Medpage Today reported that companies that administer Medicare Part D drug programs for seniors cannot tell whether antipsychotics and other drugs they cover are being used for medically accepted indications, according to a new report from the Department of Health and Human Services’s Office of the Inspector General (OIG). The investigation and report were a result of substantial concerns that nursing home residents are being over-prescribed atypical antipsychotics.

An OIG report earlier this year found that 14% of all nursing home residents with Medicare had claims for antipsychotics, and 88% of the atypical antipsychotics prescribed off-label were for dementia. More than half of all elderly nursing home residents’ Medicare claims for antipsychotics were made erroneously, the OIG found.

There are eight atypical antipsychotics approved by the FDA to treat schizophrenia and/or bipolar disorder, including clozapine (Clozaril), aripiprazole (Abilify), and quetiapine (Seroquel). None of them are approved to treat dementia and must carry black box warnings that elderly people who take atypical antipsychotics have an increased risk of death, compared with those who take placebo pills for dementia.

The report found that nursing homes were being reimbursed without documentation whether a drug was used for a medically accepted indication.

Sen. Herb Kohl (D-Wis.) asked witnesses at the hearing about the new report — all of whom were government officials or aging and nursing home experts — why antipsychotics are being so widely used to control behavior in nursing homes.

One witness, Toby Edelman, an attorney with the Center for Medicare Advocacy, pointed to understaffed nursing homes; high turnover of nursing home staff who don’t have time to get to know each patient; and to off-label marketing by drug companies who illegally promote the use of antipsychotics to doctors as a treatment for their elderly patients. Edelman also pointed to a decline in the use of physical restraints in nursing homes as a reason antipsychotic use in nursing homes has increased.

Dr. Jonathan Evans pointed to another more pervasive problem leading to overuse of the drugs among the elderly: The belief among doctors that medication is the first-line therapy for treating elderly adults with behavioral issues.

"There is a firm, fixed belief among many healthcare professionals that difficult or disruptive behaviors are causes for medication and that medication is likely be beneficial for that purpose," said Evans, who is the vice president of the American Medical Directors Association. "That belief is wrong."



In the United States, nursing home residents with dementia are too often prescribed anti-psychotic drugs to calm their disruptive behavior, a costly and risky practice that should end, according to experts. Care should be taken to determine why the resident’s agitation or behavioral issues have increased and treat those underlying causes.

Daniel Levinson, Health and Human Services Inspector General, said recent government audits have raised concerns about the use of antipsychotics by elderly people with dementia in nursing homes, raising their risk of death and wasting money for the US healthcare system.

For instance, more than half of such prescriptions were wrongly paid for in 2007 by government Medicare because the patients did not exhibit symptoms of schizophrenia or bipolar disorder, amounting to about 230 million dollars in waste. One audit showed 14 percent of nursing home residents had Medicare claims for antipsychotic drugs. However, nursing facilities’ self-reported data indicate that in the third quarter of 2010, 26.2 percent of residents had received antipsychotic drugs in the previous seven days. Facilities reported they gave antipsychotic drugs to many residents who did not have a psychosis, including 40 percent of patients at high risk because of behavior issues.

The practice persists, even though it is against federal law, because of serious understaffing in nursing facilities, high turnover of staff, and aggressive off-label marketing of anti-psychotic drugs
Residents are often given these potent drugs for behaviors that have other causes such as urinary tract infections, pressure ulcers, tooth decay, arthritic pain, or simply moving a patient from one place to another can lead to agitated behaviors.

These drugs are used as chemical restraints," said Jonathan Evans, a doctor who specializes in caring for frail elders. "Behavior is not a disease. Behavior is communication. And in people who have lost the ability to communicate with words, the only way to communicate is through behavior," he added. “Good care demands we figure out what they are telling us and help them."

See article at New York Daily News.

The medicating of Americans for mental illnesses continued to grow over the past decade, with one in five adults now taking at least one psychiatric drug such as antidepressants, antipsychotics and anti-anxiety medications, according to an analysis of pharmacy-claims data. WSJ’s Shirley Wang reports the use of psychiatric medications among adults and children in the U.S. has risen substantially since 2000.  Among the most striking findings was a big increase in the use of powerful antipsychotic drugs across all ages, as well as growth in adult use of drugs for attention-deficit hyperactivity disorder—a condition typically diagnosed in childhood.

Psychiatric medications are among the most widely prescribed and biggest-selling class of drugs in the U.S. In 2010, Americans spent $16.1 billion on antipsychotics to treat depression, bipolar disorder and schizophrenia, $11.6 billion on antidepressants and $7.2 billion on treatment for ADHD, according to IMS Health, which tracks prescription-drug sales.

