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.”

 

 

The Pittsburgh Post-Gazette reported the tragic and preventable death of Pittsburgh businessman Robert Frankel who died from asphyxiation from an incident in which his neck was trapped in bed rails.  Mr. Frankel died late Sept. 17 at the nursing home from what the medical examiner deemed at the time accidental asphyxiation, “due to compression of the neck.” The Charles Morris Nursing and Rehabilitation Center has discontinued using such railings in response, according to a Pennsylvania Department of Health report.

“Based on review of facility policy and documentation, clinical records and staff interview, it was determined that the facility failed to identify a hazard created by the use of side rails resulting in the death,” the report said.   The report said that at 11:30 pm. on Sept. 17, “a nurse aide was performing first rounds to check on the residents and found Resident R1 (Health Department inspection reports do not identify individuals by name) pulseless and without respirations, lying with his body on the floor and his neck between the air mattress and the side rail.” A nursing supervisor pronounced him dead at 11:40.

 

Kayla Evans at Reviews.com wrote to me asking to share research her team at Reviews.com conducted regarding senior safety and medical alert systems. It is a valuable research for caregivers and family.

With millions of seniors ending up in the ER due to falls each year, Kayla and her team recognized that medical alert systems can be key for contacting help when accidents occur in the home. After over 100 hours of research and hand-testing, our guide outlines which factors will help families and seniors choose the right system for their needs: http://www.reviews.com/medical-alert-systems/

To find the best modern-day medical alert system, they spent over 100 hours talking with elder-care experts, digging into service agreements, and hand-testing the top contenders. They collected 68 medical alert devices that run on cellular-enabled base stations and that connect you to an independent central monitoring center.

Not all personal emergency response system (PERS) devices connect you directly with a monitoring system where employees are trained to assess what help to send. Some operate more like long-distance walkie-talkies that either connect you to your designated emergency contact or alert 911 automatically. Those medical alert systems are better suited for an extra layer of security when you’re walking through the office parking garage at night.

The technology advancement of PERS devices is incredible, but for this review, they looked solely at their most basic function: Press a button, get help. The caregiving experts suggested that simpler medical alert systems may be less flashy, but they’re the best place to start.

The Telegram reported the Aug. 7 death and cover-up of Walter E. Haddad.  State and federal agencies investigated the suspsicious circumstances surrounding the death of Haddad who died after he fell and hit his head, and nursing home staff covered up the fall rather than send him to the hospital.

The report said that after hearing a loud thud about midnight on Aug. 6, a certified nurse assistant and a licensed practical nurse found Mr. Haddad lying on the floor and they put him back in his bed.  No assessment by a registered nurse was done. The CNA told investigators that he did not report the fall, as required by the facility, because the LPN had asked him not to.

“However, staff did not complete a thorough clinical evaluation or neurological assessment on (Mr. Haddad), which resulted in a delay of transfer to the hospital for evaluation of possible injury,” investigators said in the report.

Mr. Haddad’s daughter, Lorna Haddad, took issue with the report. She said staff should have been more careful because they knew that her father, who helped found the nursing home, had a history of falls. The retired accountant had moved into the nursing home last year, after Parkinson’s disease left him prone to falls. She said notification of his fall risk was posted throughout his area of the facility.

“I think the report is meaningless,” she said. “The fact that he didn’t have an alarmed bed or an alarmed chair is alarming.”

The report in general said professional standards of quality were not met because of the actions or inactions of the staff.  Every time a patient falls, injury or not, they’re required to call the physician and the patient’s family.

The morning after he fell, Mr. Haddad told several staff about the incident. The only thing that they did was to give him Tylenol. When Mr. Haddad’s family came to visit, he told them that he had fallen the night before and hit his head. Staff told the family that there was no report of a fall and that Mr. Haddad may have been mistaken or confused. When his speech became slurred and he complained of neck pain, he was taken to the trauma unit at UMass Memorial Medical Center, where he died.

Reuters had an article about a new study that indicates seniors living on their own may have a greater risk of fractures when they’re less mobile and less able to manage daily tasks without help, but in nursing homes the opposite may be true.  Among nursing home residents, risk factors for fracture included the ability to walk independently, wandering the halls, dementia and diabetes, the study found.

“In the community, individuals that need more assistance with mobility often have multiple health problems that place them at greatest risk for fracture,” said lead study author Dr. Sarah Berry of the Institute for Aging Research and Harvard Medical School in Boston.

“In the nursing home, all residents have health problems, but there is a tremendous variation in the ability of these residents to move independently,” Berry said by email. “Frail nursing home residents that are still mobile and independent have opportunity to fall, whereas residents that require extensive assistance have less opportunity to fall and fracture.”

