Gwen D. Hughes, who worked at Kern Valley Healthcare District’s facility in Lake Isabella, was charged in the deaths of three patients. She pleaded no contest in Kern County Superior Court to one felony count of elder abuse with a special allegation that the abuse contributed to the victim’s death. She was only sentenced to three years in state prison for overmedicating patients at a Kern County nursing home, causing at least one wrongful death.   The California Department of Public Health first began to investigate the facility in 2007, following complaints from an ombudsman that a patient at the facility had been held down and forcibly injected with psychotropic medications.  See article at SFGate here.

Hughes ordered the hospital’s director of pharmacy to write doctor’s orders for psychotropic medication for 23 patients — not for therapeutic reasons, but to keep them quiet.  Officials say the drugs were given to patients who were noisy, prone to wandering, who complained about conditions or were argumentative.  The investigation found that the drugs hastened three patients’ deaths, and all 23 suffered adverse physical reactions.

 

Pamela Ott, the former chief executive officer of the Kern Valley Health District, pleaded no contest to one felony count of conspiracy to commit an act injurious to the public health, based on her failure to adequately supervise Hughes. Ott was sentenced to three years of formal probation.

 

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Ronald E. Burrell and Michael Elliott from Caremerica, a North Carolina company that operated assisted-living facilities in both Carolinas, have been sentenced five years in prison in a corporate tax evasion case.  The Justice Department says Burrell and Elliott were also ordered to pay $4.8 million each in restitution.  Burrell was the chief executive and Elliot the chief financial officer of the company. Both had pleaded guilty earlier to conspiracy to defraud the Internal Revenue Service to avoid paying federal employment taxes.

 
 
 

A Baltimore City jury awarded a record $1.42 Million verdict against the doctor who removed the wrong ovary in a young med student, Nadege Neim.  In June of 2009, Mrs. Neim, who was pregnant at the time, went to see her doctor, Dr. Maureen Muoneke, OB/GYN, to have an ultrasound performed.

The ultrasound revealed that Mrs. Neim had an ovarian mass on her left side. Dr. Muoneke advised her that it was probably benign, but it could grow or rupture to become malignant.  Mrs. Neim went in for another ultrasound. The results revealed that, although her right side was fine, the mass on her left ovary was still there. Dr. Muoneke recommended that Mrs. Neim have the left ovarian mass removed to prevent further complications.

On September 22, 2009, Mrs. Neim was admitted to St. Agnes Hospital to have her left ovarian mass removed.  However, Dr. Muoneke not only failed to remove the left mass but also instead removed her entire right ovary and fallopian tube.  Mrs. Neim returned on October 14 for a post-surgery check-up, and complained of pelvic pain on her right side. Dr. Muoneke reviewed the pathology report with Mrs. Neim; however, she failed to inform her that she had removed the wrong ovary, as well as her right fallopian tube. In the next few days, Mrs. Neim continued to have extreme right-side pelvic pain, and Dr. Muoneke had still not informed her that she removed the wrong ovary.  Mrs. Neim went to the Howard County General Hospital Emergency Department where she learned that Dr. Muoneke not only failed to remove the left mass but also had removed her right ovary and Fallopian tube.

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 The Tennessean reported that the national for profit chain National HealthCare Corp. agreed to buy six nursing homes — including three in the Nashville area — for $21 million from a related entity and its biggest landlord, National Health Investors.  NHI was created in 1991 to own NHC properties and has since expanded to owning other medically-related facilities beyond those that the nursing home chain runs. 

In addition, Murfreesboro-based real estate investment trust NHI has extended a lease with the company’s biggest tenant, NHC, for 41 facilities — 38 nursing homes and three independent living facilities. 

Separately, NHI also sold a 148-unit senior living facility to that facility’s operator Sunrise Senior Living Inc. for $23 million.  NHI referred to the six nursing homes it has an asset purchase service agreement to sell to NHC as older facilities. NHC’s spokesman Gerald Coggin considers them well-operated with high occupancy rates in great markets.

