Category Archives: Abuse And Neglect

The Exception or the Standard?

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Listed as one of America’s poorest nursing facilities, Wentworth Rehab in Chicago has a reputation for miserably insufficient maintenance and patient care, as reported in the Chicago Tribune. It’s known for events like the death of Letasha Mims, whose family finds Wentworth to blame for her passing after she became desperately ill during her time there.

Even more recently, a 79 year old man was allowed to smoke while using an oxygen machine at Wentworth, which eventually caused a fire that killed him and caused massive damage in the nursing home. It was reported that the man had a history of destructive behavior and should have been more carefully surveyed for such danger, and also that the staff had acted in a dangerously negligent manner, with one nurse looking on carelessly as the man was burning to death and another nurse attempted to save him.

To those familiar, these kinds of events would not be surprising. None of this even mentions the seeming inescapability of insects and rodents in Wentworth Rehab. Inspectors have reported unidentifiable food being served to patients. Residents can be seen plainly in areas of the nursing home with unimaginably poor personal hygiene. When asked about any of this, Wentworth’s parent company, Alden Management Services, will either deny its facility’s negligence or decline to comment altogether.

There are plenty of bad nursing homes in the United States, many on the same lists as Wentworth. There are even plenty of other bad nursing homes in Chicago, where it’s not hard to imagine a need for affordable or accessible nursing homes. But with its history of lying, neglecting, and ignoring, Wentworth Rehab stands out as a hallmark of bad behavior in nursing homes and a way of looking at any facility’s character.

Criminal Neglect

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The Star Tribune reported that nursing home employee Francisco Javier Ramirez, a nursing assistant at the Good Samaritan Society nursing home, was transferring a female resident, Evelyn Augusta Schweim, out of a bathtub using a mechanical lift chair but failed to follow correct procedures. The resident slid out of the chair — which was raised to its highest level of about 5 feet — and then sustained multiple fractures. The fall was so severe that the woman’s left foot was almost detached from her leg, and the bones of her left leg were visible, according to a Minnesota Department of Health investigation last year of the incident. When she was found, pools of blood had formed around the woman’s ankle and she was complaining of knee and neck pain, the report said.

 After the fall, Ramirez again violated safety protocols by moving the resident away from the door by pulling on her gown, and then leaving her alone in the bathroom as he went to get help, state investigators found.  Schweim, died on Sept. 17 from complications of multiple skeletal fractures resulting from the fall.
 The state Health Department investigation concluded that Ramirez violated multiple safety protocols and was responsible for neglect. The violations include failing to obtain assistance from a second staff person, as required; failing to operate the mechanical lift properly; and leaving the resident alone in the bathroom instead of using his phone or walkie-talkie to call for help. Ramirez also violated protocol by raising the woman to the highest level on the lift. Standard procedure was to lift the chair no higher than 1 to 2 feet, according to the criminal complaint.
Ramirez has been charged with second-degree manslaughter, two counts of criminal neglect and one count of mistreatment of patients.

Are Bed Rails Safe?

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The Toronto City News reported the tragic and preventable death of Danny McNeill trapped in his bed rail, his 69-year-old body fighting desperately to escape the very rails that were supposed to protect him.  Danny McNeill died alone at the Maple Manor Long Term Care Home in Tillsonburg.

According to Health Canada there have been 25 reported incidents involving bed entrapment over the past two years, seven were fatal. Since 2008 Health Canada has issued several safety communications about the use of bed rails as restraints in hospitals and long term care homes — most recently in April 2017 — yet they are still used in most homes and hospitals.  The home has been cited for safety violations involving both the use of restraints and bed rails in the past — including in 2016 when inspectors found that the “licencee (had) failed to ensure that no resident of the home was restrained by the use of a physical device.”

In 2015, the home was cited for failing to ensure that where bed rails were “used in the home (it) had taken steps to avoid patient entrapment” and later that year, 36 of 108 beds were identified as “failed” — in some cases because of a lack of mattress keepers or rails that required ongoing tightening.

“That’s why I’m here, to let people know that they’re being used. Our family members are using them and getting their heads trapped in them,” Kevin McNeill told CityNews. “I’m disgusted.”

“He got trapped between the bars of his bed rail and mattress. That was the call. They said he had died and that was pretty much it,” McNeill says, recalling the phone call he got from the home last Sunday.

McNeill doesn’t know why the restrains were in use. He says an alarm should’ve sounded when his father fell from the bed.

“If he was to fall off the bed or make a movement, the alarm would go off and notify the nursing station and buzz at the bed as well. In the case of falling, the alarm goes off,” he explains.

