Reuters reported that more than 20,000 people living in U.S. nursing homes experienced serious injuries to the face last year, mainly from falling and hitting hard surfaces or while getting in and out of bed, a recent study suggests. Face injuries can be particularly serious for elderly people because they can affect vital functions like speech, swallowing, sight, and even breathing, said Dr. Peter Svider, a researcher at Wayne State University School of Medicine in Detroit, Michigan.

Nursing homes programs focused on fall prevention should concentrate more on averting these injuries that can cause considerable pain and disability, the research team writes in JAMA Otolaryngology – Head and Neck Surgery.  SOURCE: bit.ly/2n8c8jI JAMA Otolaryngology – Head and Neck Surgery, online March 16, 2017.

Nursing homes can reduce the risk of falling by doing exercise or physical therapy and getting their vision checked, while paying greater attention to fall risks during their patient assessments, and offering adequate fall prevention interventions.

Between 2011 and 2015, they found that 109,795 people over age 60 and living in nursing homes required emergency room care for face injuries. Half of the patients were over age 84 and 65 percent were women.

For each incident, the study team noted where on the face patients were hurt and how they sustained the injury.

The most common wounds were deep cuts or skin tears, which made up over 44 percent of all injuries. A similar proportion of patients experienced other soft-tissue injuries, including bruises on the skin or in deep tissues and the tearing off of patches of skin including eyelids or ears.

Bone fractures accounted for nearly 13 percent of injuries. More than two thirds of these breaks were to the nose, and the next most common fracture site was the eye socket.

The injuries were most often the result of falling and hitting structures like the floor, countertops, doors or cabinets, representing 57 percent of injuries.

Getting in and out of bed was the second most common source of injury, accounting for 23 percent.

“Falls are a tremendous source of disability in older adults,” said Hilaire Thompson, a professor at the University of Washington School of Nursing in Seattle.

“Older trauma patients are more likely to experience a longer hospital stay, increased number of complications, higher costs of care and a higher likelihood of dying for any specific injury than younger adults,” Thompson, who was not involved in the study, said by email.

“Facial injuries are underappreciated,” Thompson added, “as they may accompany other sometimes more severe injuries and are therefore overlooked.”

 

 

 

 

KARK investigative reporters had an incredible expose on a recent case in Little Rock, Arkansas.  “In this KARK exclusive, Working 4 You delves into the death of Clara Hoyt, the laws on what nursing homes are required to report and who is held accountable when facilities aim to keep families in the dark on suspected neglect that leads to death.”  The Coroner’s office bypassed an autopsy after police reported no signs of “criminal or suspicious activity.”  But the family got a call a day later from a whistleblower who told here that Clara’s death at Pleasant Valley Nursing and Rehabilitation could have been prevented.

Clara Hoyt died at 68 years old. The nursing home told her daughter Hillary that Clara died from natural causes triggered by the distress of falling out of bed.

“They said she wiggled her way out of bed, panicked, and scared herself to death and gave herself a heart attack,” Hillary said.
When Hillary saw her mother an hour after getting the call, she says Clara was back in bed and a sheet had been wrapped around her neck.
“They told me it was for when rigor mortis sets in they don’t want your mouth to fall open,” she said. “I thought it was odd, and something inside me told me to take a picture of her there. I’m so glad that I did.”
The whistle-blower told the family that Clara actually died “caught between the mattress and possibly the wall” Hillary said.  The results of a private autopsy proved Clara Hoyt had died from positional asphyxiation. Her air flow was cut off, which was consistent with her head being caught between the mattress and the bed rail.
The nursing home never reported the death to the coroner’s office nor did the nursing staff inform the coroner’s office that it might have resulted from suspected neglect or abuse. The nursing home did finally report Hoyt’s death to the Office of Longterm Care nearly two weeks afterward, after the coroner’s office contacted them for interviews for its investigation. Arkansas law requires nursing homes to notify the coroner’s office of deaths resulting from suspected maltreatment.
Regulations require incidents, accidents and unusual deaths to be reported immediately but no later than 24 hours. Pleasant Valley did neither. The coroner determined that between 3 and 5 a.m. Clara fell out of bed; her head wedged in the gap, and when she was finally found, she didn’t have a pulse and was turning blue
Is there any way someone is hanged on a bed rail without neglect?” KARK asked attorney Shawn Daniels.
“I just don’t see how. We see corners being cut all the time in nursing homes. If you look at the shift sheets, you can see they were understaffed, and if they had been properly staffed and checking on her regularly because of that risk, she might be alive right now and we wouldn’t be here.”

