As a follow up to recent posts regarding the kickback scheme involving OmniCare and Murray Forman and Leonard Grunstein, today I am going to post a well written article from the Chicago Breaking News about a doctor prescribing dangerous medications to nursing home residents.

Inside Chicago’s Maxwell Manor nursing home, Dr. Michael Reinstein’s patients suffered from side effects so severe that they trembled, hallucinated or lost control of their bladders. Staffers told state investigators that so many patients were clamoring to complain to Reinstein about their medications that a security guard was assigned to accompany him on his visits. In addition, staffers said Reinstein had induced patients to take powerful antipsychotic drugs with the promise of passes to leave the home.

Today he is one of the most prolific providers of psychiatric care in Chicago-area nursing homes and mental health facilities, even as he is trailed by lawsuits and complaints like the ones at Maxwell Manor.  An investigation by ProPublica and the Tribune found that Reinstein has compiled a worrisome record, providing assembly-line care with a highly risky drug.  Reinstein has been accused of overmedicating his mentally ill patients. His unusually heavy reliance on the drug clozapine — a potent psychotropic medication that carries five "black box" warnings — has been linked to at least three deaths.

In 2007 he prescribed various medications to 4,141 Medicaid patients, including more prescriptions for clozapine than were written by all the doctors in Texas put together. Records also show he is getting government reimbursement for seeing an improbably large number of patients. Documents filled out by Reinstein suggest that if each of his patient visits lasts 10 minutes, he would have to work 21 hours a day, seven days a week.  Reinstein sees 60 patients each day, he wrote in an audit report in 2007.

Working from a strip-mall office in Uptown, Reinstein says he is psychiatric medical director at 13 nursing facilities, seeing patients with chronic mental illness. Those include people with schizophrenia.

Autopsy and court records show that three patients under Reinstein’s care died of clozapine intoxication. Alvin Essary died at age 50 at the Somerset Place nursing home on the North Side in 1999.  Medical records show that when he died his blood contained five times the toxic level of clozapine.

The "black box" warnings — the FDA’s strongest — on clozapine’s label detail serious potential side effects, from enlargement of the heart to rapid drops in blood pressure to increased seizure risk.   Doctors also are required to take regular blood samples to ensure patients’ immune systems aren’t shutting down.

The FDA approved the drug two decades ago for only a sliver of the population: the actively suicidal or the quarter of schizophrenic patients who do not improve on medications with lesser side effects. Yet Reinstein last year said under oath that his practice once had more than 300 patients among 415 in one Chicago nursing home on clozapine.

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Chicago Tribune had an article that is a good follow-up or counter balance to yesterday’s blog entry.  The article discusses the overmedication of nursing home residents including Delores Fleming.  She moved into Heritage Manor of Mount Zion and scored 23 out of 30 on a mental exam and was deemed to be "moderately impaired," state inspection records show.  Fleming had few problems her first week in the nursing home, according to her medical records, which her family provided to the Tribune.  But after she repeatedly had crying spells and tried to wander away, the nursing home doctor prescribed two anti psychotic drugs, even though she was not psychotic. Her family had given consent for the Seroquel, but the medical records show the permission sheet erroneously described the drug as an anti-anxiety medication. Seroquel is an anti psychotic drug intended for serious mental illnesses, such as schizophrenia.

Records show that Fleming briefly improved on the Seroquel, but over the next three months she had episodes of extreme anxiety.  The doctor doubled the dosage of one medication no fewer than four times, putting her above the recommended limit.  Once she thought she was possessed, nursing notes state. Another time she thought her brother had left her $50 million.

Her doctor ordered multiple injections of the anti psychotic drug Haldol and the anti-anxiety medication Ativan, state inspection records show. Fleming’s dose of Seroquel also was repeatedly doubled, putting her above the recommended limit for that drug.

After Fleming’s family complained that she had grown lethargic, the staff referred her to a neurologist. According to a state inspection report, the neurologist found her catatonic and believed she had developed tremorlike "Parkinson’s symptoms, due to the Haldol."  When he gave her the same mental exam she had previously taken, she scored zero out of 30. The neurologist recommended that her drugs be curtailed, and her condition dramatically improved. When she retook the test, she scored a 30 out of 30.

