BakersfieldNow had an interesting article on the prevalence of elder abuse in nursing homes.  The article cites an investigator and ombudsman for the elderly.  They stated elder abuse in the nursing home industry happens more often than people know.

Nona Tolentino is an ombudsman for the elderly.   Tolentino’s job is to investigate cases of suspected elder abuse in the nursing home industry.   Trying to verify it, however, can prove elusive, because people refuse to talk about it for a number of reasons.

"I call it the conspiracy of silence, (because) no one is able to talk for them," said Tolentino.

Under California law and in most states, nursing home employees are mandated to report any cases of suspected elder abuse. Tolentino finds that’s not always happening, though, as employees keep quiet out of fear of losing their jobs.

Tolentino is adamant about patients’ rights to a safe environment.   It was only back in 1987 when the Older Americans Act established a legislative framework for reform to better protect the elderly in nursing homes.   It is based on the premise that it is a resident’s right to be free of verbal, mental, sexual and physical abuse, unnecessary physical and chemical restraints, and involuntary seclusion in a nursing or residential care facility.

 

Newstranscript.com had a recent article about an application filed by the Village for Health Care and Rehabilitation of Workman’s Circle for a new and different type of long term care facility.   Plans call for the construction of a twostory skilled care nursing facility containing 152 beds for long-term care and sub-acute care (short-term rehabilitation) on a 13-acre parcel.

Testifying on behalf of the applicant was engineer Robert J. Curly, of CMX Engineering, Manalapan. According to Curley, the building will have 152 private rooms and 80 parking spaces, primarily for staff members.  The plan also calls for a large buffer of pine trees and an 8-foot tall berm to keep the facility private and so as not to become a disturbance to residents who live on Oakley Drive.

Marshall Goldberg will be the administrator of the Freehold Township facility. He said he takes pride in the home-like, non-institutional environment the skilled care nursing facility will offer.  He said the idea is to have the private resident rooms clustered around a living room area, which he said is the center core of the design plan. Some living spaces will have 16 resident rooms around a core center, others will have 12 resident rooms around a core center.

Materials to be used for the exterior of the building will include stone and stucco. The front of the building will have a covered canopy.  The first floor of the building will be comprised of 54,000 square feet with bedrooms, the kitchen and the living room areas.   Also on the first floor will be resident amenities such as a library, beauty shop, gift shop and activity rooms The second floor will be comprised of 54,000 square feet to include bedrooms and administrative offices.

The structure appears to be more like a residential property with a Colonial design and unique architectural features, according to project architect Judith Mumma.  Mumma explained that the model used to design The Village is called Greenhouse, a new concept in senior care which emphasizes home-like houses with between 10 and 16 residents, rather than institutional beds and corridors.

"This is loosely based on that model," she told the board. "Residents will eat in their own dining room with just those in their house, not everyone in the building. This provides a safer, cozier environment."

The model for the Greenhouse concept has the "homes" detached and completely separated. The homes for The Village give the appearance of standing alone as separate homes, but people can walk from one end of the building to the other inside.

There area no visible nursing stations, but rather a home-like center living room with a team room where nurses and aides will conference with patients in a safe environment. Medications and treatment carts are stored in those areas, but will be behind closed doors and not visible, according to the testimony provided to the board.

 

McKnight’s had an article discussing how geography dictates the quality of care provided to residents of nursing homes.  Geography plays an important role in the cost of nursing home and other long-term care services, according to a recently released report.

Nationally, the average nursing home cost was $210 per day for a private room in the markets surveyed.   But costs vary greatly depending on where you live.   If you reside in a facility in Homer, AK, you could be paying up to $538 per day in nursing home costs, according to the report.   But a nursing home in Lafayette, LA, costs a fraction of that-$118 per day. Meanwhile Hawaii is the most expensive on average for care in an assisted living facility at $4,406 a month-more than twice what assisted living residents in North Dakota pay. Many of the nation’s Northeastern states have assisted living costs that top $4,000 per month.

The survey, which was conducted by the Long Term Care Group on behalf of Northwestern Mutual, sampled more than 7,000 long-term care facilities nationwide. For more information on the report, or the companies that commissioned it, visit www.nmfn.com.
 