UPI reported on a new technological gadget that could save lives in nursing homes.  To prevent nursing home residents from falling or otherwise injuring themselves, an alert system involving lights, alarms and call buttons lets certified nursing assistants, or CNAs, know a resident needs assistance.

In an effort to speed up the time it takes from a resident calling for help and that help arriving, scientists at Binghamton University have developed a smartwatch app to alert nursing home CNAs wherever they are at a facility, with the hope of providing better service and preventing injuries.

 The concern is in the amount of time it takes for CNAs to respond to calls for help especially when short-staffed. If a resident needs to use the restroom, after a certain period of time they’ll just stand up to go by themselves — but if they are not strong enough, they’ll fall, which can cause injuries or worse.

According to the design, published in the journal Human Aspects of IT for the Aged Population, the scientists combined the existing safety systems at nursing homes, which often include call lights, chair and bed alarms, wander guards, call-for-help options and others — into a single app.

The system requires CNAs to sign in, where they receive a display specific to their assignments. If a resident calls for help or triggers an alert, a notification shows up on the screens of all staff members, including those assigned to the resident.

Photo by John Brhel/Binghamton University
 “The alert message is more informative than the existing system and, at the same time, it will help nurses to prioritize,” Li said. “We will mark or highlight alarms from residents who are actually assigned to whoever is using the app.”

The constant monitoring and connectedness of the system, allowing CNAs to always be plugged in, could help make nursing homes safer.

“The CNAs are exited about this idea and they are interested in this device,” said Haneen Ali, a researcher at Binghamton University. “They would like to see the adoption of new technologies in their working environment because all of the problems in their current situation.”

USA Today had an interesting article about a new report on balance and aging. “Loss of balance, it turns out, is not just a problem for the oldest old.  Instead — like strength, agility and muscle mass — balance tends to start declining in midlife.”

As we grow older, all of us lose some of our ability to balance leading to falls.  This knowledge allows us to recognize our limitations and prevent falls.  However, elderly resident who suffer from dementia, delirium, or other cognitive issues may not be aware of their limitations and safety precautions.  That is why nursing homes must supervise, care plan, and monitor the effectiveness of the fall prevention interventions used.

The  new findings, published in Journals of Gerontology: Medical Sciences, shows a decline earlier in life than many might suspect, says Miriam Morey, a researcher at Duke University School of Medicine. While all the scores fell from the youngest to oldest age groups, scores on the balance and sit-and-stand tests were the first to fall, starting in the 50s, say Morey and co-author Katherine Hall, an assistant professor of medicine at Duke.

About one-third of adults over 65 fall each year, according the Centers for Disease Control and Prevention. While there’s less fall data on younger adults, studies suggest that at least one in 10 falls each year. Most are not seriously injured, but broken bones and head injuries from falls land about 700,000 people in hospitals each year, the CDC says.

“Balance is not just a matter of how well the vestibular system of the inner ear is working. Declines in strength, flexibility, vision, touch and mental functioning can all contribute to balance problems, says Peter Wayne, an assistant professor of medicine at Harvard Medical School.”

“Balance is a very complicated process,” he says. But improving it can be simple, the experts say. Here are a few tips:

• Practice standing on one foot, challenging yourself to increase the duration. You can do it on line at the grocery store or while brushing your teeth. If that’s too difficult at first, start by using a chair back or bathroom counter for support. If it’s easy, try raising your foot higher or holding it out to the side. For extra challenge, try standing on a throw pillow or closing your eyes.

• Try heel-to-toe walking, as if on a balance beam.

