The Star Tribune reported that the Minnesota Department of Health said the Gardens at Cannon Falls “did not have an adequate system to ensure cognitively impaired residents on [liquid] diets were adequately supervised.” Nursing home staff knew the resident was dissatisfied with her limited liquid diet, and that she would routinely try to take the solid foods of others and throw her own meals onto the floor, the investigation noted.

State death records identify her as 77-year-old Margarita M. Schuler.  A nephew who lives a few miles from the nursing home expressed exasperation with his aunt’s care. “Wow, we had been working with the staff for quite a while about her needing extra care,” Mike Kulhanek said. “I was personally frustrated with that.”

 According to the investigation:

On a Sunday night in mid-November, Schuler was in her wheelchair in the dining room and roughly 3 feet from where sandwiches, cookies and liquefied snacks were put out for residents.

When none of the three staff members in the room was looking, and after sitting near the snacks for more than an hour, Schuler rolled over to the food and “was trying to quickly eat the sandwich.”

When she began choking, staff members attempted to dislodge the food with chest compressions and the Heimlich maneuver, and called 911. Schuler died in an ambulance on the way to a hospital. Her choking caused her to go into cardiac and respiratory arrest, according to the death certificate.

The Hutchinson News reported on the tragic and preventable death of Anna Mae Yocham at Golden Plains Rehabilitation Center LLC.  Yocham was supposed to be on a pureed diet but the nursing home staff gave her a peanut-butter-and-jelly sandwich on Oct. 10, 2014 which caused her to choke and her wrongful death.

The Kansas Department for Aging and Disability Services, on behalf of the U.S. Department of Health and Human Services, issued a Nov. 20, 2014, statement of deficiency to Golden Plains and cited the Oct. 10 event. Medicare’s website shows a federal fine of $40,838 was assessed on Nov. 20, 2014, too.

The lawsuit names Golden Plains Rehabilitation Center LLC; its Illinois-based corporate manager, William Rothner; and Atied Associates LLC, the Illinois-based company that “owned, operated, managed, maintained, and/or controlled” Golden Plains at the time of Yocham’s death.

 The nursing facility came under new management Feb. 1, 2015. It is called Diversicare of Hutchinson and is one of six Diversicare sites in Kansas. The administrator of Diversicare of Hutchinson, Robin Saffle, assumed her role in 2015. Just weeks ago, Diversicare also became owner of the nursing facility on East 23rd Avenue.

Yocham was a homemaker who lived most of her life in Hutchinson. She moved into Golden Plains in 2011 and was 73 years old when she died three years later. Yocham’s granddaughter, Rebecca Sorenson, and Yocham’s brother, Lewis Wohlford, administrator of the estate, are the plaintiffs.

They claim:

  • Yocham had severe cognitive impairment and was “entirely dependent” upon staff for her safety.
  • She required supervision for eating and received a mechanically altered diet, such as pureed food and thickened liquids.
  • Three different documents dated in 2014 contained references to her difficulty in chewing and/or swallowing and her diet. One of those, the nutritional status review dated May 31, 2014, and signed by the registered dietitian at Golden Plains, ordered that Yocham receive a “puree diet.” Golden Plains’ “diet education binder” said peanut butter was a food to avoid for someone on a pureed diet.
  • A staff member making snacks for residents made and gave Yocham the sandwich, even though the person “knew” Yocham was on a pureed diet due to difficulty swallowing. Staff had “’regularly’” given peanut-butter-and-jelly sandwiches to Yocham as snacks, even through they knew it was forbidden by her diet.
  • Staff discovered Yocham coughing and making no sound. They asked if she was choking and she nodded yes. Staff began the Heimlich maneuver and two pieces of food, not chewed well, came out. Staff performed a finger swipe in her mouth and found no more food. She began to clear her throat and was given “thickened water” to sip. She became unresponsive and her skin turned blue.
  • Staff performed the Heimlich maneuver again, and then placed her on the floor. She had no pulse and a staff member who was not CPR-certified initiated CPR. The EMS also was notified and Yocham was taken to the hospital.

CBS local affiliate Local21News reported that maggots were found in a patient’s feeding tube at a Golden Living facility.  This facility and over 20 other Golden LivingCenters in Pennsylvania have been under fire by the Attorney General’s office which filed suit this summer.  Pennsylvania Attorney General Kathleen Kane last summer filed suit against 14 Golden Living facilities in Pennsylvania, alleging they are understaffed and fail to meet residents’ basic needs.

