Ring of Fire wrote an interesting article on one of the causes of neglect at nursing homes:  overworked and underpaid CNAs.   One of the causes of the ongoing scandals of elder abuse in nursing homes and assisted living facilities is the fact that the understaffed caregivers are physically, mentally, and financially struggling. Case in point – Nicole Jefferson, a certified nursing assistant. In a recent guest column she wrote for the Hartford Courant, she stated:

It’s hard, tough demanding work, but I love my job. I genuinely love taking care of people. . . . I have been a nursing home worker for three years and I make only $12.35 per hour. I spend all day taking care of other people’s family members and, at the end of the day, I can’t even provide for my own.

She points out that most nursing home employees wind up on public assistance – much like many employees of big-box stores and fast food chains.  Although nobody who works a full-time job should have to live in poverty, there is a difference: caregivers such as Ms. Jefferson must have training and education beyond high school. Even at a two-year community college, this comes at a cost, and usually involves incurring student loan debt.

Given that these people work such long hours, doing such difficult work for so little, it should not be surprising that elder care facilities have difficulty attracting competent, high-quality employees. As a result, it should come as no surprise that many nursing homes hire whomever they can get – and screening is often spotty, if done at all. Although forty-three states require background checks for prospective employees (there is no federal statute governing this), the Office of Inspector General of the federal Department of Health and Human Services found that over 90% had at least one employee with a prior criminal record. Forty-four percent of these were for property crimes, such as theft (disappearance of personal items and unexplained depletion of funds are a common problem at nursing homes). Sixteen percent were drug-related, while just over 13% involved crimes against persons, such as rape and assault.

Would higher wages and better working conditions make a difference?  Ms. Jefferson, who is among the nursing home employees currently lobbying the state of Connecticut for higher pay, seems to think so. She says: “a budget is a moral document…an expression of what a society values and thinks is important.”

Matt Schultz, an elder abuse attorney with Levin Papantonio, said: “society needs to place much more value on the health and well-being of our elders. We must be willing to pay to protect the mothers, fathers and grandparents who raised us, and make certain they receive the best care from workers who aren’t distracted by how they will pay next month’s bills and feed their own families.”

WoodTV reported the horrific accusations against caregiver, Tyler Malone, who is accused of throwing shoes and water at a 86-year-old patient, as well as threatening to sexually assault the victim with a stuffed animal.  Malone is charged with second-degree vulnerable adult abuse and stalking against a patient at the Lifehouse Crystal Springs Retirement Home — second-degree vulnerable adult abuse is a felony punishable by up to four years in prison. Stalking is a one year misdemeanor. His bond was set at $25,000, and he is being held at the Kent County Correctional Facility.

“We started to notice a lot of phone calls and complaints coming into us, telling us about some strange and weird stories like someone is throwing shoes at her and throwing water on her. And she’s crying and wants to get out of there so badly,” David said.  David is one of the victim’s sons. He said his mom was checked into the Lifehouse Crystal Springs Retirement home last year because she has Alzheimer’s.  The family was told by staff not to worry, that it was the disease talking.

Another staff member tells police she overheard Malone tell the victim he was “the doctor” and was going to sexually assault her. When the staff member walked into the room, the victim stated “don’t let the doctor hurt me.”  It was an employee David says that pulled his sister aside one day and told her they needed to believe their mother. David says he wishes they would have believed his mom sooner.

According to court records, Malone was a resident assistant at the home, and treated the 86-year-old patient. The victim’s family says that Malone threatened to sexually assault the victim with a stuffed animal. The victim’s family contacted police, saying Malone was harassing the victim by repeatedly calling her phone, throwing shoes and throwing water on her.

It was so bad the victim would frantically call her children in the middle of the night requesting that she be picked up and remove her from the home.  “We came over to visits and the room was just a cyclone, shoes thrown and glass and busted things all over. Lamps broken and she denied it all the time but before we checked her in she wasn’t doing that kind of stuff,” David explained.

Malone was fired from Lifehouse Crystal Springs Retirement Home and was later hired by American House Senior Living Communities.

The website NursingWorld had an article on the need for more RNs in nursing homes.  The American Nurses Association (ANA) joined with geriatric nursing and consumer advocacy organizations today to support a federal bill to improve the quality of care for nursing home residents by requiring around-the-clock staffing by a registered nurse (RN).

ANA, the Coalition of Geriatric Nursing Organizations and Consumer Voice advocated for passage of The Put a Registered Nurse in the Nursing Home bill (H.R. 952), sponsored by Rep. Jan Schakowsky (D-IL), at a Capitol Hill briefing for congressional staff. Spokespersons said the current RN on-duty requirement of eight hours per day is inadequate to ensure patient safety, the highest quality of care and maximum well-being for residents as the intensity and complexity of nursing home residents’ care needs continue to increase.