The Cincinnati Enquirer had an article about the death of a woman who was found outside of he rnursing home.   The woman died three days after she was found outside a Hyde Park nursing home on a day when the low temperature was 23 degrees.  Records do not say what time she fell or how long she was outside before she was found.   It was dry that day, with a low of 23 and a high of 40 degrees, according to the National Weather Service.

Pasquale was brought inside, taken to University hospital where she was treated for an eye injury and then moved to Hospice. She suffered from advanced dementia and stayed in a locked unit.

It is unknown how she escaped from the locked unit and left the facility.  Pasquale was found by an employee of the nursing home who was being dropped off for work.   An alarm was set off when Pasquale walked out of the facility into a courtyard.    From there, she had to open a gated area.  She was found sitting on the ground outside the nursing home.

Pasquale was moved to hospice because she grew very ill and “clearly didn’t have long to live.”

Cincinnati police said they were not called to the nursing home.

Such incidents, in which nursing home residents are found outside in the cold, are not common but not unheard of.

On Feb. 5, Dorotha Mae Gifford, 87, died outside Heartland of Woodridge nursing home in Fairfield. She was found face-down in the snow. She died of hypothermia, her death ruled an accident, the Butler County Coroner’s Office said Friday.

In January 2007, Shirley Galvin, 78, was found dead in the snow outside Sunrise Assisted Living in Finneytown. Her death resulted from heart disease, the Hamilton County Coroner’s Office said.

 

WiredPRNews.com had an article about a nursing home owner in Albuquerque, New Mexico, who was found guilty of felony abuse and neglect in connection to charges stemming from an incident on Christmas day in 2005.

Richard Gerhardt, a 76-year-old resident at the nursing home, who was recovering from a broken hip, was placed on a bed pan and left there for 24 hours. According to reports, the bedpan became imbedded in his skin, causing an open wound that became infected and resulted in his death 5 days later.

The nursing home faces a possible $5000 fine and/or exclusion from federally funded health care programs. The case is rare, and may be the first of its type to lead to a conviction. Elizabeth Staley, director of the New Mexico attorney general Elder Abuse and Medicaid Fraud Division is quoted in the report as stating, “Nursing home and care facilities are paid to provide round the clock care to those who cannot care for themselves… Protecting this population is of paramount importance to the New Mexico attorney general and similar violations will be prosecuted vigorously.”

Sentencing for the case is set for March 13.

 

There have been many articles about the recent deaths at a California nursing home from overmedication or intentional overdose.  Here, here, here, here, and here are some articles where I got some information.  It is an incredible story that is symbolic of the hiring practices and training of staff in the nursing home industry, and the use of medications as a chemical restraint.  The use of chemical restraint in elder-care facilities is not a new problem. However, it’s unethical, and if given without consent of the individual or a healthcare proxy, illegal.

Kern Valley Hospital houses a skilled nursing facility where several employees are accused of killing three patients by force-feeding them psychotropic drugs to keep them calm.
In one allegation, nursing home resident Opal Towery was injected with anti-psychotic drugs after an argument with the nursing director and spent the next week in a zombielike state.  In another, Louise Zimmerman was pinned down by four staffers and injected with the same drugs. She never regained full consciousness.

Those were among the disturbing stories in a criminal complaint filed by the California Attorney General’s office that led to the arrests Wednesday of three current and former employees of the Kern Valley Healthcare District’s skilled nursing facility. The complaint alleges a nursing director, pharmacist and physician drugged at least 22 elderly residents with mood-altering medications to quiet and control them, leading to the deaths of three. The alleged druggings occurred between August 2006 and January 2007.

“When I was handed the newspaper by a co-worker, I felt like somebody had slammed me in the stomach,” said Betty Dennison. Her mother-in-law, Beulah Dennison, died Jan. 21, 2007, less than three months after she was placed at the Kern Valley Healthcare District’s skilled nursing facility. Several days before Beulah’s death, a nurse told Dennison her mother-in-law had been drugged to keep her quiet and complacent.

Patti McGarvey’s 74-year-old mother, Norma Lee Cudahy, entered the facility in March 2006 to recover from knee surgery and died in November from a stroke. McGarvey doesn’t know what drugs her mother received but after hearing the alleged druggings targeted patients who complained or acted out, she got worried.

“These are powerful medications that were given, in some cases against people’s will, primarily for management, not health reasons,” Attorney General Edmund G. Brown Jr. said. “It’s unconscionable behavior and it’s certainly not what people expect when they entrust their parents or grandparents to a skilled nursing home.”

