The Joliet Patch reported the preventable death of Sylvia Raucci at Fairview Care Center of Joliet nursing home.  The Cook County Record reports that Rosemarie Barry, administrator of the estate of Sylvia Raucci, filed a lawsuit against the facility, citing neglect and multiple violations of the Illinois Nursing Home Care Act.

According to the suit, Raucci was accepted into Fairview in August 2013. Her physician instructed the care center to turn Raucci every two hours and ordered a specific cream to be used on her to prevent her from getting bedsores. The chart indicates the care was never provided.  Two open sores were noted by the care center, but no documentation says they were ever treated.

The complaint states that Raucci was transferred to Presence Saint Joseph Medical Center with a Stage two pressure sore to her sacrum and a Stage four pressure sore to her coccyx causing hypotension and dehydration on Sept. 20, 2013.  Nine days later, Raucci died.  Fairview had a duty to ensure Raucci was properly cared for, and to prevent the development of bed sores.

The Indy Channel and Call 6 reported the tragic case of Tim Johnson. Navy Veteran Johnson died in a Columbus hospital Oct. 11, 2014, at the age of 43 as a result of sepsis and cardiac arrest after spending four years at the Seymour Crossing nursing home operated by American Senior Communities.  See Police investigating possible neglect at nursing home.  Tim Johnson battled rheumatoid arthritis and other health issues.

State inspection reports and police records obtained by Call 6 Investigates raise questions about whether the nursing home neglected Johnson.  Following the death of Johnson, the Indiana State Department of Health/federal Centers for Medicare & Medicaid Services (CMS) conducted an investigation and inspection at Seymour Crossing on November 3, 5 and 6, 2014.

The report shows on October 4, a staffer went to check on Johnson and found him lethargic, disoriented, whimpering and saying ‘please.’  Johnson ended up in the hospital with bed sores and wounds on his body.  The Intensive Care Unit nurse at the hospital noted Johnson was unkempt, unclean and had a very strong smell. “(The right arm dressing) was saturated and foul…smelled like it had been there a while and we were all wearing masks,” an ICU nurse told investigators. Johnson’s family took pictures of the wounds, too graphic to show, including one on his right arm so deep it went down to the bone and muscle.  Johnson developed an infection complication known as sepsis, went into cardiac arrest, and was taken off life support at the age of 43.

“You put your loved one in there and you expect them to be taken care of,” said Rebekah Klaus, Johnson’s sister.  Klaus tries to remember her brother, a Navy veteran, for how he lived, not how he died.  “He loved his daughter, he loved his family, he loved animals, he loved life in general,” said Klaus. “He couldn’t walk, that’s the reason he was at the Crossing,” said Klaus. “His knees wouldn’t go.”  “I have cried every single day for a year,” said Klaus. “I still look at those pictures. I still go out to that graveyard every day and it haunts me.”

The state/federal investigation found Seymour Crossing failed to provide necessary care and services, and noted a deficiency in “Provide Care/Services for Highest Well Being.”  Seymour Crossing paid $7,897.50 in fines in 2014, according to CMS, however the fines were not connected with the death of Tim Johnson. The fines were related to a prior inspection at Seymour Crossing that found four deficiencies including failing to maintain an odor free environment and failing to respect the dignity of patients.


McKnight’s reported that HSR: Health Services Research has found that one of the leading indicators of hospital readmission in nursing homes is the prevalence of pressure ulcers. HSR’s research found that quality measures like pressure ulcer rates could affect hospital readmission rates regardless of county. Nursing homes with long term residents with pressure sores were more likely to readmit residents to hospitals. The acuity of the residents also affected whether the facility had higher readmit rates. Other quality measures weren’t found to be good predictors of readmission. Overall, HSR found that the majority of reasons patients are readmitted to the hospital are for reasons beyond their control, including nursing home care. Pressure ulcer prevalence was found to be a good predictor of readmission. Readmission rates will affect skilled nursing facilities’ payments in 2018, according to a law passed last year.

NJ Online had a great article about protecting loved ones from elder abuse quoting esteemed nursing home advocate/attorney Saul Gruber.  Our senior citizens are the heart of the population, but are often times forgotten when placed into long-term care facilities.

“The nursing homes get to a point where they are trying to make money and the biggest expense is labor, so that’s where they make cuts,” Gruber said. “Understaffing is the biggest problem. The employees are OK, but they can only do so much. If they are told to feed eight people at each meal, but those eight turn into 14, it’s tough.”

Federal guidelines were first put into place in 1987, Gruber said.  “Everything was put on paper,” he said. “Everything they had to do to maintain patient care. They know what they’re supposed to do. The problem is they aren’t doing it.”