The advocacy groups are seeking to have an RN available to create and oversee the plan of care, coordinate with other health professionals and apply their expertise for all long-term care residents at all times. The presence of an RN is especially important to evaluate and treat residents recently discharged from a hospital or at risk for hospital re-admission – times that are crucial to the health of residents and potentially costly for the health care system.

Demand for placement slots and health care services, including coordination and supervision, in skilled nursing facilities and nursing homes are expected to grow significantly as the Medicare population expands. The number of individuals aging into Medicare is projected to increase from 3.3 million this year to 4 million per year in less than a decade, nearly a 20 percent annual increase. Total Medicare enrollment is projected to increase from 55.7 million this year to 81.8 million by 2030, a 47 percent growth rate.


A study led by Mark Neuman, MD, of the University of Pennsylvania’s Perelman School of Medicine’s Department of Anesthesiology and Critical Care has found that hip fractures, which occur more than 300,000 times per year among elderly adults in the United States, can result in a loss of independence and higher rates of death in older adults.

According to the study, which was conducted using data from Medicare claim files and the Nursing Home Minimum Data set reported to Medicare, these fractures are often caused by falls, osteoporosis, or a combination of both, and are more likely to occur in elderly individuals living in nursing homes rather than residents of elderly communities. Furthermore, the study found that fractures affecting residents of nursing homes often fare worse than fractures affecting residents of elderly communities, with more than 21,000 of the 60,000 patients with hip fractures dying within 180 days of their incident.

The researchers concluded that this is due to the fact that patients’ with fractured hips ability to perform daily living activities had declined across the board, and was only worsened by some patients’ severe cognitive impairments. According to the study, patients with cognitive impairments were 1.66 times more likely to die as a result of their fracture, and patients over 90 were less likely to survive the fracture than other patients. Patients who did not undergo an operation for hip repair fared similarly, as they were 1.48 times more likely to die or require total dependence on another for mobility than patients who did undergo a corrective operation.

The study, which was funded by the National Institute on Aging and published in the JAMA Internal Medicine, suggests that care planning should involve extra precautions for elderly people who have experienced hip fractures, with special consideration given to patients who are older than 90 with hip fractures, as well as preventative measures for patients with increased fall risks.  See full article here.

The New Yorker had an incredible article written by Dr. Atul Gawande about waste, fraud, and abuse in the health care industry.  This is a fantastic article written by a general surgeon talking about what really drives up medical care – low value and unnecessary care.  Surprisingly, he doesn’t blame “frivolous lawsuits” as many doctors reflexively argue (without any evidentiary basis).  He blames the structure of the industry and, in some cases, the providers themselves.

Dr. Gawande discusses a study of “low value care” provided to Medicare beneficiaries.  They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful. Their list included doing an EEG for an uncomplicated headache (EEGs are for diagnosing seizure disorders, not headaches), or doing a CT or MRI scan for low-back pain in patients without any signs of a neurological problem (studies consistently show that scanning such patients adds nothing except cost), or putting a coronary-artery stent in patients with stable cardiac disease (the likelihood of a heart attack or death after five years is unaffected by the stent). In just a single year, the researchers reported, twenty-five to forty-two per cent of Medicare patients received at least one of the twenty-six useless tests and treatments.

Could pointless medical care really be that widespread? Six years ago, I wrote an article for this magazine, titled “The Cost Conundrum,” which explored the problem of unnecessary care in McAllen, Texas, a community with some of the highest per-capita costs for Medicare in the nation. But was McAllen an anomaly or did it represent an emerging norm? In 2010, the Institute of Medicine issued a report stating that waste accounted for thirty per cent of health-care spending, or some seven hundred and fifty billion dollars a year, which was more than our nation’s entire budget for K-12 education. The report found that higher prices, administrative expenses, and fraud accounted for almost half of this waste. Bigger than any of those, however, was the amount spent on unnecessary health-care services. Now a far more detailed study confirmed that such waste was pervasive.

Virtually every family in the country, the research indicates, has been subject to overtesting and overtreatment in one form or another. The costs appear to take thousands of dollars out of the paychecks of every household each year. Researchers have come to refer to financial as well as physical “toxicities” of inappropriate care—including reduced spending on food, clothing, education, and shelter. Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.

One major problem is what economists call information asymmetry. In 1963, Kenneth Arrow, who went on to win the Nobel Prize in Economics, demonstrated the severe disadvantages that buyers have when they know less about a good than the seller does. His prime example was health care. Doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting. Doctors, therefore, are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.

