and 12 years as a nurse I slip and fall. "… I guess I deserve what is coming to me." His California license is active, without restrictions, and does not expire until July 2010.

Randy Hopp, who was convicted in 2004 of assaulting a nursing home resident in Minnesota. It was the fourth facility since 1998 at which he had been accused of mistreating a resident, records show. The nursing boards in Minnesota and Missouri placed him on probation, and Kansas imposed restrictions on his practice. Hopp surrendered his license in Texas. In California, his license remains clear.

In the past the board took a median of 13 months to file public accusations against nurses after their licenses were first revoked, surrendered, denied or suspended by another state, according to a review of 258 such cases since 2002.

Three of these nurses got work and stole drugs from California hospitals after they had surrendered their licenses across the border in Nevada for previous wrongdoing there.

 

Ashley Julian of the marketing firm Trent & Company sent me an email.
"According to a recent report released by the MacArthur Research Network on an Aging Society, Americans living in the next 40 years will be much older than the government currently predicts.

The study contends that the U.S. Society Security Administration and Census Bureau have misjudged the average American lifespan by three to eight years.  "The significance of this study is that it not only brings up the topic but length of life, but quality of life. People living longer want to
live healthier for longer," said Dr. Steven Joyal, Vice President of Science and Medical Affairs for the Life Extension Foundation, the largest non-profit organization dedicated to research on extending the healthy human life span."

Here is a link to the study.
 

Many times, a family member of a nursing home resident will call us with concerns about bruises, unexplained injuries, falls, and pressure ulcers.  We suggest that they look at the medical records.  Numerous nursing homes will refuse to allow family members access to the medical records despite 42 CFR 483.10(j)(1)(vii) – which clearly states:

(1) The resident has the right and the facility must provide immediate access to any resident by the following:

(vii) Subject to the resident’s right to deny or withdraw consent at any time, immediate family or other relatives of the resident.

Nursing homes are either ignorant of their responsibilities or intentionally concealing material and medical information to residents and their family members.  Why would a nursing home refuse to allow a family member of the resident access to the chart?  Many times, after a family requests the chart, nursing homes send the chart to outside legal and clinical consultants to "clean up" the information in the chart.  The above federal regulation needs to be enforced.  The best way is to complain to your local ombudsman, state health agency, and your local politician.

The Government Accountability Office issued a new report titled Addressing the Factors Underlying Understatement of Serious Care Problems Requires Sustained CMS and State Commitment.  Not surprisingly South Carolina is one of the worst offendersReducing understatement is critical to protecting the health and safety of vulnerable nursing home residents and ensuring the credibility of the survey process. Federal and state efforts will require a sustained, long-term commitment because understatement arises from weaknesses in several interrelated areas—including CMS’s survey process, surveyor workforce and training, supervisory review processes, and state agency practices and external pressure.

The conclusions reached include as follows:
Concerns about CMS’s Survey Process.
Survey methodology and guidance are integral to reliable and consistent state nursing home surveys, and we found that weaknesses in these areas were linked to understatement by both surveyors and state agency directors. Both groups reported struggling to interpret existing guidance, and differences in interpretation were linked to understatement, especially in determining what constitutes actual harm. Surveyors noted that the current survey guidance was too lengthy, complex, and subjective. Additionally, they had fewer concerns about care areas for which CMS has issued revised interpretive protocols.

Ongoing Workforce and Surveyor Training Challenges. Workforce shortages in state survey agencies increase the need for high-quality initial and ongoing training for surveyors. Currently, high vacancy rates can place pressure on state surveyors to complete surveys under difficult circumstances, including compressed time frames, inadequately staffed survey teams, and too many inexperienced surveyors. States are responsible for hiring and retaining surveyors and have grappled with pervasive and intractable workforce shortages. State agency directors struggling with these workforce issues reported the need for more readily accessible training for both their new and experienced surveyors that did not involve travel to a central location. Nearly 30 percent of surveyors in high-understatement states stated that initial surveyor training, which is primarily a state activity that incorporates two CMS on-line computer courses and a 1-week federal basic training course culminating in the SMQT, was not adequate to identify deficiencies and cite them at the appropriate scope and severity level. State agency directors reported that workforce shortages also impede states’ ability to provide ongoing training opportunities for experienced staff and that additional CMS online training and electronic training media would help states maintain an experienced, well-informed workforce.

Supervisory Review Limitations.
Currently, CMS provides little guidance on how states should structure supervisory review processes, leaving the scope of this important quality-assurance tool exclusively to the states and resulting in considerable variation throughout the nation in how these processes are structured. We believe that state quality assurance processes are a more effective preventive measure against understatement because they have the potential to be more immediate and cover more surveys than the limited number of federal comparative surveys conducted in each state. However, compared to reviews of serious deficiencies, states conducted relatively fewer reviews of deficiencies at the D through F level, those that were most frequently understated throughout the nation, to assess whether or not such deficiencies were cited at too low a scope and severity level.  In addition, we found that frequent changes to survey results made during supervisory review were symptomatic of workforce shortages and survey methodology weaknesses.