 

 The New York Law Journal reported on the continuing saga regarding ownership of the national for profit chain of nursing homes known as Fundamental Long Term Care Holdings, L.L.C.  Murray Forman and Leonard Grunstein are the principals who own Fundamental and the affiliates that operate the facilities including Fundamental Administrative Services, Fundamental Clinical Consultants, Fundamental Clinical and Operational Services.  However, Reuben Schron opted to buy one third of Fundamental for $1,000—a great deal.   Schron is appropriatly concerned that funds will be diverted to the owners while the appeal is continuing.  The Order denies Schron’s request for a financial audit.

 

 

Once again, Dr. Jeffrey Levine has written an informative article found on his website about the history of the debate regarding when a pressure ulcer was "avoidable v. unavoidable."   Below is a copy of his article.

Some years ago while browsing in an antiquarian bookstore I opened a volume entitled Lectures on the Diseases of the Central Nervous System by Jean Martin Charcot published in 1877. Among the yellowed pages was an illustration of a necrotic sacral pressure ulcer, and my heart started pounding. I had come across one of the earliest descriptions of pressure ulcer pathogenesis. I excitedly purchased the book, and subsequently learned that I held in my hand the beginnings of the modern “avoidable-unavoidable” controversy on pressure ulcers and published my findings in two articles in the Journal of the American Geriatrics Society.

Dr. Charcot was one of the greatest physicians of the 19th Century, and described medical and neurologic syndromes that still bear his name. He worked in Paris where he headed the Salpêtrière, a chronic disease hospital that gained notoriety during the French Revolution when it was the site of an infamous massacre of French aristocrats. Charcot believed that pressure ulcers were an unavoidable result of damage to the brain or spinal cord because of “neurotrophic fibers” that connected the skin directly to the central nervous system. Charcot wrote:

“I have often been a witness to this fact, occurring among the aged persons in this hospital, and I have been many times able to satisfy myself that pressure on the spot occupied by the eruption did not here play an essential part.”

Charcot had an illustrious opponent by the name of Henri Brown-Sequard who tried to disprove Charcot’s neurotrophic theory of skin ulceration with experiments on small animals. In 1853 Brown-Sequard wrote:

“On guinea pigs, upon which the spinal cord was cut in the dorsal region, and on pigeons, upon which the spinal cord was destroyed from the fifth costal vertebra to its termination, I have found that no ulceration appeared when I took care to prevent any part of their bodies from being in a continued state of compression, and of washing them many times a day to remove the urine and feces…”

This was an amazing and unique time when two of the greatest minds in medicine were concerned about bedsore pathogenesis, but unfortunately pressure ulcers dropped off the medical map for over a century. It took the demographic change toward an aging society to revive the discussion on pressure ulcers and cause the medical profession to refocus on their importance. This demographic change was ushered in by improvements in public hygiene and medical advances that prolonged the human lifespan and allowed people to live longer with multiple comorbidities.

Today there is renewed controversy as to whether pressure ulcers are avoidable or unavoidable, particularly in the “pay for performance” era. Most authorities agree that pressure ulcers are a quality indicator, yet few will say that all pressure ulcers are avoidable. The expert consensus published by the National Pressure Ulcer Advisory Panel stated that “not all pressure ulcers are avoidable.” In 2010, the Centers for Medicare and Medicaid Services (CMS) enacted a “no-pay” policy for hospital acquired pressure ulcers on the assumption that pressure ulcers are reasonably preventable using currently available clinical practice guidelines.

Certainly there are medical factors that cause certain pressure ulcers to be unavoidable. Some believe that the key to unavoidability is in the process of dying, and you can read more about the Kennedy Terminal Ulcer and Skin Changes at Life’s End (SCALE). I believe that these arguments have validity, but there are also factors apart from the dying process that lead to unavoidable pressure ulceration including forced immobility, pre-existing illnesses, and hemodynamic factors that impact adversely on blood supply to skin and soft tissues.

