The Centers for Medicare & Medicaid Services posted payment updates for skilled nursing and inpatient rehabilitation facilities’ prospective payment systems for fiscal 2011. Nursing homes will realize a 1.7% increase in its market basket rate.  The nursing home increase was actually 2.3%, but federal regulators noted that an automatic click down of 0.6% was put into effect because overpayments were made at that rate in fiscal 2009. The net nationwide gain in Medicare payments to skilled nursing facilities will be $542 million in fiscal 2011.

CMS would be putting MDS 3.0 into effect on Oct. 1, which will modify resident assessment tool. As previously indicated, the RUGs-IV refined payment system will begin at the same time but will be recalibrated in the future, after CMS devises an appropriate way to recalibrate payments.

The SNF and IRF payment updates for fiscal 2011 will be officially published in the Federal Register. 

Finally an Attorney General has indicted THI entities for resident abuse and neglect.   It is about time.  Hopefully, this will open the flood gates for other state attorney generals to investigate and indict these entities who have shown a pattern of neglect and careless indifference to their residents. See indictments here and here.   The indictments have a lot of factual information showing the lack of care provided to a vulnerable adult. 

Murray Forman and Leonard Grunstein own and operate Fundamental Long Term Care Holdings which own, operate, and control the hundreds of THI facilities in the U.S. managed by Fundamental Clinical Consulting (the successor company to indicted THI of Baltimore Management).

The pattern of poor care and careless indifference by Fundamental in their THI facilities is well known in the nursing home industry.  Hopefully, these indictments will change their policies and procedures but it is doubtful.



Chicago Tribune had an article about the Joint Commission’s new campaign to help prevent falls in health care settings and in nursing homes. Millions of Americans are injured in falls each year, and many of them are preventable with proper supervision and safety devices.  The Joint Commission’s new campaign includes brochures on prevention tips. These are things like exercise to improve balance; turning on lights when entering dark rooms; and getting help before trying to get out of a bed.

The commission’s president, Dr. Mark Chassin, points out that falls can cause life-threatening injuries and can even be fatal. And he says following these simple precautions can really help.

Restraints are not typically used in nursing homes.  However, in some situations restraints are necessary to prevent a fall incident.  The percentage of nursing home patients with restraints fell to 5% in 2007, down more than half from 1999, according to a recent report from the Agency for Healthcare Research and Quality.

Roughly 11% of all nursing home patients had restraints at the end of the last decade, according to the 2009 National Healthcare Disparities Report from AHRQ. Restraint use was at 6% in 2006.

Nursing home residents who are physically restrained for long periods are prone to pressure sores and other problems, such as chronic constipation or incontinence as well as emotional problems, according to AHRQ.




USA Today had a great article on a major problem in the nursing industry.  The ability for bad nurses to move to another state and get a job.  An investigation by the non-profit news organization ProPublica found that the Nurse Licensure Compact has allowed nurses with records of misconduct to put patients in jeopardy. In some cases, nurses have retained clean multistate licenses after at least one compact state had banned them. They have ignored their patients’ needs, stolen their pain medication, forgotten crucial tests or missed changes in their condition, records show.


Nurse Craig Peske was fired from a hospital in Wausau, Wis., in 2007 after stealing the powerful painkiller Dilaudid "whenever the opportunity arose," state records say. In one three-month period, he signed out 245 syringes full of the drug — nine times the average of his fellow nurses.
Hospital officials reported him to Wisconsin nursing regulators and alerted police. Six months later, Peske was charged with six felony counts of narcotics possession. But by that time, he had used a special "multistate" license to get a job as a traveling nurse at a hospital 1,200 miles away in New Bern, N.C.

The ease of Peske’s move illustrates significant gaps in regulatory efforts nationwide to keep nurses from avoiding the consequences of misconduct by hopping across state lines. The two states in which Peske worked are part of a 24-state compact created to help get good nurses to areas where they are needed most. Under the decade-old partnership, a license obtained in a nurse’s home state allows access to work in the other compact states.