Another powerful force toward unnecessary care emerged years after Arrow’s paper: the phenomenon of overtesting, which is a by-product of all the new technologies we have for peering into the human body. It has been hard for patients and doctors to recognize that tests and scans can be harmful.  Excessive testing is a problem for a number of reasons. For one thing, some diagnostic studies are harmful in themselves—we’re doing so many CT scans and other forms of imaging that rely on radiation that they are believed to be increasing the population’s cancer rates. These direct risks are often greater than we account for.

Overtesting has also created a new, unanticipated problem: overdiagnosis. This isn’t misdiagnosis—the erroneous diagnosis of a disease. This is the correct diagnosis of a disease that is never going to bother you in your lifetime. We’ve long assumed that if we screen a healthy population for diseases like cancer or coronary-artery disease, and catch those diseases early, we’ll be able to treat them before they get dangerously advanced, and save lives in large numbers. But it hasn’t turned out that way. For instance, cancer screening with mammography, ultrasound, and blood testing has dramatically increased the detection of breast, thyroid, and prostate cancer during the past quarter century. We’re treating hundreds of thousands more people each year for these diseases than we ever have. Yet only a tiny reduction in death, if any, has resulted.

H. Gilbert Welch, a Dartmouth Medical School professor, is an expert on overdiagnosis, and in his excellent new book, “Less Medicine, More Health,” he explains the phenomenon this way: we’ve assumed, he says, that cancers are all like rabbits that you want to catch before they escape the barnyard pen. But some are more like birds—the most aggressive cancers have already taken flight before you can discover them, which is why some people still die from cancer, despite early detection. And lots are more like turtles. They aren’t going anywhere. Removing them won’t make any difference.

The forces that have led to a global epidemic of overtesting, overdiagnosis, and overtreatment are easy to grasp. Doctors get paid for doing more, not less. We’re more afraid of doing too little than of doing too much. And patients often feel the same way. They’re likely to be grateful for the extra test done in the name of “being thorough”—and then for the procedure to address what’s found.

Walmart wasn’t providing this benefit out of the goodness of its corporate heart, of course. It was hoping that employees would get better surgical results, sure, but also that the company would save money. Spine, heart, and transplant procedures are among the most expensive in medicine, running from tens of thousands to hundreds of thousands of dollars. Nationwide, we spend more money on spinal fusions, for instance, than on any other operation—thirteen billion dollars in 2011. And if there are complications the costs of the procedure go up further. The medical and disability costs can be enormous, especially if an employee is left permanently unable to return to work. These six centers had notably low complication rates and provided Walmart a fixed, package price.

Two years into the program, an unexpected pattern is emerging: the biggest savings and improvements in care are coming from avoiding procedures that shouldn’t be done in the first place. Before the participating hospitals operate, their doctors conduct their own evaluation. And, according to Sally Welborn, the senior vice-president for benefits at Walmart, those doctors are finding that around thirty per cent of the spinal procedures that employees were told they needed are inappropriate. Dr. Charles Nussbaum, until recently the head of neurosurgery at Virginia Mason Medical Center, confirmed that large numbers of the patients sent to his hospital for spine surgery do not meet its criteria.

Michael Taylor was one of those patients. Disk disease like the kind seen on his MRI is exceedingly common. Studies of adults with no back pain find that half or more have degenerative disk disease on imaging. Disk disease is a turtle—an abnormality that generally causes no harm. It’s different when a diseased disk compresses the spinal cord or nerve root enough to cause specific symptoms, such as pain or weakness along the affected nerve’s territory, typically the leg or the arm. In those situations, surgery is proved to be more effective than nonsurgical treatment. For someone without such symptoms, though, there is no evidence that surgery helps to reduce pain or to prevent problems. One study found that between 1997 and 2005 national health-care expenditures for back-pain patients increased by nearly two-thirds, yet population surveys revealed no improvement in the level of back pain reported by patients.

There are gray-zone cases, but Taylor’s case was straightforward. Nussbaum said that Taylor’s MRI showed no disk abnormality compressing his spinal cord or nerve root. He had no new leg or foot weakness. His pain went down both legs and not past the knee, which didn’t fit with disk disease. The symptoms were consistent with muscle spasms or chronic nerve sensitivity resulting from his previous injuries. Fusing Taylor’s spine—locking two vertebrae together with bolts and screws—wouldn’t fix these problems. At best, it would stop him from bending where it hurt, but that was like wiring a person’s jaw shut because his tooth hurts when he chews. Fusing the spine also increases the load on the disks above and below the level of fusion, making future back problems significantly more likely. And that’s if things go well. Nussbaum recommended against the surgery.