Both her family and the facility decided she should live elsewhere. The family wanted her in a home that specialized in Alzheimer’s care; Heritage Manor believed Fleming was endangering other residents, records show, and gave her 30 days to leave.

When the Tribune reviewed 40,000 state and federal inspection reports filed since 2001 on 742 Illinois nursing homes, numerous instances emerged in which regulators cited facilities for misusing psychotropics even though the patients’ doctors had created the problems.

When physicians or psychiatrists prescribe a drug for a patient, facilities must administer it as long as the order is consistent with state and federal nursing home regulations. If inspectors determine a violation occurred, they cite the nursing facility, not the doctor.

The Tribune found that inspectors documented many cases in which doctors prescribed powerful anti psychotic drugs without adequate justification or in doses that were too high.  The doctors also sometimes failed to provide adequate follow-up care, the inspection records show. They are required to see their nursing home patients only once every 60 days, though some do not visit even that often.  Several nursing home owners interviewed by the Tribune said they have struggled with doctors who rarely make time to visit patients.

Nursing homes are required to have pharmacists visit the facilities regularly and review prescriptions. If they discover irregularities, such as a patient placed on a drug without cause, they notify the nursing staff and doctor. But the Tribune found that when pharmacists recommended that a psychotropic be discontinued or the dosage reduced, physicians sometimes ignored the advice.

The difficult task of monitoring for side effects is left to nurses who are poorly trained in the use of psychotropic drugs. Experts say the situation can affect quality of care, and the Tribune’s review of inspection reports shows that is true — sometimes with tragic consequences.

The Chicago Tribune has done a great job researching, investigating, and writing about the use and abuse of anti-psychotics in nursing homes. See full article here.

The Washington Post had an ainteresting article about the effect of drug enforcement on nursing home residents receiving pain medications.  Efforts by the Drug Enforcement Administration to crack down on narcotics abuse are producing a troubling side effect by denying some hospice and elderly patients needed pain medication.

Tougher enforcement of the Controlled Substances Act, which tightly restricts the distribution of pain medicines such as morphine and Percocet, is causing pharmacies to balk and is leading to delays in pain relief for those patients and seniors in long-term-care facilities.  The DEA has sought to prevent drug theft and abuse by staff members in nursing homes, requiring signatures from doctors and an extra layer of approvals when certain pain drugs are ordered for sick patients.

Most nursing homes do not have pharmacies or doctors on site, adding to delays for patients who fall ill late at night or in transition from a hospital.  The pharmacies face tens of thousands of dollars in fines if they deviate from strict controls that require doctors to sign paper prescriptions and fax them to a pharmacy before a nurse can administer them in the nursing home setting.

"The system is broken. It isn’t working, and patients are suffering," said Claudia Schlosberg, director of policy and advocacy for the American Society of Consultant Pharmacists. "While we need to ensure there are proper controls on the medications, the overall law enforcement concern has to be compatible with meeting patients’ needs, and right now it’s not."

Doctors in nursing homes say the restrictions do not take into account that many more patients, with higher levels of illness and pain, are moving into long-term-care sites and out of hospitals.



The Milwaukee-Wisconsin Journal Sentinel had an article about several nursing homes in Wisconsin providing powerful prescription drugs such as Fentanyl and OxyContin to patients without a doctor’s authorization, in violation of federal rules.   Federal rules on dispensing those drugs were not followed, including rules on filing required paperwork, according to an affidavit filed by the U.S. Drug Enforcement Administration’s Milwaukee office.

Drugs in the Wisconsin nursing home kits came from PharMerica, a nationwide pharmaceutical services firm with offices in Pewaukee, according to the affidavit.   Acting on a tip that the law was being broken, DEA agents searched PharMerica’s Pewaukee office and six nursing homes across Wisconsin in late July, according to documents.

The nursing homes were:

Beaver Dam Care Center in Beaver Dam; Colony Oaks Care Center in Appleton; Heritage Square in Greendale; Mount Carmel Milwaukee in Greenfield; Village Gardens in Green Bay; and Woodstock Health and Rehab in Kenosha.