The recent inspection report says maggots were found in a patient’s feeding tube, with the nurse reporting “worm like bugs found crawling all around the PEG tube and surrounding tissue.”  he report of the Oct. 22 inspection said a nursing assistant noticed a maggot on the stomach of a patient with a feeding tube. A nurse later examined the tube entry site and found “worm-like” insects in and around the insertion site. The resident was subsequently taken to the hospital, where “multiple maggot looking” insects were found in the insertion site. The hospital said the skin around the tube “indicated severe neglect of wound care and proper cleaning,” according to the report.

The report also says feeding tubes were not changed as required 9obviously!), improper pest control was discovered, and improper hydration of patients was found. Those are just a few of the 31 deficiencies reported by inspectors on October 22, according to Medicare.gov.  The information comes from Medicare.gov.

Other Golden LivingCenters in the area are receiving a below average rating from that reporting site.  Back in September, the Attorney General’s Office filed a suit against the nursing home organization, a suit that includes over 20 of their facilities.

Thursday a spokesperson from the AG’s office wrote the following in an email:

Hundreds of complaints that have been made to our office since the announcement of the lawsuit have reaffirmed our position that pervasive issues exist in Golden Living facilities. We believe this is a very critical consumer protection case and we are committed to seeing it through.

 

 

A nursing home in Danbury, Conn. was fined only $1,040 by the state’s Department of Public Health after one of its residents died from choking on a meatball. The incident occurred when a licensed practical nurse left the resident’s evening meal tray at the individual’s bedside and left the room for the medication cart.  The resident was known to have swallowing problems and at risk for choking.  When the nurse returned, the resident was unresponsive. Records show that the tray was covered and that there was no visible food in the resident’s mouth, however.  The staff did not properly assess or care plan for the issue as the vulnerable resident was on a regular diet with cut up meat and thin liquids with no supervision.

The resident was taken to a hospital where the meatball was removed. The individual later died as a result of aspiration leading to hypoxic encephalopathy, which is a lack of oxygen to the brain.

The nursing home’s dietary director told state investigators that the kitchen staff was not responsible for ensuring that food was cut up for residents who have difficulty swallowing. Records show, however, that the meatballs served with the spaghetti that night were three-quarters to 1 inch in size and were considered appropriate for a soft diet.

This incident is not the only one to involve a resident choking on food, as state officials in Connecticut fined at least five nursing homes when their residents experienced similar cases. In some cases, the Department of Public Health found that negligence was to blame.  See article.

 

The Mini Nutritional Assessment, a short questionnaire which is used to determine a resident’s nourishment, relies on body mass index to assess residents. However, for the elderly and those with underlying conditions such as dementia, it can be incredibly difficult to measure BMI, or height and weights of bedridden patients. A new study shows that calf circumference may be a suitable alternative to BMI and height/weight measurements. The study was conducted with ~240 residents in seven Turkish nursing homes. Calves were measured at the widest point. Measurements of more than 31 cm received three points. A score of 12 or higher means someone is well nourished. In a situation like a nursing home, which is full of bedridden, frail, and sometimes impaired residents, using calf circumference can be a useful alternative to taking BMIs.

See full article at McKnights.

Malnutrition, deprivation, inanition. These words may not sound that familiar, but they all mean the same thing: starvation. So why are we writing about starvation? Because it’s a problem that still persists in nursing homes today. A whistleblower in the UK came forward in an article with The Mirror after the paper ran a story on seven people who died of hunger. In hospitals.

Unfortunately, the epidemic doesn’t end there. It is all too easy to get caught up in the ideal of helping people which naturally leads to the question of how nursing homes can get so bad that a resident could drop from a size 16 to a size 12 in two to three weeks, as in the case the whistleblower details. But nursing homes are businesses, and too often, it seems, those in charge care less about the personal and more about profits.

The whistleblower says that much of the problem arises from the food schedule, lack of options, and lack of assistance necessary from staff.  At the facility where she works, the portions are small, and the schedule has residents eating a small meal for dinner at 4:45 pm. Their next meal isn’t until 9:00 am the next morning, and the only snack they can have is a piece of toast and a cup of tea. She has 40-50 residents which are being fed at once, and about ten of them need to be fed, and many more need assistance with feeding.  There’s no way one person can assist all those who require it during a timely manner.

She says, ‘By the time you help three or four, the food is cold for everyone else.’ Another issue is that there are no options for residents. If they don’t like what’s being served, they can only have a piece of toast as a substitute. Additionally, the workers have to deal with a climate that seems hostile to those who raise complaints or threaten to blow whistles. See article at The Daily Mirror.