Six years ago, in “The Cost Conundrum,” I compared McAllen with another Texas border town, El Paso. They had the same demographics—the same levels of severe poverty, poor health, illegal immigration—but El Paso had half the per-capita Medicare costs and the same or better results. The difference was that McAllen’s doctors were ordering more of almost everything—diagnostic testing, hospital admissions, procedures. Medicare patients in McAllen received forty per cent more surgery, almost twice as many bladder scopes and heart studies, and two to three times as many pacemakers, cardiac bypass operations, carotid endarterectomies, and coronary stents. Per-capita spending on home-health services was five times higher than in El Paso and more than half of what many American communities spent on all health care. The amount of unnecessary care appeared to be huge.

What explained this? Our piecework payment system—rewarding doctors for the quantity of care provided, regardless of the results—was a key factor. The system gives ample reward for overtreatment and no reward for eliminating it. But these inducements applied everywhere. Why did McAllen succumb to them more than other medical communities did? Doctors there described a profit-maximizing medical culture. Specialists not only made money from the services they provided; many also owned stakes in home-health-care agencies, surgery and imaging centers, and the local for-profit hospital, which brought them even bigger returns from health-care overuse.

The test of health-care reform, I wrote, was whether McAllen or El Paso would become the new norm. Would McAllen’s costs come down or El Paso’s go up? Now that it has been five years since the passage of the Affordable Care Act, I thought I’d find out. I returned to the economist Jonathan Skinner, of the Dartmouth Institute for Health Policy and Clinical Practice, who had provided the earlier analysis of the Medicare data, and worked with him to get a sense of what recent data reveal. As it turns out, the cost of a Medicare patient has flattened across the country, El Paso included. U.S. health-care inflation is the lowest it has been in more than fifty years. Most startling of all, McAllen has been changing its ways. Between 2009 and 2012, its costs dropped almost three thousand dollars per Medicare recipient. Skinner projects the total savings to taxpayers to have reached almost half a billion dollars by the end of 2014. The hope of reform had been to simply “bend the curve.” This was savings on an unprecedented scale.

The passage of the Affordable Care Act, in 2010, created opportunities for physicians to practice this kind of dedicated care. The law allows any group of physicians with five thousand or more Medicare patients to contract directly with the government as an “accountable-care organization,” and to receive up to sixty per cent of any savings they produce. In McAllen, two primary-care groups, with a total of nearly thirteen thousand patients, formed to take advantage of the deal. One, as it happens, was led by Jose Peña, the Doctors Hospital at Renaissance internist. Two years later, Medicare reported that Peña’s team had markedly improved control of its patients’ diabetes; patients also had dramatically lower emergency-room visits and hospital admissions. And the two McAllen accountable-care organizations together managed to save Medicare a total of twenty-six million dollars. About sixty per cent of that went back to the groups. It wasn’t all profit—achieving the results had meant installing expensive data-tracking systems and hiring extra staff. But even after overhead doctors in one group took home almost eight hundred thousand dollars each (some of which they shared with their mid-level staff). It was proving to be a very attractive way to practice.

The medical system had done what it so often does: performed tests, unnecessarily, to reveal problems that aren’t quite problems to then be fixed, unnecessarily, at great expense and no little risk. Meanwhile, we avoid taking adequate care of the biggest problems that people face—problems like diabetes, high blood pressure, or any number of less technologically intensive conditions. An entire health-care system has been devoted to this game. Yet we’re finally seeing evidence that the system can change—even in the most expensive places for health care in the country. ♦

Healthcare workers frequently contaminate their gloves and gowns during every day care of nursing homes residents with drug resistant Staphylococcus aureus or MRSA, according to a new study published online in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America.

“We know that healthcare workers serve as a vector for MRSA transmission from one resident to another in settings such as nursing homes,” said Mary-Claire Roghmann, M.D., lead author of the study. “The use of barrier precautions, such as gowns and gloves, limit this transmission, but guidance on when to use them is limited. The goal of our research was to determine the most important times to wear gowns and gloves in nursing homes by measuring the risk of MRSA contamination during different types of care.”

High-risk activities linked to glove or gown contamination included dressing residents, transferring residents, providing hygiene such as brushing teeth or combing hair, and changing linens and diapers. Healthcare workers do not wear gowns during much of this care because they don’t anticipate that their clothing will come into contact with body secretions during this care.