• Practice getting in and out of a chair without using your hands.

• Exercise while standing on a wobble board or Bosu ball (an inflated rubber disc on a stable platform).

• Try tai chi or yoga. The evidence that tai chi can improve balance is especially strong, and studies show it is quite safe for people of all ages and fitness levels. In a typical class, a series of movements is performed in a slow, graceful flow, accompanied by meditative deep breathing.

 

ABC News had an interesting article about the decline in the use of alarms as a means of fall prevention.  The change is part of a nationwide movement to phase out personal alarms and other long-used fall prevention measures in favor of more proactive, preventative care. Without alarms, facilities need staff to better learn residents’ routines and accommodate their needs before they try to stand up and do it themselves.

We’re putting alarms on residents so we can forget about them,” said Jenna Heim, director of nursing at Oakwood Village Prairie Ridge.

The use of bed and chair alarms proliferated in the 1990s, when physical restraints were banned, and are intended to go off when a resident’s weight shifts, indicating they may be trying to stand without assistance. But a growing body of evidence indicates alarms and other measures, such as fall mats and lowered beds, do little to prevent falls and can instead contribute to falls by startling residents, creating an uneven floor surface and instilling complacency in staff.”  As we all know, an alarm is only as good as the caregiver responding to it.

 

About 1,800 older adults living in nursing homes die each year from fall-related injuries, according to the Centers for Disease Control and Prevention. Research shows a reduction in falls at multiple long-term care facilities that discontinued the use of the alarms and tailored fall prevention for individuals — things like altering bathroom schedules, room rearrangements or more mental stimulation.

Going alarm-free isn’t yet possible for every nursing home, but it’s generally becoming a best practice as nursing facilities work to create the most home-like setting for people who live there, according to John Sauer, executive director of LeadingAge Wisconsin, a network of nonprofit long-term care organizations.

An alarm system doesn’t prohibit falls,” Sauer said.

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 MyBetterNursingHome.com.

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.

The Westborough News had an article discussing Massachusetts’s attempts to improve care for elderly in nursing homes. State officials are moving to hire more inspectors and levy fines on facilities that fail patients. The steps come as a national nursing home watchdog group is poised to downgrade the state’s performance rating for nursing home care.

Two deaths last year got regulators’ attention and highlight the need for better care.  A resident with dementia, and a history of falls, died in August 2015, from injuries suffered in a preventable fall at Beaumont Rehabilitation & Skilled Nursing Center, after an employee forgot to turn on the alarm on the woman’s chair to notify staff when she got up.  A certified nursing assistant, when interviewed by the state on Dec. 21, said after assisting Crane into her personal recliner at 2 p.m. on July 29, 2015, that she forgot to turn on the chair alarm. Crane was found about an hour later, lying on the floor with the head injury. Staff failed to notify her attending physician or nurse practitioner of a change in her condition, as required, nor did they treat her for the head wound and head pain.

She “complained of head (pain) two hours after being found on the floor, continued to complain of (head pain) for the next 11 hours and there was no indication (she) was treated for (her) complaints of head (pain) and no indication the physician or nurse practitioner were notified,” investigators wrote in the state report.

The following month, another resident at the same home died after falling down a flight of stairs in his wheelchair, days after a nurse cut off an electronic tracking system because it was too tight on his leg. A physician had ordered the device. The Sept. 19, 2015, death of Walsh, who had dementia and required use of a wheelchair, resulted after he was able to move through a “WanderGuard” sensor door without being noticed by staff. WanderGuard is described as an electronic tracking system designed to prevent persons at risk from leaving a supervised area unaccompanied.

Walsh was not wearing the device ordered by his physician; two weeks before the fall, a nurse used scissors to cut it off the patient’s leg because she thought it was too tight, the report says. Even so, for the next two days, staff on every shift falsely documented that the patient was wearing the device and it was functioning properly.

Nationwide, about 1,000 elderly nursing home patients die each year from falls, and those who survive often are left with permanent disabilities and reduced quality of life, according to the U.S. Centers for Disease Control and Prevention in Atlanta.