Signs of elder neglect or abuse

Bed sores – Pressure ulcers or bedsores occur when a patient is not being moved often enough and not being fed a proper diet, according to Gruber. “We see those a lot,” he said of neglect cases. “I call them rotting, smelly holes in someone’s back.”

FallsGruber said it is the staff’s responsibility to do whatever is necessary to prevent falls. “There are a lot of things they can do,” he said. “If they fall out of bed, be sure the bed is near the wall. Use rails. If person seems to fall at 3 a.m., maybe take them to the bathroom at 2:30 a.m. so they don’t have to get out of bed. They are supposed to try to prevent falls. Prevention is key.

Strange smells – Gruber suggests conducting a “smell test.” “Bad smells are a give-away for many different issues,” he said. “Even if it’s a very antiseptic feel and smell, it’s not really a home, and what is that smell covering up?”


Care assessments – When a patient is admitted to a long-term facility, staff members are required to perform a “care assessment.” “They should be assessed so the staff knows what they need, what problems they have, and how to care for them,” Gruber said. “These assessments need to be done all the time because patients change.” Care assessments look for a patient’s “red flags” – such hazards as falling due to instability, pressure ulcers due to lack of movement, choking, and malnutrition.

“Then they are supposed to make up a care plan – it’s not magic,” Gruber said. “What are they at high risk for? And here’s what to do to prevent these issues and care for the patient.”  Then, that plan must be utilized faithfully.

“If a care plan is put into place to prevent falling and the patient continues falling, the staff can’t just say ‘oh well.’ They have to do more,” he said.

Be familiar with the staff – Gruber said, once your family member is settled, get to know the staff members who will be caring for your loved one.

“When you put someone into a facility, you have to become friendly with the staff because they will tell you what’s happening,” he said.

Vary your visitation – If a patient is being neglected or abused, staff members may pay attention to when the the family comes in and be sure that the situation looks perfect.

“Go visit at different times of the day,” Gruber said. “Don’t always go at 3 p.m. and don’t tell them when you are coming, and just see what’s happening.”

Check online – Gruber said publishes reports on the performance of each of the approximately 300 nursing homes throughout the state.

“Each nursing home has to be inspected a minimum of once per year,” he said. “It’s called a survey. They pull random charts, and interview staff and families, to make sure doing what they are supposed to be doing.”  These reports can show you what areas a facility has had problems with.

“When picking, look online at reports,” Gruber said. “If you think you don’t like a nursing home, don’t go there. If you’re already there and think something is wrong, it probably is.”  Gruber said the most import aspect is being present.

“You’ve got to be there,” he said. “some families are afraid that if they raise trouble, then when they are not there, their loved one won’t be cared for properly. Let (staff) know you will know if they neglect the patient.”

He said one of the most difficult parts of his job is dealing with a family’s guilt.

“I’ve sat here with clients crying, saying, ‘Why did I put my mom there? I knew it was bad and now she’s dead,'” Gruber said.

Medicare Quality Improvement Organization Initiative may provide the magic balm of Gilead that nursing homes have been looking for. Pressure ulcers are a major problem in nursing homes, hospitals, and assisted living facilities. By using the Medicare Quality Improvement Organization Initiative, over 780 nursing homes achieved a 38% reduction in pressure ulcers and a 76% reduction in restraint use in three years. The protocol uses risk assessments and evidence-based training to help reduce pressure ulcers and restraint use. For more information, and a fact sheet on the project, read the full article here.

WSOCTV reported that the son of a 91 year old woman reached out to Channel 9, in Charlotte, North Carolina who was concerned about the lack of care his mother was receiving at Wilora Lake Healthcare Center.  Charlie Norwood, son of the 91 year old woman has filed multiple complaints with the North Carolina Department of Health and Human Services about the unfit conditions of the nursing home.

After her admission in 2011, Norwood’s mother developed a pressure ulcer on her heel.  The nursing home was negligent in their care, leading to doctors concerned about the potential loss of her foot.  Pressure ulcers are caused by not turning and repositioning people with limited mobility.  Also, a person’s ability to heal is related to receiving adequate nutrition especially protein.  With the proper care and nutrition, pressure ulcers will not develop or heal.  Neglecting to change bandages, give the proper wound care treatment to a patient, and not giving proper nutrition can lead to the worsening of a pressure ulcer and lead a patient to be in a situation like Norwood’s mother.

