News Channel 36 in Concord, North Carolina had a tragic story of a resident  who fell to her death at a nursing home.  State inspectors have launched an investigation at the Concord nursing home.

The 87-year-old woman was found with a massive head injury on the ground beside an outside loading dock.   The article mentions that a fence near the loading dock is brand new, clearly installed after the patient at Concords Five Oaks Manor Nursing Home was found on the ground.  She’d fallen 4 feet to the ground, hit her head and died after being rushed to the emergency room.

The nursing home administrator did not report the woman’s fall or death to the state.  A state spokesman says someone else reported it to them. Concord police told News Channel 36 the same thing.

Just last week Medicare ranked Five Oaks among the worst nursing homes in the country with just one out of five stars. Two state inspections from this year showed deficiencies. One cites accident and supervision problems, with one example where a patient "was on the floor" and staff had to be "disciplined."   Another said a patient was "outside the building."

 Channel 36 had a follow up to this story here.  In the follow up article, the family expressed concern that someone else could die there. The family says she had gotten out of the facility before.

Her daughter, Rosemary Ritchie, said she is worried about other patients at Five Oaks Manor. Doctors told her that her 87-year-old mother was brain dead because of a fall that the nursing home could have prevented.

She says her mom somehow got through a kitchen door that didn’t have an alarm or lock on it. That door led out to the back of the facility and a loading dock. "I put her there trusting they would keep her safe and then this happened. It’s not right," Ritchie said.

News Channel 36 tried repeatedly to get in touch with management at the nursing home and were told they would not comment.

Fort Worth Star Telegram had an article about a nursing home facility that allowed a resident to wander away from the facility unsupervised.  The resident is a 67-year-old woman with an aggressive form of Alzheimer’s disease who walked away from a Fort Worth nursing home.

The woman was last seen about 5 a.m. at the Tanglewood Oaks nursing home.  Police described the woman, Linda Kay Eichelberger, as white, 5-feet 3-inches tall, weighing about 135 pounds, with blond hair. Police think she may have tried to walk to her home near TCU.

Anyone with information about Eichelberger can contact Fort Worth police at 817-335-4222.

I am not sure how this happens when the facility knows that the woman suffers from dementia. Why weren’t they keeping an eye on her?  How long was she missing before they even noticed?  Did they have a wanderguard on her? Were the doors locked to the facility?  Did they have enough staff to watch her?


The NY Times had an article recently discussing how the nursing home industry is concerned about the new rating system for nursing home facilities.  The industry is concerned because 22 percent of the nation’s nearly 16,000 nursing homes received the federal government’s lowest rating in a new five-star system, while only 12 percent received the highest ranking possible.

Under the new rating system, a facility could obtain up to five stars based on criteria such as staffing and how well they fared in state inspections. The lowest ranking possible was one star. Kerry Weems, acting administrator for the Centers for Medicare and Medicaid Services, said the agency was merely taking existing data already on the agency’s Web site and making it easier for patients and families to evaluate a nursing home. ”This should help consumers in narrowing their choices, but nothing should substitute for visiting a nursing home when making a decision,” Weems said.

Under the new system, five stars means a nursing home ranks ”much above average,” four star indicates ”above average,” three means ”about average,” two is ”below average” with a one indicating ”much below average.” The rankings will be updated quarterly. Of course, these ratings are based on how well the State investigates complaints and conducts surprise inspections.  In South Carolina, DHEC is so poorly funded, and investigators are so poorly trained, that many violations are not recognized or complaints investigated.  DHEC hardly ever finds any nursing home complaint substaniated. 

The ratings are based on three major criteria: state inspections, staffing levels and quality measures, such as the percentage of residents with bed sores. The nursing homes will receive stars for each of those categories as well as for their overall quality.

Consumer groups note potential problems with the data. For example, the staffing data is self-reported just before state surveys and is widely recognized as unreliable.

”From a consumer viewpoint, it’s not stringent enough,” said Alice H. Hedt, executive director of the National Citizens’ Coalition for Nursing Home Reform.   Hedt said consumers should consider the star ratings, but not solely rely on them when comparing facilities. Her organization also warned that nursing homes may appear in the ratings to give better care than they actually do.