PharMerica specializes in providing pharmacy services in institutions such as nursing homes. It is registered with the DEA to distribute controlled substances and is responsible to ensure they are distributed with a prescription, according to the affidavit.   It had net revenue of $1.9 billion and profits of $284.6 million in 2008, according to the company’s financial statements.

The infamous Golden Living, a company that runs nursing homes nationally, owns two of the nursing homes inspected by the DEA – Heritage Square and Beaver Dam.  In May, agents in the DEA’s Milwaukee office received a call from a tipster saying PharMerica was routinely breaking federal law by improperly delivering powerful schedule II drugs.  DEA agents found paperwork to back up the tipster. On May 13, agents visited PharMerica’s Pewaukee office and discovered unsigned prescriptions for schedule II controlled substances on the pharmacy operations manager’s desk.

A police report filed by PharMerica showed that a nurse had "dropped" one of the kits, containing OxyContin pills, and lost it. OxyContin is often sold on the street to illicit drug users.

The Tracy Press out of California had an article about the death of a nursing home resident caused by the neglect and negligence of the nursing home.   New Hope Care Center which is owned by the for profit corporate owner Evergreen Healthcare Companies, LLC failed to properly monitor her medication and failed to check her into an emergency room fast enough when her brain started bleeding.  Caregivers failed to keep a close eye on the condition of the patient after a doctor ordered an increase in medication to prevent blood clots. A possible side effect of the medication is excessive bleeding. Because the nursing home staff didn’t monitor a change in the woman’s condition after the doctor upped her anticoagulant prescription, the state said they missed warning signs that could have saved the woman’s life.  Days after the doctor-ordered increase in her blood-thinning medication, the woman started slurring her words and complaining of a headache.  Even though the woman woke up just a couple hours earlier, she started nodding off, waking up only to vomit.

The facility was fined $100,000 after the nursing home ignored the worsening condition of a patient.  State investigators concluded that New Hope caregivers “failed to ensure that the resident’s medications were monitored and failed to fully assess the resident or promptly notify the physician when there was a change in the resident’s condition, which resulted in the resident’s death,” according to Al Lundeen, a spokesman for the state agency. The fine levied on the nursing home is the maximum penalty the agency can impose for a “AA” citation, the harshest assessment for hospitals and nursing homes in California.

The article mentions several other complaints and investigations into New Hope. had an article about a nursing home employee caught in a drug bust.   This kind of incident seems to be happening more and more around the country’s nursing homes.

Melanie Curry is a Licensed Practical Nurse who worked at the Fiddler’s Green Manor nursing home.  The Wyoming county drug task force was monitoring Curry.  When Curry moved from Wyoming county to Springville the drug task force alerted the Erie County Sheriff’s Office. "As a result of information they had provided to us we had her under surveillance," says Erie County Sheriff Timothy Howard.

Police say Curry was stealing hydrocodone pills from the nursing home residents.  The investigation came to a head when nursing home officials say an undercover officer made contact with Curry and made arrangements to meet for a drug buy right outside Fiddler’s Green Manor. "(Officers) actually witnessed the drug sale of about 11 pills in front of the nursing home," says Howard.

Curry is now facing a felony sale of narcotics charge as well as misdemeanors of petit larceny and drug possession.   Fiddler’s Green Manor says this is an isolated incident, and patient care is their first priority.

The Post-Tribune had an article written by Mark Taylor about the negligent care provided to a resident in a hospital.  The article described the resident, Donna Durham, as an active, energetic widow with sparkling green eyes and silver hair who worked as a top real estate agent and home appraiser until June 12, the day she arrived at  the hospital for surgery. 

Prior to the surgery, the Dunham family had apprised hospital staff of their mother’s allergy to codeine and morphine.  It was entered in her medical chart.  It was identified on the red tag she wore on her wrist. And in the final presurgery meeting with physicians, Dunham’s children say they reminded anesthesiologist Dr. Nageswar Yelavarthi that their mother was allergic to morphine.

