The Montreal Gazette had the heart-wrenching story of Francois Marcotte.

“Hello. My name is François. I am 43 years old. I live in Quebec City and I am a prisoner of my body. Please help me escape.”

That is how François Marcotte began his post on Go Fund Me, a personal fundraising website. Marcotte, who suffers from multiple sclerosis and is completely paralyzed, is trying to raise at least $25,000 to hire someone to give him three showers a week at the nursing home where he is now forced to live, and to pay for an adapted vehicle.

The average age (at the nursing home) is 85; I am by far the youngest at 43,” Marcotte wrote. “I’m entitled to only one shower per week. That is the rule in public nursing homes in Quebec. The other six days of the week, I get a partial wipe-down in bed. Every morning I wake up with my back and legs covered in sweat. Where I live, they refuse to wash my back, legs or feet.”

Marcotte’s story hit a nerve with opposition parties at the National Assembly, who deplored the fact that once again, Quebecers living in nursing homes have to beg and plead to have more than one shower or bath a week.

 In April 2015, the Coalition Avenir Québec’s François Paradis revealed that some orderlies in Quebec were accepting cash payments between $20 and $40 from people wanting an extra bath.


While recognizing Marcotte has special needs, the home’s director general, Stéphan Pichette, said it is “unrealistic” to give him more showers without cutting services to the other 63 residents.

“I don’t believe Mr. Barrette when he says he is touched (by Marcotte’s plight),” said Québec solidaire MNA Amir Khadir, who, like Barrette, is also a doctor. “Twenty-first century Quebecers are entitled to basic services, three, four baths a week, no? Now, because the government is making it impossible, what do people do? Well, they pay out of pocket. And when there’s no money, they resort to crowdfunding. In other words, it is the phenomenon of accessory fees that is spreading everywhere.

Reached at his long-term care home, Marcotte argued it’s more than just a question of hygiene; it’s a question of well-being and dignity.

Showers make me relax, they soothe my body and allow me to have good days,” he said. had an interesting conversation with OR Excellence speaker Kenneth P. Rothfield, MD, MBA, CPE, CPPS

It’s disheartening, says anesthesiologist and patient safety expert Kenneth P. Rothfield, MD, MBA, CPE, CPPS, how little patient safety has improved during his lifetime. More than 400,000 U.S. citizens die from preventable medical errors each year. Only heart disease and cancer kill more Americans. In Dr. Rothfield’s thought-provoking presentation, “Patient Safety: 54 Years of Progress … or Stasis?” at the Hyatt Regency Coconut Point in Bonita Springs, Fla., he’ll plot the progress — or lack thereof — that’s been made on a 54-year timeline and challenge surgical leaders to eliminate the never events that keep happening. We recently talked to Dr. Rothfield.
Q: Despite all the talk and all the hand wringing over the astoundingly high numbers, we haven’t made much of a dent. How can that be?

Dr. Rothfield — One of the problems is that try as we might to create systems that are infallible — that make it impossible to make mistakes — there are really no human-proof systems in health care. Ultimately, we rely on the vigilance of providers who may unwittingly make errors. People are always going to make mistakes. We also have people who make decisions to bypass policies, procedures and rules that are in place to keep patients safe. They’re not trying to hurt anybody. They may just be trying to be more efficient. But they engage in risky behavior. And sometimes people are just reckless — though fortunately not very often. But it happens and our patients pay the price for it.

Q: Does that mean the human factor can’t be overcome?

Dr. Rothfield — As much as we’d like a magic bullet, for many of these challenges, the solutions are cultural and social, not technical. For example, there was a lot of excitement about implementing checklists a couple of years ago, but we continue to have issues. Why? Because it’s really a function of culture and leadership that make checklists work. As a theory, it sounds great, but the implementation is much trickier. It involves changing the way people interact and the way they feel about their work.

Q: What are some of the cultural and social factors?