Norwood’s complaints finally were investigated in 2013.  Federal investigators found substance in Norwood’s allegations, citing the facilities failure to provide clean wound dressings on a pressure ulcer that had developed on Norwood’s mother’s buttocks.  Because her wounds continued to worsen and not heal, the Department of Human and Health Services investigated the nursing home again and found that Norwood’s mother developed another pressure ulcer, this one on her calf.  Channel 9 News attempted several times to contact Wilora Lakes, however, not response was given.

Nursing staff may turn residents less than every 2 hours if high-density foam mattresses and attentive reliable documentation are being used for pressure ulcer prevention, according to a recent controversial study.  “Data suggest that the combination of support surface, repositioning, and documentation were successful in preventing ulcers in the moderate- and high-risk groups,” the authors wrote.  Of course, if a resident has a pressure ulcer they need to be turned and repositioned at least every 2 hours in bed and every 1 hour while out of bed.

The study involved nearly 950 residents in U.S. and Canadian nursing homes. They were at moderate or high risk for pressure ulcers, based on the Braden Scale. All were given a high-density foam support surface and were turned at two, three or four hour intervals.  Powered surfaces such as alternating pressure air mattresses (APAMs) or low air-loss mattresses (LAL) were not studied. High density foam is commonly used for sofa cushions, benches, chairs and mattresses, and density reflects how much weight polyurethane foam can handle per cubic foot.

After three weeks, the incidence of pressure ulcers was the same for all three groups, the researchers found. This was surprising because the moderate-risk group was “significantly different” than the high-risk group with regard to eating and brief changes, the researchers noted. They also found that the overall pressure ulcer incidence was low (2%).

The role of documentation should not be overlooked, they noted. Consistent documentation might have reminded certified nursing assistants to elevate heels, work on toileting and continence, and engage in other preventive measures. The results also suggest that facilities should consider transitioning to high-density foam mattresses, the researchers stated.

The findings appear in the current issue of the Journal of the American Geriatrics Society.  See wound care expert Dr. Jeffrey Levine’s thoughts on the study at his website here.

Once again, Dr. Jeffrey Levine has written an informative article found on his website about the history of the debate regarding when a pressure ulcer was “avoidable v. unavoidable.”   Below is a copy of his article.

Some years ago while browsing in an antiquarian bookstore I opened a volume entitled Lectures on the Diseases of the Central Nervous System by Jean Martin Charcot published in 1877. Among the yellowed pages was an illustration of a necrotic sacral pressure ulcer, and my heart started pounding. I had come across one of the earliest descriptions of pressure ulcer pathogenesis. I excitedly purchased the book, and subsequently learned that I held in my hand the beginnings of the modern “avoidable-unavoidable” controversy on pressure ulcers and published my findings in two articles in the Journal of the American Geriatrics Society.

Dr. Charcot was one of the greatest physicians of the 19th Century, and described medical and neurologic syndromes that still bear his name. He worked in Paris where he headed the Salpêtrière, a chronic disease hospital that gained notoriety during the French Revolution when it was the site of an infamous massacre of French aristocrats. Charcot believed that pressure ulcers were an unavoidable result of damage to the brain or spinal cord because of “neurotrophic fibers” that connected the skin directly to the central nervous system. Charcot wrote:

“I have often been a witness to this fact, occurring among the aged persons in this hospital, and I have been many times able to satisfy myself that pressure on the spot occupied by the eruption did not here play an essential part.”

Charcot had an illustrious opponent by the name of Henri Brown-Sequard who tried to disprove Charcot’s neurotrophic theory of skin ulceration with experiments on small animals. In 1853 Brown-Sequard wrote:

“On guinea pigs, upon which the spinal cord was cut in the dorsal region, and on pigeons, upon which the spinal cord was destroyed from the fifth costal vertebra to its termination, I have found that no ulceration appeared when I took care to prevent any part of their bodies from being in a continued state of compression, and of washing them many times a day to remove the urine and feces…”

This was an amazing and unique time when two of the greatest minds in medicine were concerned about bedsore pathogenesis, but unfortunately pressure ulcers dropped off the medical map for over a century. It took the demographic change toward an aging society to revive the discussion on pressure ulcers and cause the medical profession to refocus on their importance. This demographic change was ushered in by improvements in public hygiene and medical advances that prolonged the human lifespan and allowed people to live longer with multiple comorbidities.

Today there is renewed controversy as to whether pressure ulcers are avoidable or unavoidable, particularly in the “pay for performance” era. Most authorities agree that pressure ulcers are a quality indicator, yet few will say that all pressure ulcers are avoidable. The expert consensus published by the National Pressure Ulcer Advisory Panel stated that “not all pressure ulcers are avoidable.” In 2010, the Centers for Medicare and Medicaid Services (CMS) enacted a “no-pay” policy for hospital acquired pressure ulcers on the assumption that pressure ulcers are reasonably preventable using currently available clinical practice guidelines.