Critics say the compact may actually multiply the risk to patients. There is no central licensing for the compact, so policing nurses is left to member states. Outside the compact, each state licenses and disciplines its own nurses. But within it, states effectively agree to allow in nurses they have never reviewed. When a compact state is slow to act or fails to share information, nurses suspected of negligence or misconduct remain free to work across nearly half the country.

Compact officials do not track how many nurses are sanctioned by their primary state for misconduct elsewhere. They also don’t question whether states are adequately policing visiting nurses: 10 states have disciplined three or fewer such nurses in the past decade, compact records show.

Weaknesses in the state-based system for disciplining problem nurses have surfaced as a public health issue during the past year. California, for example, revamped its nursing board and its executive officer resigned after reports of ineffective oversight that put patients at risk.

The state recently discovered that 3,500 of its nurses had been disciplined by other states but had kept clean California licenses.

ProPublica examined the disciplinary actions taken by five compact states — Arizona, Virginia, Texas, Kentucky and North Carolina — in recent years. Reporters found four dozen examples of nurses whose primary licenses remained clean for months or longer after another compact state barred them from working there.

Among cases detailed in nursing board records:

•Therese Morgan, who now goes by Therese Holmes, retains a multistate license in Maryland. Arizona banned her in January 2009 after incidents at five hospitals in the Phoenix area, including failing to show up for work, flunking orientation and frightening a patient whose catheter she removed. Doctors and staff asked that she not be assigned to certain patients.

•Stephen Woodfin, a nurse anesthetist, surrendered his right to practice in North Carolina in January 2006 because of substance abuse. Even so, he was able to keep a clean multistate license in Texas. Nearly two years later at a hospital in Amarillo, Texas, he passed out during a surgery, bleeding from a vein in his arm. The Texas Board of Nursing found he had abused the narcotic Fentanyl. In September 2008, the board suspended him. He now is on probation and is limited to working in Texas.

•Dayna Hickman was suspended from practicing in Texas in September 2006 after she administered undiluted vitamin K too quickly to a patient at a Dallas hospital. The patient died a short time later. The next year, Hickman was placed on probation in California because of the Texas discipline. But her multistate license in Iowa remains clear.

Hickman, who now works as a critical-care nurse in Mason City, Iowa, says she notified the Iowa nursing board about the incident in Texas. "I have an exemplary record outside of this as a nurse, so Iowa chose to not do anything," Hickman says.

Allegations about nurse Craig Peske’s drug use did not stop once he reached North Carolina.

Within days of his arrival, a parent complained that Peske was falling asleep while attempting to insert an IV in her child. A hospital review found that he signed out the painkiller Demerol on dozens of occasions without a physician’s order. When he refused a drug test, he was fired in April 2008, nursing board records show.

Six months later, North Carolina banned him from working there. But Peske’s home state of Wisconsin did not revoke his multistate license until January 2009, giving him the ability to work in any of the other states until then.

Two national databases — one run by the National Council of State Boards of Nursing, the second by the federal government — are supposed to alert regulators and employers to disciplined nurses. But that doesn’t always happen. ProPublica has previously found discrepancies and missing records in both databases.

Amid such confusion, nurses accused of wrongdoing or incompetence keep working.

Alma Rice, 40, was able to work as a nurse in several states for seven years after she first got in trouble. Tennessee revoked her license in mid-2008 — only after she had been accused of stealing drugs at four hospitals in three states and had racked up criminal convictions in each state. Rice had been high on the job, tried to shred patient records to conceal her thefts and hid bottles of urine in her clothes in case she was drug-tested, nursing board and court records from several states show.

A forensic psychologist in Texas wrote in 2006: "It is still doubtful that (Rice) will be able to consistently behave in accordance with … generally accepted nursing standards."