Dr. Rothfield — We need to switch from a craft model in which doctors are completely autonomous to having doctors understand that they’re part of a team, and that what other people do is just as important as what they do. The way I like to say it is that the person taking out the trash is just as important as the person taking out the gallbladder. But that’s not the kind of social construct our hospitals have developed. Until we have physicians playing more of a leadership role, things aren’t going to change.

Q: Where are doctors coming up short?

Dr. Rothfield — For a lot of doctors, quality and safety are someone else’s job. Doctors are raised on a steady diet of autonomy, hierarchy and competition. It’s a sea change to be told to think of yourself as a member of a team, and that you should implement best practices that have been developed by other people, especially when you’re doing something that you think is working just fine. But it won’t be until we get to that level of standardization that we’re going to make a difference. Every other industry has figured out that variation yields terrible results.

Q: And doctors need to step up?

Dr. Rothfield — We need physicians to lead in a lot of these areas. To turn the tide with patient safety, we need them to get more training and to learn how to be effective leaders. We’re inclined to put them in leadership positions, but the reality is that leadership usually isn’t something you’re born with. Its something you learn. It’s a series of practices and behaviors that bring people together to rally around a common goal. It’s being able to share that vision and get people to come along willingly. It’s not about using authority to compel people to do things.

Q: Is there a growing emphasis on leadership skills in medical schools?

Dr. Rothfield — I think there are pockets where that is happening, but it’s not the defining feature of medical education. Until we get to where physicians not only communicate effectively with patients, but also understand their roles as leaders, we’re not going to have a lot of progress. It all comes down to communication. We know it’s the underlying thread in the overwhelming majority of patient safety events. Until we get that piece right, we’re not going to fix the problem.

Q: Is the trend toward transparency likely to have a significant impact?

Dr. Rothfield — The problem is people don’t shop for health care the way they shop for cars. If you’re getting a new car, you spend hours poring over it, figuring out what you want. But most people are afraid of healthcare services. They don’t shop as hard or as carefully for their doctor or their hospital, or with the same discernment, as they do when they shop for a new refrigerator or new tires.

Q: What’s the tipping point — what will finally bring the number of injuries and deaths from preventable medical errors down to an acceptable level?

Dr. Rothfield — The tipping point will be when healthcare organizations take full risk for their outcomes — when outcomes determine what they get paid. That’s happening now in a small way around the CMS penalties for outcomes, but it won’t be until every penny is at risk for safety and quality that organizations will get 100% behind making quality job 1.


McKnight’s reported on the plan from CMS (FY 2016 to 2017 Nursing Home Action Plan) which laid out five strategies that will “guide” the CMS’ Division of Nursing Homes in improving safety and quality throughout the nursing home industry.

The top item is enhancing consumer awareness and assistance in navigating nursing home care, through tools like the Five-Star Quality Rating System. Consumers also would benefit from improved staffing data on the CMS website which will be bolstered by the mandatory payroll-based staffing data starting July 1.

CMS also plans to strengthen guidance and training for surveyors following the finalization of the requirements for nursing homes participating in the Medicare and Medicaid programs, expected to be released in September. The agency expects to streamline its nursing home complaint investigations, and develop a revised survey methodology that combines the “best of both traditional and QIS processes.”

On the enforcement side, CMS will expand its relationships with regional, state and federal programs, consumer advocates and national associations in order to focus on the “transparency, consistency and application” of enforcement activities. Among those activities is improving monitoring of persistently poor performing “special focus facilities” through pilot programs across various CMS regions.

The agency also anticipates taking on several quality improvement areas, including antipsychotic reduction, as well as a reduction of physical and chemical restraints.

The final strategy in the action plan focuses on partnerships between consumers, providers, professional associations, surveying agencies and other stakeholders in the healthcare system.

“Although each entity within the system may have different roles and responsibilities, the goal of quality care is advanced when an increasing number of entities in the system can act synergistically,” the plan reads. “When such a concerted action is achieved, the total can indeed become greater than “the sum of its parts.”

