ABC News had an article about new report released by the inspector general of the U.S. Department of Health and Human Services found that more than 80 percent of hospital errors go unreported by hospital employees.  Hospital incident reporting systems captured only an estimated 14 percent of the patient harm events experienced by Medicare beneficiaries. Hospitals investigated those reported events that they considered most likely to lead to quality and safety improvements and made few policy or practice changes as a result of reported events. Hospital administrators classified the remaining events (86 percent) as either events that staff did not perceive as reportable (61 percent) or as events that staff commonly report but did not report in this case (25 percent).   In order to be paid by Medicare, hospitals are required to track and analyze medical errors. But organizations that inspect hospitals loosely regulate hospital tracking records, the study said.

Also, many hospital employees may not recognize "what constitutes patient harm," or they may not realize that particular events harmed patients and should be reported, according to the report.

All of the hospitals  reviewed had incident reporting systems designed to capture events; hospital administrators we interviewed indicated that they rely heavily on the systems to identify problems. Hospital accreditors reported that they do not investigate event collection methods, such as incident reporting systems, unless evidence of a problem emerges through the survey process.

The report, which looked at data from hospitalized Medicare patients, also found that most hospitals where errors were reported rarely changed their policies and practices to prevent repeat errors.  The errors included overused or wrong medications, severe bedsores, hospital-based infections and even patient death.

The national report looked at nearly 300 adverse patient events acquired from medical records and traced the records back to its respective hospitals to see whether the hospitals had identified medical error. The report found very few hospitals did.

The study is one of many finding similar results. In April 2011, a study released in the journal Health Affairs found that one third of hospital visits will lead to hospital related injuries, and as many as 90 percent of hospital errors are missed by current surveillance systems.  Forty-four percent of the errors identified were preventable, Dorrill said.

But beyond staff education, family members and patients themselves should be educated too, said Ehrenclou, who authored the book, "Critical Conditions: The Essential Hospital Guide to Get Your Loved One Out Alive."

 

The Fresno Bee had a great article on the problem with nursing homes altering or falsifying records.  Falsifying nursing home charts is an epidemic. It is standard practice in the vast majority of nursing homes. Of course, the defense lawyers say everyone makes mistakes but the chart is a legal and medical document where accuracy is key to good care.  Medications and treatments are documented as being given when they are not. Inaccurate entries have masked serious conditions in some patients, who ultimately died after not receiving proper care,  The article has a few recent examples from California:

A 77-year-old Cameron Park woman, Johnnie Esco, died in 2008 after suffering a fecal impaction so severe her rectum had dilated to 10 centimeters, or about 4 inches. The condition, in which the stool hardens and backs up in the body, is common in elderly or bedridden people and is known to be fatal.  The woman’s chart reflected that she had been having bowel movements in the days before her death – an assertion that medical professionals later said would be extremely unlikely, given the severity of her condition.

A supervisor at a nursing home admitted under oath that she was ordered to alter the medical records of a 92-year-old patient, who died after developing massive, rotting bedsores at the facility.  In a recorded deposition for the lawsuit, the director of nursing at Rosewood Terrace testified that she had been ordered by the facility’s administrator – along with a corporate representative – to alter the medical records to indicate that Ritter had arrived at the facility with "softened heels.
The corporate representative told the nurse "to falsify the medical records because the current records did not ‘look good’ and he was worried about a lawsuit," according to court papers.  Numerous suspicious and "downright fraudulent" chart entries were found involving at least seven different employees.
A nursing home was fined only $2,500 by the state for falsifying a resident’s medical chart, which claimed that the patient was given physical therapy five days a week. At least 28 of those sessions were documented by nurse assistants who were not at work on those days.

 

 

A woman severely injured at a convalescent home discovered a string of false entries – several written by nonexistent nurses.

A nursing home was fined $800 for making 12 false entries in a patient’s medication record because none of the medications was available in the facility at that time, according to the state-issued citation. The woman missed multiple doses of four drugs used to treat high blood pressure and a psychiatric disorder.

"While regulators have dogged facilities for years over fraudulent Medicare documentation, the issue of bogus records is more than a money matter. In California and elsewhere, nursing homes have been caught altering entries and outright lying on residents’ medical charts – sometimes with disastrous human consequences, according to a Bee investigation."

Some nursing home administrators to re-create medical records to hide neglectful care.
"The idea that they chart things before they happen or make things up way after the fact if something hits the fan – those are things that we’re familiar with," said Mark Zahner, chief of prosecutions for the attorney general’s Bureau of Medi-Cal Fraud and Elder Abuse.
"And we see (this) with regularity." Suspicious or sloppy record-keeping is so common they encounter some aspect of it in virtually every case they investigate.  It is part of the culture.  It is part of the training.

A Bee review of nearly 150 falsification cases reveals that residents are the victims of records fraud in California nursing homes.  The most common patterns include:
Covering up bad outcomes. A patient dies or is injured, and the nursing home staff or administrators rewrite the records to minimize blame or liability.
• Fill-in-the-blank charting. Overworked or lazy staff members take massive shortcuts, filling out charts en masse, not knowing whether treatments took place or if the information is accurate.
• Missing medicines. Medications are checked off as being given, but investigators later find unopened boxes or discrepancies with pharmacy records.