“The alarm should have been going off as soon as he probably left the area of the pad. He made it to the floor and got his head trapped for too long. That was the case. We really don’t know how long it took until that alarm was heard. I don’t know if they heard.”

Staff at the home told Ministry of Health inspectors that they had received no training on rail safety.

McNeill is still very much grieving the loss of his father but says the practice of using bed rails has to be re-examined.

“Maybe they’ve got to change those rails and make sure we’re not using them as restraints, just using them for getting out of bed. i didn’t know what they were used for until I did some research myself. gotta let people know.”

Video Proves Custodial Neglect

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The Stamford Advocate reported that St. Camillus Center was fined only $6,000 by Connecticut’s health department and three employees were fired following the death of a resident who hadn’t been checked on for 12 hours.  The footage also showed staff had not opened the door to the resident’s room or checked on the resident between 6:26 p.m. on Feb. 15 and 5:19 a.m. on Feb. 16.

In the Feb. 16 incident in Stamford, a resident with lung cancer was found unresponsive and without a pulse, according to DPH, and video footage subsequently showed staff waited 10 minutes to administer CPR.  The resident was taken to the hospital and later pronounced dead. A registered nurse, licensed practical nurse and nurse aide subsequently were terminated, DPH said.

Past incidents at St. Camillus

2016 – Inspectors report observing 40 violations at the nursing home over the past year, including an incident in which a nursing aide called patients fat. As a result of the observations from unannounced visits in 2015 and 2016, the nursing home failed to meet certain state Department of Health standards during annual licensing inspections.

2014 – The facility receives a $1,680 fine related to protection of patients’ rights and/or failure to monitor patient condition.

2010 – The state Department of Social Services threatened to shut down the center and revoke its eligibility to collect Medicaid after investigators find patients’ health in immediate jeopardy.

According to Medicare’s website, St. Camillus has 124 beds and has not received any federal penalties or payment denials by Medicare in the last three years. However, the site received a lower-than-average health inspection rating a year ago after being cited nine times for deficiencies in quality of life and care as well as other issues.

 

 

Lawsuit Against Genesis Healthcare Corp.

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The West Virginia Record reported on a lawsuit by the estate administrator against Saddle Shop Road Operations LLC, which does business as Hilltop Center, Genesis Healthcare Corp. and Brian Chapman, alleging that the deceased, Harold Gene Nutter, received improper care while he was a resident of the Hilltop Center nursing facility.

Estate administrator Charles Fitzwater filed a complaint May 3 in Fayette Circuit Court, alleging that Nutter suffered serious and permanent injuries on May 8, 2017 that resulted in his death.

Fitzwater also alleges that Nutter’s surviving family members have suffered sorrow, mental anguish and loss of society, companionship, comfort and guidance, as a result of the negligence of the defendants in providing inadequate health care and protective and support services to the decedent.

Specifically, the plaintiff claims the defendants failed to employ a sufficient number of staff and failed to ensure that residents received the proper care, treatment, hydration and hygiene requirements.

The plaintiff requests a trial by jury and seeks a judgment against defendants for damages, attorney’s fees, costs and expenses, punitive damages and other relief that the court deems just. He is represented by Jonathan R. Mani of Mani, Ellis & Layne PLLC in Charleston.

Nuedexta Used as a Chemical Restraint

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McKnight’s had an article about FDA concerns over the use of Nuedexta as a chemical restraint.  Nuedexta is the only drug approved to treat uncontrolled laughing and crying due to pseudobulbar affect.  However, some nursing homes are using it for residents without pseudobulbar affect.   It’s a rare condition yet the U.S. government is cautioning private insurers to look for suspicious off-label use there because officials fear the drug is being misused to control behavior.

A CNN investigation published in October found Nuedexta’s maker had been “aggressively targeting frail and elderly nursing home residents for whom the drug may be unnecessary or even unsafe.”   CNN unearthed what seems to be a concentrated effort to keep the increasingly controversial drug in nursing home’s formularies.  The station obtained complaints sent to the Food and Drug Administration from insurers and nursing home physicians who questioned the maker’s marketing and advertising tactics.

In a follow-up article published Monday, the news organization said the Centers for Medicare & Medicaid Services issued a March memo asking Medicare Part D providers to monitor prescriptions for appropriate use.

The CMS memo told plan sponsors that Nuedexta is only approved to treat pseudobulbar affect, and that they are legally required to ensure the drug is only covered for medically-accepted prescriptions. Neudexta’s maker, Avanir Pharmaceuticals, has said that dementia patients may suffer from PBA.  No medical research supports that contention.  Since the drug launched in 2011, CNN reports Avanir has generated millions of dollars in annual sales in nursing homes.