CMS used three year’s worth of inspections to rate nursing homes based on an annual survey designed to measure how well homes protect the health and safety of their residents. The measurement for staffing reports the number of hours of nursing and other staff dedicated per patient each day. The measurement for quality looks at 10 areas, including the percent of patients with bed sores after their first 90 days in the nursing home and the number of residents whose mobility worsened after admission.

Industry officials said surveys conducted in some states are stricter than others, so they cautioned against using the new ratings to conclude that one state’s nursing homes were better than another’s.



McKnight’s had a great article on Senator Kohl’s new bill, "Retooling the Health Care Workforce for an Aging America Act of 2008."   The bill has garnered strong praise from the nation’s top nursing home advocates.

"The ability to recruit, retain and support high quality talent is essential for providing high-quality care and services," said Larry Minnix, president and CEO of the American Association of Homes and Services for the Aging, in a statement. This act will offer more opportunity to invest in the long-term care workforce and effectively meet the needs of an aging society, he added.

The nursing home industry claims that 110,000 full-time healthcare positions in the country are vacant.

Alan Rosenbloom, president of the Alliance for Quality Nursing Home Care, added.

"We are pleased Senator Kohl has introduced this sweeping piece of legislation which deals directly with the fact that demand for long-term care workers far outstrips the available supply of the key workers our profession requires to sustain the provision of quality care today and the years ahead," he said in an announcement.

Oregon had an article about a Portland judge who ordered the jailing of the former nursing director of a Northeast Portland nursing home where a 60-year-old woman cried in pain with broken legs for five days before staff called an ambulance.

Suzanne Kay Ruddell was found guilty of felony criminal mistreatment by a jury.  She must serve 19 months of prison time and three years probation for her role in the death of Linda Ober, who was dropped by aides while being moved into her bed.  The nursing home covered up the fal and failed to get x-rays or notify the family as required by law.

Ruddell waited five days before ordering X-rays for Ober despite multiple reports from different staffers that Ober was screaming or crying in pain. Ober died after a surgery to repair two shattered leg bones.

Sara Cunningham, one of Ober’s five adult children, said the nursing home failed to notify them.  The family never got a chance to say goodbye.   "It wasn’t until she’d endured five days of excruciating pain that my mom was taken to the hospital," she said. "This is inexcusable, especially for a nurse who’s supposed to help people."


Sarasota Herald Tribune had an article recently about a Bradenton caregiver arrested for leaving her post as the only caretaker at a Bradenton nursing home where a resident later suffered heat stroke and seizures while she was gone.

Linda Shaw, 48, was employed by Personal Care II, an assisted living facility located at 120 8th Ave. E. in Bradenton. 
Shaw was responsible for providing care and supervision to the victim and 15 others at the facility.  Authorities say Shaw left the residents unsupervised during an overnight shift in July.

During that time, a 47-year-old resident fell ill, and his roommate had to call 911 for help. The patient was taken to the hospital in critical condition.

The State Journal-Register of Illinois had an interesting article about how most nursing home deaths are not investigated. This comes as a surprise to many families and violates the state and Federal regulations stating that incidents should be investigated to determine cause. The nursing homes generally do not want deaths investigated because the investigation would show that neglect was a contributing cause of the resident’s death.

Many county coroners believe Illinois should pass a law requiring nursing homes to notify coroners whenever one of their residents dies so the circumstances can be investigated for potential abuse or neglect. But even after a yearlong pilot study involving 10 Illinois counties, it doesn’t appear that such a mandate is any closer to reality.

Public Health, which doesn’t know how many Illinoisans die in nursing homes each year, this summer completed a yearlong pilot project in 10 Illinois counties — including Morgan — to determine whether such a policy should become the standard.  State officials and the Illinois Coroners and Medical Examiners Association don’t plan to lobby for legislation to require that nursing home deaths be reported and investigated.

Only the states of Arkansas and Missouri require all nursing-home deaths to be reported to local coroners for potential investigation. The Arkansas law piqued the interest of the Illinois Department of Public Health. Public Health spokeswoman Melaney Arnold said state officials will leave the option of proposing legislation to the coroners association.