Less common are accusations that staff falsify consent forms to sedate patients, or backdate forged documents agreeing to settle disputes through arbitration.  Attorneys on both sides agree that a medical chart is an integral aspect of patient care – a changing, living record of big events and small.  The chart follows a patient, sometimes for decades. Other providers rely on its accuracy to determine care or revise treatment. An accurate chart leads to quality care. An inaccurate one can cause serious harm and cover up the lack of care. 

Elder abuse experts agree that fraudulent charting can be traced to understaffing. Public documents reveal tales of chaotic shifts on which certified nurse assistants are scrambling to provide care.
The Bee found several falsification cases in which nursing staff continued filling in the "activities of daily living" on charts of patients who were already dead.  Another incident where a nursing supervisor documented that she performed a 35-minute treatment on the elderly man on the day he was hospitalized eight miles away.

Sylvia Saucedo, a retired housekeeper who had been recuperating from pneumonia at Mission Terrace Convalescent Hospital in Santa Barbara. Four days after being admitted in January 2009, she fell, suffering a permanent brain injury.  The attorneys said they suspected that the director of nursing had rewritten the assessment to say Saucedo was, in fact, at low or no risk of falling when she checked in. If so, that would potentially diminish the facility’s liability.
Shortly before trial, the attorneys said they suddenly realized that their copy of the director’s assessment did not have enough holes punched in the margin to fit in the original binder.
"It was such an ‘aha’ moment," said Moore. "We thought, ‘These records were never part of her chart.’ "

In 2004, the California attorney general’s office relied on hidden-camera footage in an Escondido nursing home to charge 12 employees with felony elder abuse. Ten of the workers also were accused of the misdemeanor offense of falsifying medical records.
A year later, though, an appeals court found the employees had been improperly charged because the regulations applied to the facility’s owners, not its workers.
 

 

Kentucky.com had an article about Lynwood C. Bauer, a nursing assistant charged with one count of reckless abuse of an adult in connection with the abuse of a patient at Britthaven Nursing Home in Pineville, according to Kentucky Attorney General Jack Conway’s office.

The criminal complaint alleges that Bauer recklessly inflicted physical pain and injury on a Britthaven resident while working as a certified nursing assistant at the facility.  The victim was a male resident paralyzed on the left side of his body from a stroke.  His treatment plan called for him to be moved with a mechanical lift by two staff people.

The nursing assistant, presumed to be Bauer, told investigators he moved the male resident from a chair to the bed without the lift or help from staff. The nursing assistant then left the resident sitting on the edge of the bed while he walked across the room. The assistant said he did not check the man’s treatment plan and did not know he was paralyzed.

When the resident fell from his bed, the nursing assistant told investigators, he put the man back to bed with no assistance from other staff. In addition to the man’s treatment plan, nursing home policy requires that after falls, residents be assessed by a RN for injuries before they are moved.

When other members of the nursing staff came into the room after the injury, they discovered that the resident had "raised" and "red painful areas" on the back of the head, and his left shoulder, rib cage, hip and knee, according to documents.

The resident was taken to a local hospital and then transferred to a Tennessee hospital where he later died.

 

NBC New York had the tragic and mysterious story about the investigation into and death of Adriana Neagoe.  Midway Nursing Home is facing a State investigation, and a lawsuit about how the 65-year-old resident could have dropped to the floor not once, but twice, the second time fatally.  Adriana Neagoe’s family had decided on Midway Nursing Home after she fainted in front of her church and was diagnosed with a brain tumor. Surgery to treat it left her paralyzed.  Neagoe’s family says surgery left her able to move only one arm. So it was a surprise when she was injured in the spring of 2008 and they say nursing home staff told them she’d toppled off a bed surrounded by guard rails.

"She cannot fall because she could not move. She was paralyzed," says the victim’s nephew Cristin Buiciuc. What does he say really happened? The Romanian immigrant had to be mechanically hoisted up for bathing and so bed sheets could be changed. "They drop her from like five feet. They drop her on her head. That’s what she told me before she died," says Buiciuc.

After she hit the floor that second time, Buiciuc, who is also executor of her estate, says he was determined never to bring her back to Midway Nursing Home. It was August 8, 2008. Adriana Neagoe died six days later, still at Elmhurst General Hospital where she’d been rushed for treatment of severe head injuries, of what her family says were complications from them.

After her death, relatives kept their concerns private for more than a year, until the nursing home thought it would be a good idea to send a final bill, for $51,749. "The policy is clearly ‘kill them and bill them,’ " says family attorney Kenneth M. Mollins, "they negligently kill this woman. They hurt her first, then they hurt her bad enough to kill her and it did kill her the second time, and then they’re billing her."

Now the family has sued to reverse that huge final bill and for punitive damages, which means Midway officials might be compelled to explain what happened in their care–under oath. There’s little doubt that Midway was required to be reported to the State–and were not.

State Health Department files show Midway has a record in recent years of 43 complaints and incidents for every 100 beds–almost double the statewide average.