Endangering the Welfare

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McKnight’s had an interesting article regarding the arrests of operator-owner Joseph Zupnik and Daniel Herman, a top-level manager.  The men ran Focus Ostego, which was operated by CCRN, which was owned almost entirely by Zupnik, according to The Daily Star.  They were arraigned May 31 on three counts of first-degree endangering the welfare of an incompetent or physically disabled person, a felony; two counts of second-degree endangering the welfare of an incompetent or physically disabled person, a class A misdemeanor; and three counts of willful violation of health laws, an unclassified misdemeanor.

In 2014, the Ostego County nursing home had 298 employees. By 2016 — under new, private ownership — that number was down to 225, despite immediate jeopardy findings and plenty of other regulatory and staff warnings about quality of care.  Short-staffing always affects the quality of care.

“Upon taking ownership and control of the home’s operation in October 2014, Zupnik, Herman and CCRN cut staff payroll, cut staffing and cut other necessary services and supplies needed to provide safe and adequate care to more than 200 individual residents who were in the care of Focus through at least November 29, 2016, when Focus was designated as a Special Focus Facility by the Centers for Medicare & Medicaid Services,” read the state’s complaint.

The Attorney General’s office said CCRN disregarded communications from local and federal officials and senior staff “that residents were at risk for harm.”   Those missed opportunities for improvement included:

  • State health inspection surveys and reports that contained immediate jeopardy findings in 2015 and 2016.
  • Warnings from senior managers about the defendants’ 50% cuts in payroll and staffing and required double shifts.
  • Six arrests between May 2015 and August 2016 of Focus staff for crimes at the facility involving healthcare offenses. These included neglect of a 91-year-old fall victim and a 94-year-old woman who developed a pressure sore after 41 hours in a recliner.

Otsego County owned and operated the nursing home in question before selling it to Focus for $18.5 million. Focus has since been resold to Centers Health Care, which renamed it Cooperstown Center for Rehabilitation and Nursing.

Video Camera Records Sexual Assault

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Fox25Boston reported a tragic incident that occurred at a Rhode Island nursing home.  Frank Palin, age 67, was arrested for sexually assaulting a patient with dementia in a nursing home. Palin is charged with a single count of indecent assault and battery on a person over age 65, stemming from an incident through his work with Old Colony Hospice.

According to the police report, on May 19th, Palin showed up to Cornerstone without an appointment, asking and employee to unlock the secured facility where the victim stays.  According to authorities, the woman’s children had installed a video camera inside her room, so they could check in on her, which helped them find out what was happening.

Palin is a contract employee with Old Colony but was working as a nurse practitioner at Cornerstone at Canton, where the victim is a resident of the facility. She reportedly suffers from dementia and lives in the memory care unit at Cornerstone.

Bob Larkin, the president of Senior Living Residences, the management company in charge of operations at Old Colony Hospice and Cornerstone at Canton, issued the following statement on Friday afternoon:

“The alleged violation of a vulnerable elder is appalling beyond words. We support the victim’s family and the police department in seeking criminal prosecution to the fullest extent of the law. Nothing is more important to us than the safety and well being of our residents. The accused nurse practitioner was not an employee of our company; he worked for a third-party local hospice agency that has no contractual or other relationship to our assisted living community. Any questions about the individual’s employment or exact duties should be directed to his employer, Old Colony Hospice in West Bridgewater, 321 Manley St, West Bridgewater, MA,  781-341-4145. Also please call the Canton Police for any information about the ongoing investigation. Please note, HIPAA patient privacy and confidentiality standards preclude me from providing specific information about any resident. “

Where is the Compassion and Empathy?

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 North Carolina has substantiated claims that a nursing home mistreated a resident after a daughter secretly recorded staff insulting her father.  Knapton said she placed a camera in her father’s room after he told her that staff routinely insulted him. She also suspected she wasn’t being told about all the times her father, who had had a stroke, had fallen out of bed.  The hidden camera Rebecca Knapton placed in her father’s room at Universal Health Care/North Raleigh captured staff belittling him after he had fallen out of bed and was calling for help.

ichard Johnson, 68, is recovering from a stroke, and video from the hidden camera shows that he fell out of his bed early on April 10. It took more than an hour for staff to respond, and they berated him when they did.

“Man, you stink,” one worker told Richard Johnson as he lay on the floor. He told them he fell trying to get to the bathroom.  One worker told the 68-year-old that he shouldn’t complain about lying on the cold floor.

“You were on the bed, you decided to go on the floor, so that’s your fault,” one worker said. “You decided to go on the floor, so don’t complain that it’s cold.”