McKnight’s reported the new recommendations urging stroke patients to receive treatment at an inpatient rehabilitation facility instead of long term nursing homes according to the American Heart Association/American Stroke Association.

The new recommendations urge stroke patients to receive treatment in an inpatient rehabilitation facility “whenever possible,” unless they have a condition that would require more skilled nursing care. Research found “considerable evidence” that stroke patients benefit from a rehab-focused facility’s minimum three hours of daily therapy and “team approach” in the early period after a stroke.

“If the hospital suggests sending your loved one to a skilled nursing facility after a stroke, advocate for the patient to go to an inpatient rehabilitation facility instead — unless there is a good reason not to — such as being medically unable to participate in rehab,” wrote Carolee J. Winstein, Ph.D., P.T., lead author of the guidelines.

The guidelines, published in Stroke, also encourage stroke patients and their caregivers to insist upon participation in a “structured” education program on preventing falls. That program may include ways to make their homes safer, decreasing the risk of falls linked to medication side effects, and how to safely use wheelchairs, walkers and canes.

For stroke patients, the association recommends “intense” mobility task training to relearn tasks such as climbing stairs, individually tailored exercise programs, speech therapy, balance training, and eye exercises. Rehab providers should also provide an “enriched environment” with computers, books, music and virtual reality games to increase patient engagement.

“All of the studies [used in the recommendation] rather consistently found that outcomes for stroke patients are better in acute-level rehabilitation than in skilled nursing rehabilitation,” Stein said.

CBS News reported on the tragic story of nursing home resident Geneva Hilton.  Geneva, 68, was admitted into Centinela Skilled Nursing & Wellness Centre West in Inglewood in 2014. Five weeks later, she was dead.  Her daughter, Czersale Hilton, believes the facility’s neglect caused her wrongful and premature death.

Hilton has sued Centinela West, claiming elder abuse and negligence. According to the lawsuit, her mother “was admitted for rehabilitative care following a hospitalization for chest pains. Her lungs were clear and she was in good condition.”

But five weeks later, she was rushed to a hospital in critical condition, suffering from pneumonia, dehydration and a body temperature of lower than 80 degrees.

“I was shocked. Of course, I was shocked, because the last time I spoke to my mom, she was herself,” Hilton recalled. “I loved my mother with all my heart, and I miss her every day.”

Los Angeles millionaire Schlomo Rechnitz owns and operates the facility as part of California’s largest chain of nursing homes.  Rechnitz’s companies own 81 nursing homes in California, the most in the state.  The FBI has raided two of Rechnitz’s facilities, including the Alta Vista Healthcare & Wellness Center in Riverside. No charges have been filed yet.

“It was like zombies walking around here,” said South Pasadena police chief Art Miller, who described patients at South Pasadena Convalescent Hospital when it used to be owned by Rechnitz.

The federal government decertified it last year, denying its eligibility to get Medicare money. It happened after Courtney Cargill, 57, set herself on fire.

The California attorney general filed involuntary manslaughter charges against the Verdugo Valley Skilled Nursing facility in Montrose and two staff supervisors after a 58-year-old male patient died.

The attorney general tried unsuccessfully to block Rechnitz from owning more nursing homes saying his “continued and repeated refusals to comply with industry laws and regulations was harming the skilled nursing industry.

As for Hilton, she is still searching for answers and hopes telling her story will help others. “I didn’t want my mom’s death to be in vain.”




The Pittsburgh Post-Gazette reported the verdict involving a nursing resident of Providence Care Center. Elma Betty Temple, 86, and her son brought suit four years ago against Providence Care Center, where Ms. Temple fell in November 2011 and suffered broken bones and other serious injuries, according to their claim. The suit said the home was negligent in not supervising her closely enough.

Last month, the jury compensated the resident and her family with a verdict of more than $2 million against the nursing home, and another $250,000 in punitive damages.

WPXI reported that Mindy Mench never knew what Snapchat was until a nursing home employee shared pictures and video of her grandmother on the toilet.