Brian E. Lee, executive director of Families for Better Care, a nursing home patients’ advocacy and national nursing home watchdog group, said some falls in nursing homes are attributable to inadequate staffing.  The federal CMS requires “sufficient nursing staff” for long-term care facilities to participate in Medicare and Medicaid. Inadequate staffing is one of the biggest problems at nursing homes across the country, he said.

Somewhere somebody … some decision maker said we have to keep our profits high, labor costs low to maximize our profitability,” he said. “They cut back on front-line caregivers first, which put residents in danger of abuse, neglect and death.

“The underlying reason is that Massachusetts continues to have an abundant lack of staff in nursing homes,” Lee said, pointing out that each nursing home resident in Massachusetts on average gets 2.37 hours of care from staff per day, compared with the national average of 2.55 hours.

“That is an 18-minute differential per resident daily in Massachusetts when compared to the national average. Eighteen extra minutes per day per resident could offset potentially hazardous falls, bedsores or medication errors,” said Lee.

 

 

 Woodbriar Health Center will face thousands of dollars in fines for providing substandard care, reports The Boston Globe after a resident died after a worker negligently dropped her.  Mary Meuse suffered two broken legs in the fall. She was taking blood thinners and bled internally from her injuries.

A 21-year-old nursing assistant who had been working at Woodbriar only a few months failed to get another nurse’s help when she used a mechanical lift to move Meuse from her bed to a wheelchair Christmas morning. Most mechanical lifts require at least two people for safe operation, according to the US Food and Drug Administration.

“Although [the nursing assistant] looked in a lot of resident rooms and common areas, she could not find anyone to assist her,” the report states. The nursing assistant “said this was not unusual and in the past when she had asked for help she was told staff ‘were too busy,’ or ‘wait a few minutes but then [they] never show up,’ ” according to the report.

An investigation by state authorities found a widespread breakdown in communications and care at Woodbriar, part of a chain of troubled nursing homes owned by Synergy Health Centers. Investigators concluded that three shifts of nurses learned that Meuse broke her legs in the Christmas Day fall but failed for 24 hours to let her, or her family, know the results. She died Dec. 27.

An X-ray taken at the nursing home revealed within two hours after the accident that Meuse, who told staffers her knees hurt after the episode, had broken bones below both knees, according to the state investigation. But a nurse who read the X-ray report shortly afterward later told investigators, “there was a lot of writing on the report, and to the best of her recollection she thought no fractures were seen.”

A nurse on the night shift reviewed the X-rays, discovered the broken bones, and alerted the day nurse who earlier missed the finding. Upon learning of the injuries, the day nurse called a physician and left a message with his answering service.

The physician told investigators he called the nursing home, but “no one answered his call,” so he instructed his answering service to immediately transfer any call from the nursing home to his cellphone. No one ever called him back, he said.

A nursing supervisor wasn’t told about the broken bones until the next morning, which prompted the supervisor to seek an order to get Meuse to the hospital, the report said.

The nursing home is one of several in Massachusetts owned by Synergy Health Centers in New Jersey. Synergy, the New Jersey company that owns Woodbriar and 10 other Massachusetts nursing homes, has faced mounting citations for substandard care — medication errors, poor infection control, inadequate staff training — since buying its first Massachusetts facility in 2012. The citations concerning the Woodbriar death are among the most serious. Synergy has received other citations for substandard care since 2012.

Helen Mulligan, spokeswoman for the Centers for Medicare & Medicaid Services, said federal regulators are trying to determine the exact fine, but it will range from $250 to $3,000 per day, likely dating back to the Dec. 25 accident.

Read the full story in the Globe .

News4Jax reported the tragic and preventable death of Nadine McBurnett while a resident at Terrace of Jacksonville nursing home.  McBurnett suffered a preventable fall at the home but the facility failed to contact the family or provide emergency care for over three hours.

The family is suing the nursing home entrusted with her care.  Letter of intent to sue  They said if she had gotten timely medical attention, she would not have died, and they said the facility has been covering it up.

