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.
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.”
The Indy Channel had a sad story about a 102 year old nursing home resident that suffered a wrongful death after Bethel Pointe Healthcare nursing home removed her safety bed rails allowing her to fall out of bed. Thelma Pauline Rector would have celebrated her 103rd birthday in March if not for the fall that led to her wrongful death nearly three months earlier.
Rector’s family was pleased with Bethel, until her accident this past November revealed her bed rails had been removed. Dowling says no one bothered to call Thelma’s power of attorney to report their removal or explain the decision.
“She actually fell out of bed and hit the floor – face-first – and that’s when we actually realized that they were gone,” Dowling said. “When we went in to talk to the people at the facility – that’s when they actually told us [about a] new law that you have the right to fall which I could hardly believe.”
“It didn’t go over well with me,” Dowling said. “Somebody is in a facility and that’s why you put them (there), to have 24-hour care and you put them there because we were having trouble keeping them from falling at home. You expect that care to be given to them.”
The WYDaily reported the tragic death of a nursing home resident from a preventable improper transfer, and the family’s search for answers and justice. Lee Cleveland Scruggs, the executor of the estate of Fannye Doris Holden Scruggs Rorer, is suing Williamsburg Landing in a neglect lawsuit, stating the home was, at times, negligent in their care of Rorer. Court documents allege Rorer fell “at the hands of” staff on April 15, 2016, while being transferred from her bed into a hoyer lift. The lift is used for mostly or completely immobile patients. Rorer died eight days after her fall.
“At all pertinent times, Fannye was a helpless, mentally compromised, one-eyed amputee with inter alia limited communication ability, who was totally dependent on defendant… for her basic activities of daily living … and everything else,” according to a civil complaint filed in the Williamsburg-James City County Circuit Court.
According to court documents, Rorer was a resident patient at Woodhaven Hall at Williamsburg Landing from April 2011 to April 23, 2016, when she died. In those five years, the family paid over $600,000 for her care, the complaint said.
The complaint cites multiple surveys completed by the Virginia Department of Health in 2015 and 2016 which cited the nursing home for safety violations, including not immediately notifying a doctor when a patient fell, not developing an “appropriate” care plan for another patient, and more. The complaint states Rorer was injured at least six times during transfers using a hoyer lift in the months leading up to her fall and death.
Rorer was dropped around 5:40 a.m. April 15, 2016, while being transferred out of her bed by a single nursing assistant. Employees later told Rorer’s family the transfer should have been made by two people, the complaint states. X-rays after the fall showed Rorer had multiple compression fractures on her lumbar spine.
The State reported that a Lexington County jury has found Lexington Medical Center Extended Care guilty of gross negligence in the death of one of its residents. Jurors compensated the family of Samuel B. Cunningham $450,000, including $200,000 for Cunningham’s pain and suffering, medical and funeral expenses, and $250,000 for the family’s mental shock and suffering, wounded feelings and loss of companionship.
Cunningham was admitted to the facility at 815 Old Cherokee Road in Lexington on April 29, 2013, at age 81. He was suffering from dementia and was legally blind. The family alleged that Cunningham often was found by his family soaked in urine, unclean and lacking in oral care. Nursing home records showed Cunningham suffered 26 falls. He was found on the floor 19 times without anyone seeing him fall. On one occasion, he was found on the ground outside the building with multiple ant bites.
“We were heartened by the jury’s verdict and hope that it will provide incentive for the facility to get its act together and start treating its residents with the dignity and care that they deserve.,” Ken Connor, the Cunningham family’s attorney, said in a news release.
The suit alleged improper care; on one occasion, Cunningham fell and required a hip replacement at Lexington Medical Center, which also operates the nursing home.
Cunningham also developed bed sores because of improper care, and was not properly fed. He also developed pneumonia, which was not addressed in a timely fashion by the nursing home.
On July 1, 2015, Cunningham was admitted to Lexington Medical Center suffering from multiple areas of skin breakdown, malnutrition, dehydration and infections, the suit claimed. He was unable to recover from his decline and died two weeks later at Agape Hospice House in Columbia.
WFAA had an interesting article discussing the problem of short-staffing and chemical restraints at nursing homes. This article was Part 4 of WFAA’s continuing investigation of nursing home abuse and neglect. (See Parts 1, 2 and 3 ). The ongoing WFAA investigation into Texas nursing homes has already revealed questionable practices in the hiring of criminal caregivers – and now WFAA has uncovered inappropriate and unnecessary drugging of residents.