“I kept asking her, ‘why?’” Mench said. “Why did you do this? Why would you do this? How would you feel if someone did this to you?”

In Massachusetts, two nurse’s aides are facing charges after posting a patient’s picture and captioning it “Chucky’s Bride.”

Senator Chuck Grassley (R-IA) said every case is a form of abuse of the elderly and he has sent a letter to the Department of Justice demanding a nationwide investigation.

“It’s just taking advantage of people in a way. That’s inhumane,” Grassley said.

Grassley also asked Medicare and Medicaid to see if anything could be done in nursing home inspections.

Messina v. North Central Distributing, Inc., 2016 WL 2640911 (8th Cir. May 10, 2016), involved an employee’s claims of wrongful termination and breach of contract against his employer.  The employee brought those claims in Minnesota state court.  In response, the employer removed the case to federal court, filed an answer asserting 24 affirmative defenses, and later moved to transfer the case to federal court in California.  Only after the federal judge in Minnesota denied the motion to transfer did the employer move to compel arbitration.  That motion came eight months after the plaintiff had filed his complaint.  The district court denied the motion to compel, finding the employer had waived its right to arbitrate, and the appellate court affirmed that result.

The appellate court agreed that all three elements of the test for waiving arbitration rights were met.  First, the employer “knew of [its] existing right to arbitration,” because it had the arbitration agreement in its possession.  Second, the employer “acted inconsistently with that right” by litigating for eight months, including making two motions (removal and transfer), and filing scheduling reports that indicated the case would proceed to trial.  The court also faulted the employer for not raising arbitration at the earliest possible time — in its Answer or in the Rule 26(f) report.  And third, the employer “prejudiced the other party by these inconsistent acts,” in that it caused delay and forced the employee to respond to motions and participate in procedures not available in arbitration.

The 8th Circuit seemed most concerned about the gamesmanship, however.  It commented that “[t]he timing of [the employer’s] actions demonstrates that it ‘wanted to play heads I win, tails you lose,’ which ‘is the worst possible reason’ for failing to move for arbitration sooner than it did.”

The test used by the 8th Circuit to determine waiver of arbitration rights is similar to that used in many circuits, so this case is a good opportunity to remind parties and counsel that there are serious risks to not raising the existence of an arbitration agreement early in a case.  My rule of thumb — not yet adopted by any court — is that it should be raised within the first three months of litigation and before making any (other) affirmative motion that requires court resources.


For the second time in just over a month, a Minnesota nursing home has been cited for neglect in the case of a patient who died after a medical transcription error according to a report by the Star-Tribune.

Nurses at a Golden Living nursing home last October mistakenly [read: negligently] entered a physician’s order for blood-thinning medication on the wrong person’s medical record. The error went unnoticed by multiple nurses for nine days, until the patient developed blood clots in the brain and died of a stroke, according to a state Department of Health investigative report.

Golden Living is the nation’s third-largest nursing home chain with facilities in 21 states.  After visiting the Golden Living home last November and interviewing staff, state investigators concluded that the facility “was not monitoring the performance of the nurses and had not conducted annual medication competencies of the nurses.”

The findings against Golden Living come weeks after another Minnesota nursing home neglected a patient who was mistakenly given 10 times his prescribed dose of morphine. Staff at the Mahnomen Health Center, a hospital with a 42-bed nursing home, had transcribed the wrong amount of morphine on the patient’s record, and did not detect the error until it was too late, state investigators found.

 In a case early last year, a patient at a Golden Living home in Moorhead fell out of a mechanical lift, suffering a skull fracture and brain bleeds; the resident was placed on hospice services and died three months after the fall, state investigators found.

In another case, a resident from a Golden Living home in Benson appeared at a hospital malnourished and dehydrated, with multiple open sores, after staff failed to notify a physician that the patient’s condition had worsened. Since 2013, health officials have substantiated maltreatment at five of the company’s homes in Minnesota.