In spite of those warnings he allegedly ordered a nurse to administer the potent narcotic to which Dunham was allergic, according to Pinnacle medical records obtained by Dunham family attorney George Galanos. Yelavarthi allegedly told the nurse that he and the staff could deal with the expected allergic reactions, such as nausea and vomiting, a nurse’s note states.

By 12:08 p.m., Dunham was in respiratory arrest and having difficulty breathing.  Medical records indicate Pinnacle staff attempted to stabilize Dunham and around 12:30 p.m. began attempts to transfer her to an acute-care hospital. 

Dunham’s doctor, Dr. Kucharzyk,  did not complete a spine fellowship and does not have the additional training required to perform spinal procedures.  According to the Patient Compensation Fund of the Indiana Department of Insurance, Kucharzyk has been named in at least 14 medical malpractice lawsuits.  Kucharzyk never disclosed this information to the family.

Nonetheless, Kucharzyk held surgical privileges in back surgery at Pinnacle.

After Dunham went into respiratory distress at 12:08 pm., Pinnacle staff connected her to a ventilator to breathe for her.   Anesthesiologist Yelavarthi gave her an antidote to the morphine, but it didn’t work.

Kucharzyk was enlisted to attempt to transfer Dunham to Methodist or Saint Anthony. But he said he did not hold full privileges at Methodist or Saint Anthony and wasn’t successful in arranging a transfer. Kucharzyk soon after told Pinnacle staff, “He would not be following the patient,” according to Dunham’s medical records.

Khalid contacted Methodist to alert staff there about Dunham’s condition and the sequence of events, and at 1:01 p.m. Superior Ambulance arrived at Pinnacle to transport Dunham to Methodist.  Again at 1:20 p.m., Pinnacle staff contacted Methodist and were told that Methodist could not accept Dunham until case management reviewed her insurance “to make sure she was not a (patient) ‘dump’,” hospital slang for a patient unable to pay, according to Pinnacle records.

Patient dumping is when a hospital transfers a patient to another health-care facility because of the person’s inability to pay. It’s a practice that is illegal, as is delaying care while considering payment or insurance information.

The Pinnacle staff continued working on Dunham even as they attempted to transfer her to Methodist, a hospital with an intensive-care unit better equipped to handle such emergencies.

Finally at 2:30 p.m., nearly 150 minutes after Dunham had gone into respiratory distress, Superior transported her to Methodist.  Dunham arrived at Methodist still in distress and deteriorated rapidly.

Methodist’s ER staff worked on her until 3:30 p.m., when she was pronounced dead of heart failure.  A Methodist ER nurse asked the family if Pinnacle ever explained their mother’s condition when it transferred her.

Cheryl Harrell said Kucharzyk phoned that evening.   “He asked what happened and acted like he didn’t know anything had gone wrong,” she said. “He said when he left she was fine.”


David Krough wrote, for Portland’s, an article stating that a nurse assistant at a nursing home was arrested for stealing narcotics from residents in other nursing homes.  Nursing assistants provide about 85-90 percent of all the care to residents.

The article is informative but does not provide key information such as prior arrests, employment history, knowledge of the mangement of the nursing homes regarding the missing narcotics or her conduct.  How could she get hired?  Was she a user or a pusher?  What safeguards do they hav ein place to make sure this doesn’t happen?  Below is a summary of the article.

Surveillance cameras caught a woman on camera, posing as a resident’s granddaughter, then as an employee. Administrators there said the woman snuck in and spent at least three evenings with one of their residents.

Theresa Smith was a nursing assistant who worked at nursing homes in the Portland Metro area.  Police listed Smith as a person of interest after a report of theft of Fentanyl patches at the Laurelhurst Village Nursing Home on SW Stark Street.  She was accused of stealing Fentanyl pain patches from nursing home residents while the residents were wearing the patches. Detectives said she stole from several patients at area nursing homes.

Detectives arrested Smith Wednesday while she was working at the Care Center East Nursing Home on NE Wielder Street.  Smith was charged with burglary, criminal mistreatment, possession of a controlled substance and theft. Police said she may face more charges.