“How old are you? You’re supposed to be enjoying your retirement. Instead, look what you are doing, pooping on yourself. Shame on you,” a staff member says.

At one point a worker told him that his suffering was his own fault. “You must have done something really, really bad,” she said.

Knapton said her father told her, “they talked down to him, they treat him mean, they call him names, they fuss all the time.”

A state investigation triggered by Knapton’s complaint pointed out problems with the care of other patients.

According to documents Knapton received, surveyors for the state Division of Health Service Regulation interviewed staff and residents and reviewed document at the nursing home from April 10-15.

One patient complained of chest pain for two days, but there was no indication that he received nitroglycerin as the doctor ordered, according to the state report. The man was sent to the hospital on the second day. Hospital records show a nurse saw him at 1:30 p.m. in the emergency room, and that he died about four hours later. However, a nurse’s record at the nursing home had the man leaving for the hospital at 7 p.m.

The N.C. Department of Health and Human Services said that the Centers for Medicare & Medicaid Services will initiate enforcement action and notify the facility.

Steven Bryant recorded a recent visit he made to Universal Healthcare of Lillington to see his 82-year-old mother. Sudie Bryant had complained of the care she had been receiving, he said, so he wanted to document what happened while he was there.  Sudie had been lying in a puddle of urine for so long that it had turned brown.

“Sir, I’ll be honest with you. We’ve been doing our best,” an aide said. “It’s just two [aides] in this hall, and honestly, we’re doing the best we can.”

As one aide leaves to get an administrator, the other explains staff cutbacks are the problem.

“I am glad that you are here to see it because we tell them time and time again that it’s too much, too much,” she said. “They don’t listen to us. We need the families to complain. We need families to see how it really is.”

Choice Health Management Services has 16 facilities in North Carolina, most operated under the Universal Healthcare brand. Medicare has levied fines totaling $567,976 for problems at six of the facilities since 2015.

Universal Healthcare Fuquay-Varina topped the list, with $234,260 in fines, followed by Universal Healthcare Lillington, with fines of $151,483. Universal Healthcare North Raleigh was fined $31,186 two years ago, the smallest fine against any of the six facilities.

The Raleigh facility has a history of repeat federal violations for insufficient staffing and failing to answer patients’ call bells in a timely manner.

The fines assessed against the three Universal Healthcare facilities in the Triangle combined to top the $246,000 in fines Medicare levied against 22 other nursing homes within a 25-mile radius of Raleigh in the past three years.

The incident at Universal Healthcare Lillington, where a man recently recorded a video showing improper care for his mother, involved a patient infested with maggots.

A doctor from an outside clinic found “maggots living in a wound on the resident’s foot” when he removed the patient’s shoes, according to a report. An aide at Universal Healthcare told investigators she discovered the maggots the previous day and went “screaming out of the room” without taking further action.

Universal Healthcare of Fuquay-Varina was fined after a resident at risk for wandering walked out the front door and across the parking lot. Inspectors checked all of the bracelets worn by at-risk patients to alert staff if they were about to wander off and found that none of them worked, according to a report.

“That’s ridiculous,” Powell said when he heard about the issues at Universal Healthcare facilities. “I am at a loss for words. I got to find a place to move my mom.”

See more information at WRAL, The News & Observer, and WFMY.

Bullying: “It’s like ‘Mean Girls,’ but everyone is 80.”

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WSLS ran an article on the epidemic of bullying in today’s nursing homes.  Around the U.S., caregivers say they’ve seen gossip, exclusion and even incidents of physical violence popping up.  Arizona State University professor Robin Bonifas says for some who see their independence and sense of control disappear late in life, bullying gives them a feeling of regaining lost power.  Bonifas, a social work professor at Arizona State University and author of the book “Bullying Among Older Adults: How to Recognize and Address an Unseen Epidemic,” said existing studies suggest about 1 in 5 seniors encounters bullying. She sees it as an outgrowth of frustrations characteristic in communal settings, as well a reflection of issues unique to getting older.

Every month, as many as 20 percent of older Americans who live in nursing homes are subjected to seriously bad behavior from one of their fellow residents, such as physical and verbal abuse, privacy invasions or unwanted sexual attention. “The findings suggest that these altercations are widespread and common in everyday nursing home life,” says study co-author Karl Pillemer, Ph.D., professor of gerontology in medicine at Weill Cornell Medical College in a press release.

Nationwide, that translates to hundreds of thousands of people who endure abuse. Many incidents of name-calling, bossy behavior, loud arguments and, at its most extreme, physical violence go unreported.