The Pennsylvania Attorney General’s Office last year sued Golden Living for failing to provide basic services at more than two dozen nursing homes in Pennsylvania, alleging that facilities were understaffed and residents were left “thirsty, hungry, dirty, and unkempt.”

The company has repeatedly denied these allegations, asserting that the lawsuit stems from an inappropriate relationship between the attorney general and an outside law firm that is paid by contingency fees.

McKnight’s had a great article by Eleanor Feldman Barbera, PhD, author of The Savvy Resident’s Guide. Barbera is a 2014 Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. A speaker and consultant with nearly 20 years of experience as a psychologist in long-term care, she maintains her own award-winning website at

As McKnight’s Staff Writer Emily Mongan points out in “Depression treatments may increase risk of falls in SNF residents, study shows,” a psychosocial treatment for depression increased the likelihood of resident falls. Barbera spoke with Suzanne Meeks, Ph.D., first author of the study, to discuss the problem and the results of her research.

Meeks and her colleagues studied the impact of the Behavioral Activities Intervention (BE-ACTIV) on depressed nursing home residents. They determined that the risk of falls in the treatment group was six times that of the control group, a statistically significant number.

Meeks told me all treatments for depression, including medication and behavioral interventions, increase the chance of falls. When an individual is no longer depressed, he or she has more energy to stand and walk, thus creating more opportunities to fall. If depression has immobilized them for some time, deconditioning may exacerbate the problem.

Meeks points out that more than 81% of her research subjects in both treatment and control groups were receiving antidepressants, suggesting that the behavioral intervention activated the residents more than the medication.

It’s important to treat people for depression despite the increased risk for falls because, as Meeks states, “depression is a fall risk.” Other researchers have found that the risk of falls increases when an individual has more of the following risk factors: depressive symptoms, antidepressant use, high physiological fall risk, and poorer executive function. Any two of these risk factors increase the likelihood of a fall by 55%. Participants with three or four risk factors were 155% more likely to fall — 155%!

The BE-ACTIV intervention

The BE-ACTIV model was quite successful in reducing depression, Meeks and her colleagues found, as described in an earlier article about their work. Study subjects in the 10-week treatment group were encouraged and assisted to participate in pleasant activities such as regularly scheduled group programs, in-room crafts and self-care such as haircuts. Compared to the “treatment as usual” control group, BE-ACTIV was “superior … in moving residents to full remission from depression.”

In addition, there was this particularly noteworthy point: “Staff did not report spending more time with the residents than they had before the intervention, but 86.4% reported improvement in their relationships with the residents.”

This is notable for a number of reasons: First, the intervention didn’t require extra staff time, which is always at a premium. Second, having more pleasant relationships with residents improves workers’ experiences on the job, which reduces turnover. And third, when residents have better interactions with staff members, they are less likely to be depressed.

Mitigating the risk of falls

If depression can contribute to falls and treating depression can also lead to falls, this creates a dilemma that can be addressed by using the following recommendations:

Increase awareness of fall potential. Meeks and her coauthors encourage clinicians and researchers to be aware of the increased risk of falls as residents become less depressed and more active. Those in other LTC roles, such as nurses, aides and recreation therapists, can be directed to more closely monitor a resident whose depression is abating and to use the techniques listed below.

Teach the residents about fall prevention. Many elders can benefit from knowing that they’re at increased risk for falls as they become more active. They’re likely to appreciate the opportunity to self-monitor and will be more motivated to participate in the subsequent suggestions.

Refer for rehabilitation services. A resident who is starting to become more active after a period of inactivity may be helped by a stint in rehab to strengthen areas of physical weakness and reduce the likelihood of falling.

Promote attendance in activities like tai chi. Recreation programs such as tai chi, exercise groups or balloon volleyball can simultaneously improve physical functioning while enhancing mood. Follow the lead of the BE-ACTIV program by including several of these pastimes on the recreation calendar each week and encouraging residents to attend.

Both falls and depression are significant health risks for elders in long-term care and, as the findings of the study show, they should be treated in conjunction with one another.