Rice also had been indicted on charges of child abuse by a Dyer County, Tenn., grand jury in February 2008 after her 18-month-old son was found with needle marks on his arm and tested positive for a powerful anesthetic, court records and newspaper reports said. Rice called police after she forgot where she left him, a report said. She later was convicted of misdemeanor assault.

Nurse Krystal Bauer, like Rice, moved so fast she amassed allegations in multiple states before her home state caught up. Bauer, 37, was accused of stealing drugs in October and November 2007 while working at a hospital in Glendale, Ariz., in December 2007 while at a hospital in Weston, Wis., and in June 2008 at a hospital in Greenville, N.C.

Tracy Weber and Charles Ornstein are reporters for ProPublica, an independent, non-profit newsroom based in New York City that produces investigative journalism. USA TODAY editors worked with ProPublica editors in preparing this story.


This is a good follow up to this morning entry about the failure of nursing homes to report incidents and the failure of regulatory authorities to investigate and prosecute most incidents.  McKnight’s had an article about a new proposal that would cut penalties by 50%.  Ridiculous.

The newly proposed rule from the Centers for Medicare & Medicaid Services would reduce civil monetary penalties (CMP) issued against nursing homes by as much as 50%. To qualify for the reduced CMP under the rule, a nursing home would have to report a deficiency before it is discovered by either CMS or a state agency, and correct the deficiency within 10 days.

The penalty reduction would not apply in cases of immediate jeopardy, or in cases that are part of a recurring pattern of harm, according to the proposal. The new rule also would establish an escrow account where CMP would be held during any appeals process. In the event of a successful appeal, CMS would return the money with interest.

Currently, CMPs range from $50 to $10,000 per day of noncompliance, according to background information in the proposed rule. The rule was created in accordance with section 6111 of the Patient Protection and Affordable Care Act. CMS is asking for feedback on the rule, which was published Monday in the Federal Register. Comments are due by August 11.


Lexington Herald-Leader have been running a series of great articles on the failure of authorities to investigate complaints or for the facilities to report complaints and incidents.  See also article from WLWT.  The article uses the death of Ruby Goode as an example of lack of reporting, investigating, and prosecuting neglect and abuse of vulnerable adults.

The death of Ruby Ethel Goode in a nursing home was one of more than 100 incidents over three years in which Kentucky nursing homes were cited for violating state regulations. Few of those cases were prosecuted as crimes. When Brenda Goode Woitke learned that her 93-year-old mother had died in the Calvert City Convalescent Center, she assumed that she had died of natural causes.  But the death of Ruby Ethel Goode was far from natural or peaceful. She was found on the floor with her head stuck between the side rail of the bed and the mattress, her neck unnaturally stretched.

Not only did officials at the Western Kentucky nursing facility fail to tell Woitke how her mother died, but they intentionally hid the facts. A nurse told others "not to talk about this to anyone because they would all get in trouble," according to a state citation issued to the nursing home after Goode died.  "There was no evidence the family, the physician, the administrator, or the director of nursing were immediately notified" of how Goode, known as Ethel, died, according to a Type A citation, which is issued by state regulators when there is an immediate threat of death or injury to a nursing home resident.

Goode’s own doctor said that if he had been told about the circumstances of his patient’s death he would have contacted the coroner himself.  After a local newspaper reported how her mother had died, she walked into the office of Paducah lawyer Richard Walter and said: "I just want to know what really happened."

The civil lawsuit that was filed as a result has been settled for an undisclosed amount. Through the civil process, Woitke learned that the facility had not thoroughly assessed whether her mother — who had memory problems, was at a high risk of falls and frequently slid to the bottom of her bed — should be left alone with her bed rails up.

"It’s not about the money," Woitke said. "The truth of the way my mother died was withheld from me deliberately. I don’t want this to happen to another family."