Use of antipsychotics such as J&J’s Risperdal and Bristol-Myers Squibb Co.’s Abilify grew substantially in the past decade in both kids and adults. The rise, despite increased awareness about potential side effects like weight gain, high cholesterol and diabetes, is worrisome, according to Mark Olfson, a professor of clinical psychiatry at Columbia University who studies psychiatric drug utilization patterns

West Virginia’s WSAZ reported the sentencing of Darren Canada, a nursing home employee, to only one to three years in jail. In December, Canada pleaded guilty to a lesser charge of attempting to commit a felony.  Canada was indicted on charges of abuse or neglect of incapacitated adult and second degree sexual abuse in September 2010.  The charges were the result of an incident involving an 81-year-old female patient at the Chateau Adult Care Facility.

The criminal compliant says that another employee at the facility caught Canada attempting to sexually assault the incapacitated patient.  When confronted, the complaint says Canada exited the building by jumping through a window.  Canada later confessed to the incident  

And he only has to serve a year?  Where is the justice?

Kaiser Health News had an interesting article on how the failure to communicate can have dire consequences in the health care setting.  Medical tests reveal critical information about a person’s health, and must be communicated to clinicians and patients.  Sometimes, the ball gets dropped somewhere between the lab or the radiology department and the clinician who ordered the test and the patient.

The article uses Peggy Kidwell’s case as a typical example.  A mix-up over doctors’ names led to a year-long delay in a breast cancer diagnosis.  After her annual gynecological exam and mammogram several years ago, she got a letter from her doctor saying the results of her Pap test were normal. Her doctor did not mention anything about her mammogram exam. A year later, when Kidwell went back for her annual exam, her doctor, finding no mammogram results in her chart, asked why she hadn’t gotten a screening exam the previous year. When Kidwell said she had, the doctor investigated. Five hours later, the doctor called Kidwell to tell her she had found the results and it looked as though she had breast cancer.  The test results had been sent to an orthopedic surgeon at the medical center who had the same last name as Kidwell’s gynecologist. The folder had been sitting on his desk for a year, according to her gynecologist.  By that time her cancer had spread to her chest wall. Kidwell had a lumpectomy, chemotherapy and radiation. The following year, the cancer came back and Kidwell had a mastectomy. She filed a lawsuit and eventually settled the case. 

A recent study in the Journal of the American College of Radiology found that annual medical malpractice payouts for communication breakdowns, including failing to share test results, more than quadrupled nationally between 1991 and 2010, to $91 million. For patients, the missteps and mistakes can be life-altering. Patient follow-up could make a difference in many instances. The study examined medical malpractice claims from 425 hospitals and 52,000 providers.

Of the 306 cases in which test results were specifically cited as a factor in a malpractice case, the most common problem — it occurred almost half the time — was that the patient didn’t receive the test results, cited in 143 cases. The second-most-common problem was that the clinician didn’t receive the results, cited in 110 cases. Other problems included delays and slow turnaround in reporting findings and test results that were filed before the clinician reviewed them.


The nursing home industry has complained for years that understaffing was caused by the lack of available nurses.  It is a myth.  That’s the upshot of a study in the policy journal Health Affairs. The authors, economists from RAND Health and Dartmouth College and a nursing professor from Vanderbilt University, found a significant upswing in the number of young women (aged 23-26) choosing nursing as a career between 2002 and 2009.  Funding for nurse training programs tripled between 2001 and 2010, from $80 million per year to $240 million.

It will be the largest cohort of registered nurses ever observed.  In fact, the 62 percent increase means that the ranks of registered nurses are expected to grow at roughly the same rate as the population between now and 2030. One reason cited by the researchers are accelerated degree programs designed to appeal to people who already have degrees in other fields. These programs can get nurses trained and ready to practice in as little as a year in some cases.

In 2010, according to the study, 55,000 qualified applicants were turned away — up from 16,000 in 2003.


The West Virginia Gazette had an article about the history of poor care provided at Heartland of Charleston in West Virginia.  Federal authorities revoked its’ Medicare and Medicaid funding in September after inspectors cited the home for several serious violations after the corporate owner/operator failed to fix the deficiencies that state inspectors found in June.

"The violations listed in the initial 156-page inspection report ranged from administrators failing to keep notifications of procedures and nurse availability posted to more serious cases where one patient bled profusely from a pressure sore after nurse’s aides failed to check whether a blood-clotting test had been performed.  A supplemental report lists several instances where the home’s administrators failed to properly investigate allegations of staffers abusing patients, including one case where a patient had accused two nurse’s aides of beating him in a shower room."

Other deficiencies listed in the inspection report included:

A resident, labeled as a fall risk, was found face down on the floor six hours after she was admitted.  Nurse’s aides had placed a fall mat on one side of the woman’s bed.

One resident had an unnecessary catheter for more than two months, while two more residents were not given proper treatment after doctors had declared them incontinent. The inspector found that one of those residents had been sleeping on a bed with a large wet ring stretching across the bottom sheet. 

Some residents were taking medications they did not need. According to the report, nurses continued to give one resident "sliding scale" insulin doses despite a pharmacist’s recommendation to stop. The pharmacist noted that the resident’s blood sugars were in "excellent control, " and detailed the facility’s need to closely monitor the resident’s future insulin intake. Staff had not checked the resident’s hemoglobin levels in months, according to the report.