Lake County Coroner Dr. Richard Keller said they would like to see a law passed, regardless of financial concerns and statistics.   Uncovering suspicious deaths in nursing homes is part of a coroner’s job, regardless of whether it’s specifically outlined in a new law, he said.

Brigit Dyer-Reynolds, a Springfield-based long-term-care ombudsman who advocates on behalf of nursing home residents, said people in nursing homes would benefit from a death-reporting law.

Even in the state’s largest counties, including Cook, coroners and medical examiners often look into nursing home deaths only after they receive complaints from family members or if criminal activity is suspected.  McHenry County Coroner Marlene Lantz said she asks all nursing homes in her county to report deaths to her, but some facilities refuse. She said a state law that both requires nursing homes to report all deaths and also includes funding for investigations would be a big help.


The Clarion-Ledger of Mississippi had an article about nursing home employees abusing and torturing residents.  Two of the nursing home workers were arrested for crimes including one nurse accused of pouring aftershave on a patient’s genitals, Attorney General Jim Hood said.

 Hood said that the women worked as licensed practical nurses at Graceland Care Center in New Albany.   Cynthia Hunt of New Albany was charged Thursday with two felony counts of abuse of a vulnerable adult after being indicted by a Union County grand jury.

Hood accuses the 46-year-old Hunt of "pouring aftershave on the genitals of a patient" and administering medication that caused pain.   Kathy Brooks, 59, of Blue Mountain is accused of taking the pain medication hydrocodone that was meant for more than one patient, Hood said.

"Any person found guilty of torturing a disabled person or stealing their pain medications leaving them to suffer should receive little mercy for such sinful crimes," Hood said. 

How did the nursing home Administrator or Director of Nursing not know what was going on?  Who is supervising the LPNs?

The Chicago Tribune recently had an article talking about the shortage of qualified and compassionate nurses in Indiana.  The article states that Indiana’s nursing homes are facing critical shortages of registered nurses and nurses aides.  An industry survey found nursing homes in this state had the nation’s highest vacancy rate for registered nurses last year, and the rate for vacant aide positions was the eighth highest in the nation.

Advocates for seniors agreed with the urgent need for more nurses and aides. An AHCA survey released last month found 26.0 percent, or more than a quarter, of registered nurse positions in nursing homes were vacant last year on June 30. The survey found that 13.7 percent of certified nurses’ aides slots – about one in seven – also were empty on that day. The national vacancy rate for nurses was 16.3 percent and for nurses aides, 9.5 percent.  This hurts the quality of care since many nursing homes will hire anybody and not fire anyone even if caught abusing or neglecting residents.

What we’re seeing over and over again is there’s a direct link between quality and staffing.   With unqualified or incompetent staff, many nurses get burnt out or over worked which leads to high turnover rates. The AHCA report estimated the two-thirds of RNs in nursing homes left their jobs last year and that 93 percent of aides did.

Michelle Niemier, executive director of the advocacy group United Senior Action of Indiana, agreed nursing homes needed more RNs and aides, but said those staffs also had to have the training, supervision and consistent hours to adequately serve residents and their families.

“The number one concern of family members is the number of well qualified, well trained, well supervised staff in nursing homes,” Niemier said.


Another nursing home employee was arrested by Florida authorities on charges she abused an elderly nursing home resident under her care. Karlene Brown was arrested by the Attorney General’s Medicaid Fraud Control Unit.   Brown was employed as a Certified Nursing Assistant by Bay Pointe Terrace, a in Broward County.

Attorney General’s Medicaid Fraud Control Unit’s Patient Abuse, Neglect and Exploitation (PANE) team had investigated.  They wee acting on information received from the Department of Children and Families. According to investigators, Brown became angered at an 88-year-old resident who suffers from dementia. She grabbed the resident by the collar and forcefully dragged the elderly woman into the woman’s room. The events were captured by a video recorder which was in the resident’s room.

Did the facility train her on how to handle demented residents?  Was the facility short-staffed leading to frustration and burn-out?  Did she have too much responsibility and not enough help? How long had she worked there?