State Agency Practices and External Pressure In a few states, noncitation practices, challenging relationships with the industry or legislators, or unbalanced IDR processes—those that surveyors regard as favoring nursing home operators over resident welfare—may have had a negative effect on survey quality and resulted in the citation of fewer nursing home deficiencies than was warranted.  In one state, both the state agency director and over 40 percent of surveyors acknowledged the existence of a noncitation practice such as allowing a home to correct a deficiency without receiving a citation.  Forty percent of surveyors in four other states also responded on our questionnaire that noncitation practices existed.   Twelve state agency directors reported on our questionnaire experiencing some kind of external pressure. For example, in one state a legislator attended a survey and questioned surveyors as to whether state agency executives were coercing them to find deficiencies. Under such circumstances, it is difficult to know if the affected surveyors are consistently enforcing federal standards and reporting all deficiencies at the appropriate scope and severity levels. States’ differing experiences regarding the enforcement of federal standards and collaboration with their CMS regional offices in the face of significant external pressure also may confuse or undermine a thorough and independent survey process. If surveyors believe that CMS does not fully or consistently support the enforcement of federal standards, these surveyors may choose to avoid citing deficiencies that they perceive may trigger a reaction from external stakeholders. In addition, deficiency determinations may be influenced when IDR processes are perceived to favor nursing home operators over resident welfare.

Recommended Action includes:

Make sure that action is taken to address concerns identified with the new QIS methodology, such as ensuring that it accurately identifies potential quality problems; and clarify and revise existing CMS written guidance to make it more concise, simplify its application in the field, and reduce confusion, particularly on the definition of actual harm.

To address surveyor workforce shortages and insufficient training, we recommend that the Administrator of CMS take the following two actions: (1)  consider establishing a pool of additional national surveyors that could augment state survey teams or identify other approaches to help states experiencing workforce shortages; and (2) evaluate the current training programs and division of responsibility between federal and state components to determine the most cost-effective approach to: (1) providing initial surveyor training to new surveyors, and (2) supporting the continuing education of experienced surveyors.

To address inconsistencies in state supervisory reviews, we recommend that the Administrator of CMS take the following action:
Set an expectation through guidance that states have a supervisory review program as a part of their quality-assurance processes that includes routine reviews of deficiencies at the level of potential for more than minimal harm (D-F) and that provides feedback to surveyors regarding changes made to citations.

To address state agency practices and external pressure that may compromise survey accuracy, we recommend that the Administrator of CMS take the following two actions: (1)  reestablish expectations through guidance to state survey agencies that noncitation practices—official or unofficial—are inappropriate, and systematically monitor trends in states’ citations; and (2) establish expectations through guidance to state survey agencies to communicate and collaborate with their CMS regional offices when they experience significant pressure from legislators or the nursing home industry that may affect the survey process or surveyors’ perceptions

Chicago Tribune had a scary article about Federal, state and county officials finding dozens of resdients with outstanding arrest warrants and wanted on charges ranging from disorderly conduct to burglary to assault.  The raids involved about 20 federal marshals and Cook County sheriff’s police.  Illinois Attorney General Lisa Madigan initiated the sweep in response to Tribune investigative reports about Illinois nursing facilities that house high numbers of felons and sex offenders.

Five people were arrested, including a sex offender wanted in another state for failing to register. In three cases, the residents were too sick to be taken into custody, and the other warrants were not immediately enforceable because they were issued in other jurisdictions.  The team found nine people with outstanding warrants when it swept Columbus Park Nursing & Rehabilitation Center on Chicago’s West Side and another nine at Heather Health Center in Harvey.

Authorities also examined records for Somerset Place on the North Side and discovered three residents with outstanding warrants, but jurisdictional limits prevented immediate arrests.

The number of felons known to be living in Illinois nursing homes has grown as the state increasingly relied on the facilities to house younger psychiatric patients, thousands of whom have criminal records.  The Tribune reported that Illinois State Police once ran similar sweeps of nursing homes for felons with outstanding warrants and unregistered sex offenders. From January 2005 through June 2006, when 20 northern Illinois nursing homes were swept and roughly 80 fugitives and sex offenders removed, state police in that region recorded a nearly 67 percent decrease in nursing home abuse and neglect complaints, according to a department citation issued to the sweeps unit.   But the program was halted after five years in 2006 because federal regulators questioned whether the sweeps were an appropriate use of Medicaid anti-fraud funds. State police were not part of Tuesday’s sweeps.

The Tribune has reported that the criminal background checks and risk assessments carried out for new residents of the state’s nursing homes were riddled with errors and omissions.