In effort to cut costs, troubled nursing homes may drug the elderly rather than hire needed staff. The practice has been dubbed “chemical restraints.” It’s a practice of using powerful drugs to sedate or quell agitated, disruptive or violent patients. When a facility is chronically short-staffed, often the staff will administer medications that sedate the residents so the residents are easier to take care of for the overworked and burnt-out caregivers. In the latest report, called “Drugged and Dying,” News 8 investigative reporter Charlotte Huffman found that 96 percent of Texas nursing homes admit they’re giving drugs to residents who don’t need them.
According to the FDA, unnecessary use of antipsychotic medication kills 15,000 nursing home patients every year. Of all the drugs used as chemical restraints, antipsychotics are the most widespread and may be the most dangerous.
The federal government has previously caught drug manufacturers improperly promoting their antipsychotic drugs for use in nursing homes. (See here and here.)
Before nursing homes can give residents antipsychotics, new federal guidelines require doctors to diagnose them with at least one of three mental illnesses, the most common being schizophrenia. A WFAA analysis of nursing home data shows that, after this new rule, the number of residents diagnosed with schizophrenia has skyrocketed 26 percent. Schizophrenia develops in a patient’s early 20s, not later in life, experts say.
Various healthcare officials and advocates, when reached for comment, have found WFAA’s findings troubling:
“There’s no doubt that it raises a big red flag,” said Amanda Fredriksen, AARP Texas director of advocacy and outreach. “It’s pretty disturbing when people are that motivated to drive their numbers down to falsify medical records or to make up diagnoses. But to the extent that that’s happening, that’s a real serious issue.”
Dr. Daniel Pearson, head of psychiatry at Methodist Hospital, questions a first-time schizophrenia diagnosis of an elderly nursing home resident. He said such a diagnosis, especially to sedate, may be inappropriate, and possibly dangerous. “Does that surprise me? No. Are those diagnoses legitimate? Probably not,” Dr. Daniel Pearson told WFAA. “If you are using it just to keep people quiet, there are significant risks that are associated with that…increased risk of cardiac death, increased risk of falling, breaking a hip,” added Dr. Pearson, who spent a decade as a psychiatrist in nursing homes.
“About 70 percent of a nursing home’s expenses are staffing,” said attorney Ernest Tosh, who handles nursing home lawsuits. “So, if they can cut back on staffing, they can directly increase their profitability.”
Last year, the state of Texas warned nursing home administrators about inappropriately drugging residents.
That same watchdog created this brochure to inform nursing home residents about the dangers of them being inappropriately drugged.
Here is a link to federal government regulations dealing with medication administration and monitoring – see p. 505.
The New York Times had an interesting article on how the Dutch are helping elderly residents from falling. Falling can be a serious thing for older adults. Aging causes the bones to become brittle, and broken ones do not heal as readily. The Dutch, like many elsewhere, are living longer than in previous generations, often alone. As they do, courses that teach them not only how to avoid falling, but how to fall correctly, are gaining popularity. The classes are designed for people over 65.
There is the “Belgian sidewalk,” a wooden contraption designed to simulate loose tiles; a “sloping slope,” ramps angled at an ankle-unfriendly 45 degrees; and others like “the slalom” and “the pirouette.” The obstacle course was clinically devised to teach them how to navigate treacherous ground without having to worry about falling, and how to fall if they did. In order to learn, the students start by approaching the mats slowly, lowering themselves down at first. Over the weeks, they learn to fall. Hundreds of similar courses are taught by registered by physio- and occupational therapists across the Netherlands.
PennLive reported the $250,000 verdict after the jury found a nursing home was at fault for the death of an 85-year-old resident. The family of Bruce Dove had filed suit against the United Church of Christ’s Sarah A. Todd Memorial Home in Carlisle.
Dove had five children, now adults, some of whom were there throughout the trial, and it was the circumstances of his February 2014 death at the nursing home that spawned the lawsuit, filed in 2015. According to the complaint and testimony at trial, the incident occurred like this:
On Feb. 5, 2014, Dove was in his wheelchair, waiting, near the entryway to the dining room, for dinner to be served. A supervising registered nurse asked another registered nurse to push him into the room. But the second nurse pushed his wheelchair fast and recklessly down the hall toward the dining room without giving Dove warning or attaching footrests – a violation of safety standards. This motion flung Dove from his wheelchair. He hit his head on the floor and broke his neck. The nurses rolled him over — failing to immobilize him — placed him back in his wheelchair and then moved him into his bed.