“This research is particularly important since residents in these communities require a lot of assistance from their healthcare workers. New MRSA acquisition in nursing homes is substantial. Our study, for the first time, defines the type of care that increases the risk of transmission and suggests modifications to the current indications of gown and glove use,” said Roghmann.

Californai Advocates for Nursing Home Reform published an article about a money making scheme by the nursing home industry to evict Medicaid resident to make more money off of Medicare and hospice residents.  Nursing homes throughout the country are rapidly adopting a “new” business model: attract lucrative short term patients paying through Medicare, and then throw them out once their Medicare coverage ends.

People are often admitted to nursing homes to recuperate after a hospital stay, and typically have up to 100 days of rehabilitative services covered by Medicare, which pays a generous rate compared to Medicaid. If a person needs to stay in a nursing home for long term care after their rehabilitation days have run out, their Medicare coverage will end and they will need to switch to another payment source.

As a business practice, nursing home owners will often market their facilities as “short term stay” or “rehab centers” to attract lucrative Medicare patients. They will spread the fiction that they have limited or no “long term care beds” (i.e. Medicaid beds), and then aggressively discharge residents — denying them care when they have nowhere else to turn — once their Medicare-funded days are over. Some facilities will even include illegal notices in their admissions agreements requiring residents to acknowledge the limited availability of long term care beds in their facility. These practices are completely illegal, driven by profit at the expense of patient care.

In reality:

FACT 1: There is no such thing as a “short-term” or “rehab” skilled nursing facility. In order to be licensed as a nursing home a facility must provide long term care.

FACT 2: A facility cannot have a limited number of “Medicaid beds.” Any nursing home that is Medicaid certified must make every single bed in the facility available for patients paying through Medicaid.

FACT 3: You do not have to leave a nursing facility just because your Medicare days are over! In fact, the facility must allow you to stay so long as you need skilled nursing care and those services are paid for.

FACT 4: In Medicaid certified facilities, residents on Medicare have a right to transition to Medicaid if they are eligible. If you apply to Medicaid, you cannot be evicted for nonpayment while your application is pending. If you are in a shared room, you even have the right to remain in the same bed and not be moved to another room. It is illegal to discriminate against residents who are on Medicaid.

So, if a nursing home is pressuring you to leave voluntarily when your Medicare days are up, simply don’t go. Tell them that no discharge can be performed without following all of the notice and other legal requirements and that changing payment source is not a sufficient legal reason for discharge. See CANHR’s fact sheet on Transfer and Discharge Rights.

Don’t let the nursing homes endanger your loved one because they’ve decided that compassion is just not profitable.


WLOS reported that a family has filed a complaint of elder abuse against staff at Blue Ridge Retirement Center in Hendersonville.  Vietnam veteran Robert Barnwell has been a resident at the facility for years.  Barnwell’s son William said he filed a formal complaint with Hendersonville Police, after his father called him and asked to be taken to the hospital. William says when he arrived to pick his father up, the Army veteran had big knots from rheumatoid arthritis on either side of his neck that staff had apparently failed to notice or treat.  His father says his medicines are always delivered late, several staff members verbally abuse residents, and the manager of the center has refused to take him to the VA Medical Center for treatment, telling him it’s too far away.

The latest DHHS inspection of the nursing home from last spring reveals that multiple residents told investigatiors that staff were verbally abusive. Patients reported that two specific staff members repeatedly said things that made them feel hurt, embarassed or insulted.

The Barnwell family says they are considering hiring a lawyer and taking legal action against the nursing home.

Crystal Marie Leyhue, a healthcare worker in Fulton County has been indicted on an assault charge for allegedly putting a hot pepper in an elderly person’s mouth. The indictment stems from Leyhue putting a hot pepper in residents’ mouths while laughing and videotaping  their reaction. Another employee at the facility says they saw what happened and reported it to her superiors.  A press release from Attorney General Jack Conway’s office states Leyhue was a caregiver at the Haws Memorial Nursing and Rehabilitation Center.   Leyhue was then fired and now faces a 4th degree assault charge.


NWItimes reported that multiple agencies are investigating the death of Ivan Jovanovic, a Burnham nursing home resident, found with latex gloves shoved down his throat and a toothbrush and eyeglasses crammed up his rectum, investigators said.  Jovanovic was pronounced dead at Franciscan St. Margaret Health hospital in Hammond, the Lake County coroner’s office said.

He choked to death after cramming two pairs of medical gloves down his throat at the nursing home. It is unknown if he was under supervision but it is apparent he was not supervised as he needed.  Medics were called at 7:40 a.m. Thursday to BRIA Health Services of River Oaks, 14500 S. Manistee, for a report of an unresponsive suspect in the dining room, Belos said.