Gwen Hughes was the director of nursing.  Debbi Gayle Hayes was the facility’s pharmacist.  Dr. Hoshang M. Pormir was medical director of the skilled nursing facility.

 

The 27-page complaint describes interviews with facility nurses and medical experts who say Hughes ordered certain patients to receive high and unnecessary doses of anti-psychotic drugs.

Pharmacist Hayes followed her orders, telling investigators she thought Hughes was knowledgeable in the treatment of psychiatric conditions. Pormir, the physician, signed off on the orders after the drugs were administered.

Hughes’ orders often came after residents "acted out" or complained, and were often administered without patient consent.   At least two residents were forcibly injected; a third had psychotropic drugs sprinkled on her food.  The investigation found none of the residents received a medical exam or diagnosis prior to receiving the powerful doses.

The attorney general’s investigation identified three residents believed to have died as a result of being drugged and neglected:

• Fannie May Brinkley died Dec. 23, 2006, after receiving Depakote, a drug to treat mood disorders. After not eating for six days, she was rushed to the emergency room, where she died.

• Eddie Dolenc was given unnecessary anti-psychotic medication that caused him to become extremely sedated, and unable to eat or drink. He died one month after being admitted to the facility, likely from dehydration or pneumonia.

• Joseph Shepter went to the emergency room on Jan. 14, 2007, for dehydration and died five hours later. He had been given three anti-psychotic drugs.

In addition to the three deaths, the drugged residents suffered serious side effects ranging from severe lethargy that inhibited eating and drinking for long periods to weight loss, drooling and incoherence.

People interviewed by investigators pinned most of the blame on nursing director Hughes, who was fired in 1999 from a Fresno nursing home after the state cited the facility for over-medicating patients.   Nurses at the Kern Valley facility said the drugging of patients began when Hughes was hired.  She held “interdisciplinary team meetings” in which she and the staff discussed residents’ behavior and Hughes told the pharmacist what drugs to prescribe.

Tish Orr, a registered nurse at the Kern Valley facility for 25 years, said the druggings were orchestrated by nursing director Hughes.

Orr recalled Hughes ordering a potent anti-psychotic drug be given to an Alzheimer’s patient.

“I would have him up at the nurses’ station while I was working, and he’d been drinking coffee and eating graham crackers and was happy as could be,” she said. “But he’d say the same thing 140 times in a row and it drove her nuts, and that’s why she had him medicated.”

“From that day on, he didn’t eat or drink. He was so weak he couldn’t be in his wheelchair anymore.”

The man eventually died.

When the nurses objected or raised concerns, Hughes threatened to fire them and have their nursing license revoked.  Several nurses left the facility during Hughes’ tenure. One nurse told investigators she was so distraught by the situation that she was on the verge of “a nervous breakdown.”

Gwen Hughes was fired from two nursing facilities for over-drugging patients yet landed a job at Mercy Hospital in Bakersfield and to this day has a clean nursing record. How did Hughes — facing criminal charges in the deaths of three local nursing home patients — keep getting hired?

Interviews with health care regulators and a former employer showed that nursing homes blame privacy laws despite the firings, the result of twice being implicated in state investigations for over-drugging elderly patients.

It’s public now. Threats kept the truth about what happened at Kern Valley from coming out sooner, said Tish Orr, a registered nurse there for 25 years. When nurses objected to patients receiving heavy doses, Orr said, Hughes threatened to fire them or have their licenses revoked.

“We were so cowed and threatened with losing our jobs and our licenses that after a while we just shut our mouths and did what we had to do,” Orr said.

Nurses who worked under Hughes at the Sunnyside Convalescent Home in Fresno in the late 1990s described a similar situation, Fellen said.

“She would go up to (a nurse) and basically force them to write an order (for medications),” he said. “She threatened to fire them. She could be very intimidating.”

Hughes was fired as nursing director there in 1999 after a state investigation revealed her role in overmedicating patients. She was hired in Kern Valley in 2006. After being terminated from that job, she briefly worked at Mercy Hospitals.

Incredibly, there are no blemishes on Hughes’ nursing record. The Board of Registered Nursing said it will now act to suspend Hughes’ license. A little to late for the dozens of victims of her "care".