Jean Martin Charcot was a visionary and pioneer in the medical field. He was one of the first to use photography in his medical work, and studied hysteria and hypnosis decades before the psychoanalytic era was ushered in by his student Sigmund Freud. He also started the controversy on avoidable and unavoidable pressure ulcers a century and a half before these wounds became commonplace in today’s medical practice.

 

The Livingston Patch reported on yet another example of a nursing home employee taking advantage of a vulnerable resident.  Helien Williams, a certified nursing assistant at CareOne nursing home, and her friend, Michele Walker, both of Newark, NJ are accused of taking photos of a resident’s genitalia and posting the pictures to Facebook.

Both women are charged with conspiracy and invasion of privacy. Williams allegedly photographed the resident in January of 2012 and then sent the photos to her friend who then posted the picture to her personal Facebook page.  Williams was fired from the facility and could face up to five years in prison and a fine of up to $15,000.

Several media outlets have reported that national health spending has remained stable as a share of the economy since Obamacare was enacted.   Spending increased overall to $2.7 trillion in 2011, or an average of $8,700 for every person.  The rate of increase in health spending, 3.9 percent in 2011, was the same as in 2009 and 2010 — the lowest annual rates recorded in the 52 years the government has been collecting such data.   National health spending grew at roughly the same pace as the overall economy, without adjusting for inflation, so its share of the economy stayed the same, at 17.9 percent in 2011, where it has been since 2009.

Kathleen Sebelius, the secretary of health and human services, said that “the statistics show how the Affordable Care Act is already making a difference,” saving money for consumers. Medicaid spending grew less quickly in 2011 than in the prior year, as states struggled with budget problems. But Medicare spending grew more rapidly, because a one-time increase in Medicare payments to skilled nursing homes.

A sign that the effects of the recession have begun to fade is the percentage of people with private health insurance increased 0.5 percent in 2011 after losing ground the previous three years. 
And the share of Americans with health coverage is expected to grow substantially in 2014, when some states will expand their Medicaid programs, and federal subsidies will be offered through insurance exchanges under the Affordable Care Act.  More people gained health insurance as a result of the health law’s requirement that young adults can stay on a parent’s plan until age 26.

 

Health care spending is highly skewed toward the sickest people. Five percent of patients account for nearly half the total spending in any given year.  Prevention and early treatment are the keys to keeping health care spending low.

See articles at The Washington Post, The N.Y. Times, The Wall St. Journal, and Politico.

Foster’s Daily Democrat reported that Nina Perez has been convicted and sentenced for stealing morphine that was supposed to go to an elderly nursing home patient.  Perez was a licensed practical nurse at The Edgewood Centre who pleaded guilty to one class B felony count of possession of a controlled drug and one misdemeanor count of abuse of facility patients.

Perez took a quantity of the controlled drug morphine that was prescribed for a resident and retained it for her own use. Perez received a sentence of twelve months followed by two years of probation. Six months of the sentence was suspended for two years upon the condition of good behavior. Perez also received a sentence of two to five years at the New Hampshire State Prison and a $350 fine. The term of incarceration was suspended for three years upon the condition of good behavior.  Perez’s nursing license has been revoked and she has been added to a federal database of individuals who are excluded from working in health care facilities for five year.

 

Medical Express had an interesting article  about a review in The Cochrane Library that found that education and social support for staff and caregivers can reduce the use of antipsychotics in nursing home patients with dementia.  Improved staff training and education, communication between personal and professional caregivers and support for everyone involved in the patient’s care are effective non-pharmacological methods to try before using antipsychotic medications.

Unfortunately nursing homes use antipsychotic drugs as the first line of treatment for any challenging behavior in nursing homes, despite the fact that they can have serious side effects including over-sedation, falls and cardiovascular problems.

"Despite the reduction in antipsychotic use with the behavioral interventions, none of the four individual studies found significant changes in the behavioral and psychological symptoms of dementia. I agree with the main findings but further research to study the effectiveness of non-pharmacological approaches to managing behavioral symptoms of dementia is sorely needed."