Nurses found one resident on the floor at least five times in two months. In January, the elderly patient fell twice in a span of about 12 hours. Staff labeled some of the falls as "attention-seeking behaviors," according to the inspector’s notes.

Inspectors found that the home’s medications were not properly labeled.

One resident lost seven pounds in three days because staff had failed to provide dietary supplements a doctor had prescribed.

A resident with a right hand muscle contracture (a permanent shortening of a muscle or joint) was not fitted with a device designed to help minimize the loss of range of motion. The resident’s care plan noted a need for the device in February — four months before the June inspection.

Nursing staff took 10 to 20 minutes to answer several residents’ call lights.

One nurse’s aide was fired after intentionally unplugging a resident’s call light.  Administrators did not report the incident to Adult Protective Services.

A resident known as No. 228 was neglected.  The inspector could see dried blood on a cut above the 76-year-old woman’s left eye, which was still swollen and bruised from a fall she had while trying to pick up a bag of birdseed at about 2:30 that morning.  The woman’s nursing notes revealed that she was admitted to the facility at 8:30 p.m. the previous evening. A doctor wrote on her admission form that she suffered from dementia and had a history of falling.

The fall earned her a trip to the emergency room, where doctors assessed, cleaned and repaired her head wound, according to the inspection report. She was back in her bed at Heartland by 6:30 a.m. with a doctor’s instructions for follow-up care.

Since 2006, federal authorities revoked Heartland’s Medicare and Medicaid funding three times and have fined the home a total of $232,375.  Toledo Ohio-based HCR Manor Care, Heartland’s overarching corporate owner, operates hundreds of nursing homes across the country and lists assets of more than $8 billion. The company, which itself falls under the ownership of equity giant Carlysle Group, has attracted criticism for reportedly hiring too few staff at low pay in order to maximize earnings.



ProPublica, in collaboration with PBS “Frontline” and NPR, took an in-depth look at the nation’s 2,300 coroner and medical examiner offices and found a deeply dysfunctional system that quite literally buries its mistakes.   ProPublica and PBS "Frontline" have identified more than three-dozen cases in which the alleged neglect, abuse or even murder of seniors eluded authorities. But for the intervention of whistleblowers, concerned relatives and others, the truth about these deaths might never have come to light.  Below are excerpts of the report:

When it comes to the elderly, the system errs by omission. If a senior like Shepter dies under suspicious circumstances, there’s no guarantee anyone will ever investigate. Catherine Hawes, a Texas A&M health-policy researcher who has studied elder abuse for the U.S. Department of Justice, described the issue as "a hidden national scandal."


Because of gaps in government data, it’s impossible to say how many suspicious cases have been written off as natural fatalities. However, the limited evidence available points to a significant problem: When investigators in one jurisdiction comprehensively reviewed deaths of older people, they discovered scores of cases in which elders suffered mistreatment.

An array of systemic flaws has led to case after case being overlooked:

•When treating physicians report that a death is natural, coroners and medical examiners almost never investigate. But doctors often get it wrong. In one 2008 study, nearly half the doctors surveyed failed to identify the correct cause of death for an elderly patient with a brain injury caused by a fall.
•In most states, doctors can fill out a death certificate without ever seeing the body. That explains how a Pennsylvania physician said her 83-year-old patient had died of natural causes when, in fact, he’d been beaten to death by an aide. The doctor never saw the 16-inch bruise that covered the man’s left side.
•Autopsies of seniors have become increasingly rare even as the population age 65 or older has grown. Between 1972 and 2007, a government analysis [2] found, the share of U.S. autopsies performed on seniors dropped from 37 percent to 17 percent.

In a 2008 study, 225 physicians were asked to determine what killed an elderly man who had fallen and suffered a severe head injury. Just over half of the doctors correctly identified bleeding of the brain as the primary cause of death. Nearly two-thirds didn’t list the fall as a contributing factor.Erroneous death certificates and faulty reporting practices are partially responsible for few senior deaths being investigated. But there’s another factor: Many coroners and medical examiners resist looking into these cases.

Of the 1.8 million seniors who died in 2008, post-mortem exams were performed on just 2 percent. The rate is even lower — less than 1 percent — for elders who passed away in nursing homes or care facilities.



87-year-old Susanna West became so hungry and thirsty after being left alone for more than 14 hours on a nursing home bus that she opened a first aid kit and ate the Tylenol and drank the hydrogen peroxide.  West was a resident of Hearthstone Assisted Living Facility.  She was finally found face down on the bus, soaked in urine.  She died a few weeks later.

The family filed a lawsuit in the name of West’s estate in 2010 against Texas-based Hearthstone. But the company never responded to requests for records and information.   The facility did not carry any insurance.  The owners sold the facility and walked away scot free.  Hearthstone defaulted because it failed to provide documents and because it had withdrawn its previous counsel and had not hired a substitute attorney.  Judge Christopher Yates approved a default judgment of  $1.65 million.