Three of the four drugs allegedly over-prescribed to patients at a Lake Isabella nursing home can pose such deadly side effects to the elderly that they bear the U.S. Food and Drug Administration’s “black box” warning label. Zyprexa, Resperidol and Seroquel were developed to treat severe psychotic disorders, such as schizophrenia, but are increasingly given to nursing home residents, often to treat behavioral issues, said Dr. Kathryn Locatell, a geriatric physician who specializes in forensic investigation of elder abuse.  Common side effects in the elderly are constipation, risk of falling and difficulty swallowing, which can lead to dehydration, weight loss and other life-threatening problems. In most cases, the risks or prescribing the drugs to elderly patients far outweigh the benefits, Locatell said.

Because the drugs can cause sudden death in elderly patients, said Locatell, they bear the FDA’s strongest designation for medications that may have life-threatening side effects.

The use of anti-psychotic drugs in the elderly can pose serious risks. Geriatric physician Kathryn Locatell and longterm care ombudsman Nona Tolentino said people with a loved one in a nursing home, skilled nursing facility or other residential care setting should asked for detailed information about medications.

Here are some questions to ask:

• What medication is my loved one on?

• What are you trying to treat with this drug? What are the specific behaviors that need treatment?

• How will this drug improve my loved one’s condition?

• How often and how long will it be administered?

• What are the side effects?

• Has a doctor examined my loved one to determine if this is appropriate?

• How will side effects be monitored?

• Why are drugs even being considered?

• What other approaches could be used? What has been tried?

“If you can’t get good answers, then ask for a meeting with the director of nursing or the pharmacist,” Tolentino said. Or, seek an outside pharmacist’s opinion. Facilities should also have a “care plan” for each resident or patient. Ask for a meeting to review it with facility staff.

Locatell said national statistics show about 50 percent of nursing home residents are on some form of psychotropic medication. Most are on anti-depressants, which she considers OK since there’s high incidence of depression among nursing home residents. But about 30 percent of residents are now on anti-psychotics, a class of psychotropics designed to treat serious mental illness. The use of those drugs in a nursing home should “raise a flag” for loved ones, she said.

“As far as I’m concerned, it’s replaced the use of physical restraints,” said Nona Tolentino, former director of the county’s adult protective services program who now oversees the long-term care ombudsman program at Greater Bakersfield Legal Assistance. “That’s what I see and that’s what we hear. There are behavioral problems in a nursing home and staff readily presents that to a doctor and the doctors agree to prescribe the drug or increase the dosage.”

 

 

The Washington Post had an article about the Bush administration’s rule to stop a source of information about abuse and neglect in long-term care facilities that are crucial to finding answers.

The rule designates state inspectors and Medicare and Medicaid contractors as federal employees, a group usually shielded from providing evidence for either side in private litigation.  The new rule, which was issued in September, generally prohibits state health departments and contractors from participating in private lawsuits involving facilities that are in the federal assistance program without approval by the head of the Department of Health and Human Services.

The restrictions affect about 16,000 nursing facilities and 3 million residents in the United States. The practical effect is to force families to go to greater lengths, including seeking court orders, to get inspection reports or depositions for cases they are pursuing.

The change, which affects the $144 billion nursing-home industry, was enacted with no public notice or attention.

"This change hurts nursing-home residents and their families by allowing bad practices to be kept in secret by nursing homes and inspectors," said Eric M. Carlson, an attorney with the National Senior Citizens Law Center in Los Angeles. "Government inspectors have the right to go into nursing homes and investigate, and they learn things that residents and families otherwise could never find out."

The effect of the directives has started to play out in the nation’s courtrooms. Requests for information, once fairly routine, now are stalled between state and federal officials.

 

Maryland allows nursing homes to prohibit families from monitoring their loved ones via video or webcam.  NBC 25 had a story and article about  local lawmakers trying to make it illegal for nursing homes to prevent people from installing cameras in patient’s rooms.  Cameras prevent neglect and abuse, and make sure that residents are getting the services they need.

The bill would require nursing homes to give people the choice of installing cameras that the patients or their families would pay for themselves. Cameras would not be allowed in bathrooms.

All rooms being monitored would be required to have a sign on the door.

For families, it’s legislation that would bring them piece of mind.  It would also help management determine the competency of the staff and the effectiveness of treatments.  The nursing home industry does not want families to know what is going on at the facility when they are not there. 