But when prosecutors reviewed Goode’s case, they said there was not enough evidence to charge anyone with a crime — even though regulators said the nursing home failed to adequately assess whether Goode should be placed in a bed with side rails. The citation even said that might have prevented her death.

A Herald-Leader examination of 107 Type A citations issued over a three-year period by the Kentucky Cabinet for Health and Family Services Office of Inspector General found a number of gaps in the system that mean few nursing home deaths are ever prosecuted as neglect or abuse. They include:

■ Police and coroners are rarely notified of nursing home deaths or serious injuries.

■ Although the state sends all of the most serious nursing home regulatory violations to the attorney general’s office, that office can only prosecute with the permission of local prosecutors. And local prosecutors say they seldom hear about the cases.

■ The attorney general’s office misplaced or never received at least five citations issued by the cabinet from December 2006 through 2009.

The responsibility for criminal prosecutions involving long-term care facilities is spread over several agencies, with no single authority as overseer. That results in confusion and finger pointing among officials who do not want their offices blamed for not protecting the elderly.

The inspector general says it’s the attorney general’s responsibility to review nursing home citations and determine whether a crime was committed. The attorney general says that the inspector general or Adult Protective Services office can notify local police or prosecutors when criminal activity is suspected.

The 107 citations involved 18 deaths and 30 hospitalizations. Seven of the type A citations resulted in criminal charges. Eight cases are still open.

Cases where no charges were filed included those at facilities where a man wandered away and froze to death; a patient who was not monitored lost 87 pounds in 19 days and was later hospitalized; and a patient who fell and broke her hip but did not receive medical attention for seven hours.

The examination also found that nursing home employees who are prosecuted seldom serve jail time.

Much of the problem, experts said, can be attributed to the lack of a central authority to oversee investigations and prosecutions of incidents at nursing homes.   Advocates for the elderly, family members and attorneys say that nursing home deaths and injuries are not often scrutinized as potential crimes because the victims are elderly and often have serious illnesses.

If many of the same things happened to children, there would be a public outrage, said Kathleen Quinn, the director of the National Adult Protective Services Association, a trade group for adult protection workers.

Most nursing home incidents "are not investigated at all," said Dr. Barbara Weakley-Jones, Jefferson County coroner and a former state medical examiner who first noted Kentucky’s lack of attention to nursing home deaths in a 1991 study. "Unfortunately some nursing homes try to cover up what happened," she said.

Experts say criminal prosecutions in nursing home cases are difficult. Even if it seems clear that a crime was committed, it may not be certain which staff member or members did it. And elderly residents often cannot tell what happened.

Consider the case of Aden Owens, a construction worker who suffered a closed head injury at age 61 when a concrete slab collapsed. He entered Sunrise Manor Healthcare and Rehabilitation in Somerset in 1999. But his family became concerned about bruises he received — 114 injuries of unknown origin over seven years, the family alleged in a civil lawsuit.

Stephen O’Brien III, a Lexington attorney who represents Owens’ son Bryan, said Owens’ worker’s compensation carrier required him to be at Sunrise Manor. The family spent several hours a day at the nursing home and in 2006 placed a hidden camera in his room.The videotape showed a nursing assistant pulling Owens’ hair, twisting his fingers and striking his hands.  Another nurse’s aide is seen striking him, jerking him by his neck and placing a knee on his chest while changing his diaper.   After Owens fell out of bed, an aide left him on the floor while changing his bed, the videotape shows.

Bryan Owens said he couldn’t understand why his father’s case wasn’t prosecuted, while in another case, three nurse’s aides caught on a hidden camera abusing an elderly woman at Madison Manor nursing home near Richmond in 2008 were prosecuted and convicted.

In the Madison Manor case, one aide was found guilty of abuse after she roughly handled 84-year-old Armeda Thomas. Another was convicted after she ate Thomas’ food and said in records that Thomas ate it.

One key difference between the cases — Thomas’ case received widespread media coverage. Owens’ didn’t.


Read More →