Dove suffered cervical spine fractures of the C1 and C2 and an odontoid fracture with displacement, as well as neurological damage. He died the following day.
“It was very important to my clients that the truth come out,” attorney Michael Kelley said. “They had been told early on that he just fell out of his wheelchair. They never believed that.” The two nurses involved had been fired after the incident, which Kelley said was among the strongest pieces of evidence against the home.
The Pittsburgh Post-Gazette had an interesting article about the danger of entrapment in bedside rails and restraints after prominent Pittsburgher Robert Frankel’s recent accidental strangulation from entrapment in bed rails at the Charles Morris Nursing and Rehabilitation Center nursing home highlighted a danger that has concerned regulators and consumer advocates for years. Mr. Frankel, a businessman, arts patron and father of a state legislator, was pronounced dead of accidental asphyxiation from “compression of the neck” after being found on the floor of his room. A state Health Department inspection report said he was “lying with his body on the floor and his neck between the air mattress and the side rail.”
Are they too dangerous or a necessary safety intervention? The risk of injuries from bed rail use, particularly in the case of dementia patients like Mr. Frankel, has been among the issues cited in a successful effort over the past two decades to reduce a variety of dangerous restraints that restricted nursing home residents. The FDA, which regulates hospital beds as a medical device, counted 531 rail-related deaths from 1985 to 2013, the most recent period in which it did an analysis.
The safety movement has been driven primarily by the goal of enhancing the dignity and independence of residents, who were once often tied to their beds or wheelchairs. However, other interventions don’t necessarily achieve their goal of enhanced safety including bed rails and alarms attached to beds or patients’ clothing. Those include placing adjustable beds low to the floor, using protective padding beside the bed and having staff learn and follow residents’ patterns for needing assistance getting to the bathroom. The only truly effective intervention is proper supervision which can only be achieved with adequate staffing.
“Even when portable bed rails and hospital bed rails are properly designed to reduce the risk of entrapment or falls, are compatible with the bed and mattress, and are used appropriately, they can present a hazard to certain individuals, particularly to people with physical limitations or altered mental status, such as dementia or delirium,” the U.S. Food and Drug Administration reports on its website.
The state report on Mr. Frankel’s death said the nursing home was using rails not to protect him from falling out of bed, but to help him in repositioning himself due to his physical limitations. Such use of side railings is better accepted by consumer advocates, because their purpose is then as an “enabler” serving to promote independence of residents, but facilities are still supposed to ensure safety. For dementia patients, in particular, rails can be hazardous from attempts to climb over them, as well as the entrapment issues. They can fall from greater heights and incur more serious injuries, most notably to the head.
As part of a comprehensive update of nursing home regulations adopted in 2016, the federal Centers for Medicare & Medicaid Services became more restrictive on use of full side rails. Residents must be assessed for risk of entrapment beforehand and steps must be taken to ensure that beds and rails are properly designed for use with one another, avoiding dangerous gaps.
Fox 8 reported that police are investigating a suspicious death at Concord Care and Rehabilitation Center in Ohio after a confrontation between two nursing home residents. Police Detective Joe Rotuno said Richard Cain, 65, was found unresponsive in his room at Concord around 7 p.m. Thursday. Rotuno said Cain’s roommate, who is 63 and usually in a wheelchair, told staff Cain was lying on the ground, and he believed he was dead. Staff then found Cain clutching a chunk of his roommate’s hair and called police, according to investigators.
The roommate told officers that the pair had argued over whether to close the room door when Cain began choking the roommate, according to Rotuno. He said the roommate reported he then punched Cain in the stomach, causing him to fall backward and hit his head.
Rotuno said both roommates suffered from mental health and other issues, and that staff reported the roommate had a history of anger issues. He said they had gotten into arguments in recent weeks. “We’ve heard there’s been a lot of verbal altercations between the two,” Rotuno said. “Our suspect does have a history of being what we would call ‘angry’ at the facility, having issues with other residents, having issues with other staff.”
“If his roommate had to defend himself, I don’t blame him at all. I blame the nursing home and staff for not paying attention,” said Bonnie Cain. “They’ve been in several verbal confrontations weeks prior and nobody’s done anything about it. Why couldn’t you separate them?”
She said she wants justice and more training for nursing home staff.
“Every time I close my eyes I see my dad, and it’s just so heartbreaking,” Cain said. “Why couldn’t something be done? Maybe my daddy would still be with me today.”