Nearly 10 percent of hip fractures in the U.S. occur among nursing home residents, researchers note in The Journals of Gerontology: Series A. More than one-third of nursing home residents who fracture a hip will die within six months, and many others who were mobile before the fracture will become completely disabled.

Among residents who survive hip fractures, infections and pressure ulcers, or bed sores, are common, leading to functional decline and diminished quality of life.

Even if mobility might carry an increased fracture risk for nursing home residents, the fix isn’t staying in bed, said Dr. Joe Verghese, director of the Albert Einstein Jack and Pearl Resnick Gerontology Center in Bronx, New York.  That’s because being immobile is associated with an increased risk of blood clots, malnutrition and death for elderly people.

To prevent falls, bright lighting during the day and night lights after dark can help boost visibility, said Jean-Michel Brismee of Texas Tech University Health Sciences Center in Lubbock. Removing rugs that might slip, placing hand rails in showers and tubs, and keeping walkers and canes within easy reach can also help, Brismee said in an email.

The Gerontologist reported that a new study regarding fall occurrence during a nursing home (NH) to community transition. This study sought to examine whether the presence of supports and services impacts the relationship between fall-related risk factors and fall occurrence post NH discharge.  Falls are a major source of morbidity and mortality among older adults.

“Fifteen percent of participants fell within 30 days of NH discharge. Factor analysis of fall-related risk factors produced three latent variables: fall concerns/history; activities of daily living impairments; and use of high-risk medications. A supports/services latent variable also emerged that included caregiver support frequency, medication management assistance, durable medical equipment use, discharge location, and receipt of home health or skilled nursing services. In the SEM model, high-risk medications use and fall concerns/history had direct positive effects on falling. Receiving supports/services did not affect falling directly; however, it reduced the effect of high-risk medication use on falling (p < .05).”

King5 had an article about fall prevention in nursing homes.  Any facility accepting residents must assess residents to determine their fall risk.  Understanding the cause helps prevent falls. Alternative interventions are necessary if the resident has dementia and lacks safety awareness.

“So, the key is preventing injury and that takes a little detective work on the part of the staff. They have to figure out just when a resident falls; can routines be changed to prevent falls? It may be as simple as more supervised trips to the bathroom.”

The best interventions include lowering the bed; raising side rails in bed; placing a safety mat next to bed; using a pressure alarm; but the best intervention is adequate staffing to safely supervise the residents.

Forbes had an article on a company called EarlySense.

“One company, EarlySense, is bringing skilled nursing facilities into the digital age through a practical and inexpensive approach. For several years, its contact-free patient monitoring systems have been used by hospitals to continuously track respiratory rate, heart rate and movement. The technology is a direct response to the challenges hospitals face in monitoring non-critical (non-ICU) patients—tracking their care status and preventing costly falls and pressure ulcers. With monitor bells ringing frequently, over time, nurses can develop alarm fatigue. Standard bedside equipment becomes the “machine that cried wolf”—making nurses less likely to respond to alarms they hear all day. This is exactly where continuous monitoring steps in.”

“Real-time alerts show 43% fewer patient falls, 64% fewer pressure ulcers and 86% fewer code blue events. A statistical analysis estimated that institutions using EarlySense leveraged the data and far-less-frequent alerts to save more than 550 lives, 800 falls and more than 45,000 hospitalization days in 2016.”

The key takeaway: improved care and reduced costs.

EarlySense technology is also user-friendly. Nurses can view the data at the bedside, nursing station or on a tablet, and receive alerts in real time.

JAMA Network had another article on the overuse and abuse of anti-psychotics in nurisng homes.  In May 2011, the Office of Inspector General (OIG) released a widely publicized report, “Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents,” revealing that 83% of atypical antipsychotic drug claims were prescribed for nursing home residents without a US Food and Drug Administration (FDA) indication, and that 88% of claims were related to use in residents with dementia, for whom antipsychotics are associated with an increased risk of mortality as specified in the FDA black box warning.

“Despite long-standing and widely recognized concerns about safety and efficacy, antipsychotic agents, including older “typical” agents (ie, haloperidol and chlorpromazine) and newer “atypical” agents (ie, quetiapine, risperidone, and olanzapine), have been commonly used to treat behavioral and psychological symptoms of dementia.”

This Viewpoint describes a national initiative of the Centers for Medicare & Medicaid Services (CMS) focused on the use of antipsychotics in nursing homes. These efforts have led to a 33% relative reduction (from 23.9% to 16.0%) in the prevalence of antipsychotic use among long-term nursing home residents over the past 5 years.

Percentage of Long-Term Nursing Home Residents Receiving Antipsychotic Medication, 2011-2016