Many times, when demented residents suffer abuse, the nursing home cannot substantiate the abuse and rarely try.   Imagine if there was a video–wouldn’t that be a deterrent to any neglect or abuse?

The Chicago Tribune has had a series of articles about the tragic death of a nursing home resident who was unsupervised and allowed to wander away from the facility.  The articles are good although many questions remain unanswered.  See articles here, here, here, and here.  Below is a summary of what I believe has been found out thus far.

Sarah Wentworth — who suffered from dementia — was found in a snowbank outside The Arbor of Itasca the cold morning of Feb. 5.  She had been exposed to the elements for at least 90 minutes and more likely 5 hours. Wentworth was unable to leave her bed without assistance.   No one is sure how she could have left her room and the building without being noticed by staff.  Staff are required to do a bed check every two hours.  She was known by staff to be a wanderer and wore an ankle bracelet that reminded the staff.

Wentworth was wearing only a hospital gown when police arrived at the nursing home.  She had on an ankle bracelet that should have (and may have) triggered an alarm at the facility’s nursing station when she passed through the first of two exit doors.   Inside the nursing station at The Arbor of Itasca is a handwritten note reminding staff that "if this buzzer sounds, staff must go out to the courtyard to check for a resident."

Nursing home staff members told Itasca police they checked the door to the courtyard when the alarm went off, but did not see anyone.   No mention of a polygraph test was noted.

Neglect and obstruction of justice charges may be filed against as many as four employees. Heidi Leon, a 23-year-old staff member on duty the night of the incident, was watching TV in a room adjacent to the nursing station when Wentworth exited a door and triggered the alarm.  She watched three straight episodes of "Dog The Bounty Hunter" and "shrugged off " an alarm that indicated a resident had wandered outside into near-zero conditions.  Instead of checking the courtyard as instructed, the staff member assumed someone "stepped outside to have a cigarette" and turned the alarm off "so it didn’t distract her television program."

Tom Hendrix, an attorney for the nursing home, did not respond directly to the allegations but said that "policies and procedures were in place for the supervision and safety of residents, including an alarm system which was in working order." Hendrix did admit that some employees had been suspended.

Mr. Hendrix nor the nursing home employees can explain how she got outside.   She was unable to get out of bed on her own.  Although an alarm sounded at a secure door during the middle of the night when Wentworth left the building, no nursing home employee checked on her.   The outside temperature that morning was about 1 degree.

Heidi Leon was charged Tuesday with criminal neglect of a long-term-care facility resident, criminal neglect of an elderly person and obstruction of justice. If convicted, she faces up to 7 years in prison.

 

 

A pressure ulcer is an area of skin that breaks down when you stay in one position for too long without shifting your weight. This often happens if you use a wheelchair or you are bedridden, even for a short period of time (for example, after surgery or an injury). The constant pressure against the skin reduces the blood supply to that area, and the affected tissue dies.

A pressure ulcer starts as reddened skin but gets progressively worse, forming a blister, then an open sore, and finally a crater. The most common places for pressure ulcers are over bony prominences (bones close to the skin) like the elbow, heels, hips, ankles, shoulders, back, and the back of the head.

McKnight’s had a recent note about the most recent study analyzing the data of pressure ulcers in nursing homes.  More than one in 10 nursing home residents had a pressure ulcer in 2004, according to newly released statistics from the Centers for Disease Control and Prevention.

The report proves widespread neglect related to wound care.  Roughly 159,000 nursing home residents—11% of the total—had some form of pressure ulcer. Stage two pressure ulcers were the most prevalent, the report found.   However, many nursing home employees have no training in wound care and do not know how to properly stage a pressure ulcer.  

Younger residents who experienced shorter lengths of stay also were more likely to have pressure ulcers.   This disproves the defense argument that "old" people get pressures ulcers and that they are "unavoidable".  

A total of 35% of those with pressure ulcers stage two or higher (more severe) received "special" wound care treatment, according to the CDC.   There were no significant differences in pressure ulcer rates between white and non-white residents, according to the report.

The report, "Pressure Ulcers Among Nursing Home Residents: United States, 2004," was released Wednesday.   Authors gathered data for the report from the 2004 National Nursing Home Survey, which sampled responses from more than 14,000 nursing home residents around the country. The CDC report can be found online at http://www.cdc.gov/nchs/pressroom/upcoming.htm.