 

The family said McBurnett was having her bed sheets changed by a nursing assistant, and the railing on the bed was pulled down.  McBurnett required two nursing assistants to safely transfer her, but at the time of her fall, only one was helping her.  McBurnett fell off the bed and was severely injured.  The caregivers just cleaned the blood up and put her back in the bed. There was a video camera outside McBurnett’s room door, but the facility deleted the video

McBurnett’s wounds were not addressed, because when she went to the hospital, she was covered in bruises on her head and shoulders. The ambulance company report said McBurnett had a large 4-5-inch long and 1.5-2-inch wide hematoma beginning just above her right eye.  She remained alive for around another month, but with a painful broken hip.

“If this has been a child, if this had been a teenager, if this had been a young mom, or excuse me, if this had been a dog and this happened to them, this would be outrage. This would be everywhere,” her daughter Patte Wallace said. “But this is an old lady who looks pathetic right there, and they see her as no value.”

 

Medical News Today had an interesting article on the new guidelines issued by The American Academy of Orthopaedic Surgeons (AAOS) Board of Directors.  AAOS approved Appropriate Use Criteria (AUC) for treatment and rehabilitation of elderly patients with hip fractures, in addition to postoperative direction to help prevent fractures from recurring.

Hip fractures are one of the most feared injuries in older adults because this trauma creates pain and can force a change in lifestyle or limited mobility. We are providing evidence-based assistance for physicians and patients to determine the best course of action for surgery and follow-up care,” said Robert Quinn, MD, AUC Section Leader for the AAOS Committee on Evidence-Based Quality and Value.

Pinning bones back together using surgical screws versus reconstructing the hip joint through total hip replacement (THR) surgery has long been debated. The AUC criteria rely on peer-reviewed studies and practices to recommend different procedures depending on a patient’s individual indications such as activity levels, bone and joint health, location(s) of the fracture, and whether the break is stable or displaced. The AUC addresses patients age 60 and above with fractures caused by low-impact events.

The AUC panel reviewed 30 potential patient scenarios to create the “Appropriate Use Criteria for the Treatment of Hip Fractures in the Elderly.” Each treatment in each patient scenario is rated “appropriate,” “may be appropriate,” and “rarely appropriate.”  For example, THR is rated “appropriate” for a highly active patient with a non-displaced fracture in the neck of the femur bone. However, the same procedure is “rarely appropriate” for a non-ambulatory patient.

Another example rates reattaching bone with a specific type of screw (sliding hip anti-rotation screws) as “appropriate” for highly active patients with and without arthritis who have a stable fracture of the intertrochanteric crest, located near the top of the femur.

Accompanying the AUC, the AAOS created a “Preoperative Checklist” to assist surgeons and allied medical providers in delivering quality care to patients by completing 12 important initiatives. They include limiting preoperative traction; managing Warfarin, a blood-thinning medication; and discussing the patient’s home environment prior to discharge.

The second AUC, “Appropriate Use Criteria for Postoperative Rehabilitation for Low Energy Hip Fractures in the Elderly,” provides universal recommendations for recovery across elderly patient populations including:

  • Interdisciplinary care to prevent deep vein thrombosis
  • Prevention or management of postoperative delirium
  • Multi-modal perioperative pain management
  • Interdisciplinary management of recovery at rehabilitation and skilled-nursing facilities
  • Home care therapy following discharge
  • Osteoporosis assessment and management.

Supplementing the AUC, a “Perioperative Prevention of Future Fractures Checklist,” emphasizes important follow-up measures to reduce patients’ risk for future injuries. Participation in a fall prevention program, and supplements and medications to improve bone density are among the recommendations.

“It is very important to think ahead to make the right care choices after a fracture is repaired. Not only can this help patients recover, but this also helps prevent fractures from happening again, which is a big problem,” Dr. Quinn said.

AAOS created the AUCs following the 2014 release of the Clinical Practice Guideline (CPG) “Management of Hip Fractures in the Elderly,” which gives a broad overview of care options. In contrast, the AUC provides guidance for circumstances when a specific surgical procedure should be applied.