NY Times had an article about the overuse of certain medications in elderly residents.  Below are excerpts of the article.

Ramona Lamascola thought she was losing her 88-year-old mother to dementia. Instead, she was losing her to overmedication.  Last fall her mother, Theresa Lamascola, of the Bronx, suffering from anxiety and confusion, was put on the antipsychotic drug Risperdal. When she had trouble walking, her daughter took her to another doctor — the younger Ms. Lamascola’s own physician — who found that she had unrecognized hypothyroidism, a disorder that can contribute to dementia.

Theresa Lamascola was moved to a nursing home to get these problems under control. But things only got worse. “My mother was screaming and out of it, drooling on herself and twitching,” said Ms. Lamascola, a pediatric nurse. The psychiatrist in the nursing home stopped the Risperdal, which can cause twitching and vocal tics, and prescribed a sedative and two other antipsychotics.

“I knew the drugs were doing this to her,” her daughter said. “I told him to stop the medications and stay away from Mom.”

Not until yet another doctor took Mrs. Lamascola off the drugs did she begin to improve.

The use of antipsychotic drugs to tamp down the agitation, combative behavior and outbursts of dementia patients has soared, especially in the elderly. Sales of newer antipsychotics like Risperdal, Seroquel and Zyprexa totaled $13.1 billion in 2007, up from $4 billion in 2000, according to IMS Health, a health care information company.

Part of this increase can be traced to prescriptions in nursing homes. Researchers estimate that about a third of all nursing home patients have been given antipsychotic drugs.  [Blogger’s note: Typically these medications are used as "chemical restraints" to quiet the residents down–a sure sign of understaffing.]

The increases continue despite a drumbeat of bad publicity. A 2006 study of Alzheimer’s patients found that for most patients, antipsychotics provided no significant improvement over placebos in treating aggression and delusions.

In 2005, the Food and Drug Administration ordered that the newer drugs carry a “black box” label warning of an increased risk of death. Last week, the F.D.A. required a similar warning on the labels of older antipsychotics.   The agency has not approved marketing of these drugs for older people with dementia, but they are commonly prescribed to these patients “off label.” Several states are suing the top sellers of antipsychotics on charges of false and misleading marketing.

Ambre Morley, a spokeswoman for Janssen, the division of Johnson & Johnson that manufactures Risperdal, would not comment on the suits, but said: “As with any medication, the prescribing of a medication is up to a physician. We only promote our products for F.D.A.-approved indications.”

Nevertheless, many doctors say misuse of the drugs is widespread. “These antipsychotics can be overused and abused,” said Dr. Johnny Matson, a professor of psychology at Louisiana State University. “And there’s a lot of abuse going on in a lot of these places.”

Dr. William D. Smucker, a member of the American Medical Directors Association, a group of health professionals who work in nursing homes, agreed. Though the group encourages doctors to conduct a thorough assessment and prescribe antipsychotics only as a last resort, he said, “Many physicians are absent without leave in the nursing home and don’t take an active role in the assessment of the patient.”

Nursing homes are short staffed, and insurers do not generally pay for the attentive medical care and hands-on psychosocial therapy that advocates recommend. It is much easier to use sedatives and antipsychotics, despite their side effects. 

Common causes of the symptoms include ministrokes, reparable brain hemorrhage from a mild bump on the head, hypothyroidism, dehydration, malnourishment, depression and sleep disorders.

The Medicare Web site has basic information on individual homes at The National Citizens’ Coalition for Nursing Home Reform, at, offers a consumer guide to choosing a nursing home.

Theresa Lamascola still has dementia, but she went from confinement in a wheelchair — unable to sit still and screaming out in fear — to being able to walk with help, sit peacefully, have some memory and ability to communicate, understand subtleties of conversations and even make jokes.

Or, as her daughter put it, “I got my mother back.”

This article has been revised to reflect the following correction:

Correction: June 25, 2008
An article on Tuesday about the use of antipsychotic drugs in dementia patients misspelled the names of two drugs in a different class, sometimes used to treat the symptoms of Alzheimer’s and Parkinson’s diseases. They are Exelon and Namenda, not Exalon and Menamda.