Certainly there are medical factors that cause certain pressure ulcers to be unavoidable. Some believe that the key to unavoidability is in the process of dying, and you can read more about the Kennedy Terminal Ulcer and Skin Changes at Life’s End (SCALE). I believe that these arguments have validity, but there are also factors apart from the dying process that lead to unavoidable pressure ulceration including forced immobility, pre-existing illnesses, and hemodynamic factors that impact adversely on blood supply to skin and soft tissues.

Jean Martin Charcot was a visionary and pioneer in the medical field. He was one of the first to use photography in his medical work, and studied hysteria and hypnosis decades before the psychoanalytic era was ushered in by his student Sigmund Freud. He also started the controversy on avoidable and unavoidable pressure ulcers a century and a half before these wounds became commonplace in today’s medical practice.


KRISTV news of Corpus Christi, Texas reported that a family filed a lawsuit against La Hacienda Nursing Home after their father was not properly cared for after sustaining a knee injury. The family says the facility’s neglect caused the injury to become infected which resulted in the amputation of the leg. The family came to a settlement with the nursing home outside of court, but it seems that the facility’s issues do not end there.

Recent research on the nursing home determined that the Department of Aging and Disability Services filed a claim on the nursing home in recent months that lists several state violations.  It states that in the most recent inspection of the facility, the nursing home exceeded the allowable medication errors, which is five percent. The facility was also sited for not getting food from approved places and failed to store, prepare, and administer food in a safe and sanitary way. Lastly and most relevant to the recent settlement, the facility was sited for not having a program to keep infections from spreading. Perhaps that is why their father lost his leg.

Overall, this report scored the facility as a 50 out of 100 which is extremely low considering the average nursing homes that accept Medicaid and Medicare score an average of 66 out of 100. The nursing homes administrator, James Baker, defended the facility claiming that many of the violations were “minor” and had all been addressed with the exception of one. When asked about the low scores he claimed, “We work on that rating year long. We try and improve it everyday.” Obviously his facility’s efforts are not doing enough.

Dr. Jeffrey Levine is a well known and respected geriatric doctor who specializes the prevention and treatment of pressure ulcers.  He recently wrote an article on his blog about new research on hospital acquired pressure ulcers from the new study published in the Journal of the American Geriatrics Society.  Below are excerpts from Dr. Levine’s article.

The study sheds light on hospital acquired pressure ulcers (HAPU) with data on epidemiology, mortality, and patient characteristics. Its results are certain to fuel the debate on avoidability of pressure ulcers.

The majority of HAPU’s were located on the coccyx or sacrum (41%) followed by hip and buttocks (23%) and heels (23%). Several patient characteristics were associated with HAPU including age, obesity and use of corticosteroids. Associated diagnoses included cancer, congestive heart failure, emphysema, stroke, and diabetes mellitus. Patients with HAPU had higher in-hospital mortality, increased mortality within 30 days of discharge, and higher readmission rates within 30 days. Patients with HAPU had significantly longer hospital length of stay (11.6 ± 10.1 days) compared to those without (4.9 ± 5.2 days).

This study is valuable because it provides the first reliable national benchmark rate for HAPU occurrence. But is this rate of 4.5% acceptable for an outcome known to be associated with deficits in quality of care? In their discussion, the authors suggest that the rate “might be acceptable” because of prevention programs currently implemented in hospitals across America. Such a view would support the theory that pressure ulcers can develop independent of good care, supporting the “unavoidable” theory. However this research does not supply any supportive date for the assumption that HAPU developed in the presence of preventive measures.

It is not surprising that HAPU were associated with higher in-hospital and post-discharge mortality, and the authors carefully note that their data do not infer a causal relationship between pressure ulcers and death.  However, these findings might provide new support for the SCALE theory – or Skin Changes at Life’s End – which states that pressure ulcers might be an unavoidable consequence of impending death.

The study does not offer explanation for the wide geographic variation in hospital acquired pressure ulcer rates. Why is the HAPU rate in Pennsylvania nearly twice the rate in Wisconsin? The answers could include quality of prevention measures, quality of documentation, array of co-morbidities, or other population characteristics of hospitalized patients. It would be interesting to follow HAPU rates to determine the effect of CMS policy changes which deny payment to hospitals for new stage 3 and 4 pressure ulcers, a rule which which went into effect October 2010 — after the study period for this article. Hopefully these questions will be addressed in future research.

For further information, we encorage you to vist Dr. Levine’s blog which has many excellent articles on this issue.