Midway Executive Director Moshe Kalter and Administrator Burt Kohn declined repeated requests for response to the family’s allegations.

 

The family of a 69-year-old woman has filed a lawsuit against a Chicago nursing home for failing to protect her from being sexually assaulted by a 21-year-old mentally ill resident.  Maplewood Care’s administrator tried to cover up a rape by calling it consensual sex.  It is an example of how mixing frail senior citizens and younger mentally ill residents in nursing homes can lead to violence if facilities do not monitor potentially dangerous residents.

"The only possible reason that you would be in this situation is a profit motive," attorney for the family said. "You want more residents in your facility, but you’re unwilling to pay for the necessary elements to protect all the residents."

Christopher Shelton had been diagnosed with bipolar disorder with aggression when he was admitted to the nursing home in November.  Shelton, a convicted felon and a former resident of the Elgin facility, was readmitted to the nursing home without a proper review of his criminal history. Had the facility checked, it would have discovered Shelton had an outstanding arrest warrant on felony battery charges. The state report showed he had told the nursing home staff in December that he was sexually frustrated, but the facility failed to monitor him.

Shelton was missing at bed check, but no search was made or alarm sounded to alert residents and staff that a young, aggressive, sexually frustrated, convicted felon was prowling the halls of the nursing home. Later, a night shift nurse heard an elderly woman moaning and crying.  The nurse found Shelton in her bathroom, where he was calling 911 to report that someone was attacking the woman.  Paramedics and an emergency room doctor later examined the woman and noted signs of sexual trauma.  Doyle who was the Administrator at the facility downplayed the encounter as consensual sex in a report to the state and encouraged employees to lie about it to cover it up.

The state and federal governments only fined the nursing home $44,400 for violations related to the incident.

 

The Edmond Sun had a recent article about a 131 page investigative report that supports complaints against a nursing home in Oklahoma.  One of the complaints includes a lack of an effective system for investigating and reporting abuse and failure to consult with a resident’s physician when there was an injury.  The investigation was triggered by a Sept. 16, 2008, incident at Grace Living Center. On that day, a resident, Lester Pendergraft, allegedly sexually assaulted a 67-year-old resident.   Pendergraft has been charged with one count of rape by instrumentation.

A meager $10,000 penalty resulting from the investigation has been proposed by the Centers for Medicare and Medicaid Services. 

Documentation showed the victim’s daughter was notified at 8:45 a.m., 1 hour and 35 minutes after the incident occurred at 7:10 a.m. Edmond Police arrived shortly after they were notified, at about 9 a.m. The victim’s doctor was called between 8:15-8:25 a.m., shortly after he arrived at his office.

On Sept. 25, the detective assigned to the case said, “The facility did a poor job of protecting the evidence.” He said facility staff threw away evidence and washed the victim’s bed linens and clothing and Pendergraft’s clothing.   Why would the facility do that unless they were trying to cover up what happened?

According to the report, the facility’s staff should immediately notify the director of nurses and the doctor, get the resident out of harm’s way and assess the resident whenthere is an allegation of abuse or neglect.  “The resident was not assessed timely after the incident,” the report stated.

The detective said someone in charge said to another officer that he felt  “The situation was being blown out of proportion.”

Citizen advocate Wes Bledsoe, founder of A Perfect Cause, an advocacy organization for disability and elder rights, said when he read the report he was “deeply disturbed."  Bledsoe said what was most shocking was that the incident happened in the first place, that evidence was destroyed with either intent or by incompetence and that a staff member voiced concern about police blowing the situation out of proportion.  Furthermore, there were warning signs before the incident that Pendergraft posed a threat to residents. Pendergraft was entering rooms of residents without reason or explanation who could not call out for help.

According to the report, a certified nurse aide reported before the Sept. 16 incident that she observed Pendergraft touch another resident who was dependent on staff for assistance. The same day, Pendergraft was seen pulling up the shirt of still another resident who was dependent on staff for assistance.

 

Oregon Live.com 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."

 

Koco.com,  a news website from Oklahoma City, had an article about a resident being physically abused with video evidencing significant bruises.  The article states that the resident’s family is looking for answers after a woman was found covered in bruises while she was staying in a Norman nursing home.

The workers at the Whispering Pines Nursing Home said Carol Crow, 60, was injured when she fell but did not provide any details to support this conclusion.  The family doesn’t believe the injuries could come from a fall. The family is offering a reward for information because the Department of Human Service has refused to investigate.

"It was very traumatizing. She just cried the whole time," said Julie Glass, Carol’s daughter. "She had bruising all the way around her face, all the way completely down her chest and around her neck."

"Her story is that a man knocked her down, got on top of her and beat her unconscious," said Jack Crow.  The family said they took their story to DHS, which sent them a letter saying that it wouldn’t open a case because there was no indication of abuse.

The Crow family offered a $2,500 reward for information. They posted signs around Norman and in front of the nursing center. The sign posting led to a confrontation with Whispering Pines representatives.

"I’m angry at the fact that I don’t know what they’re covering up," said Glass. "The people that are left there have no one. They have no one to protect them."

Here is another article about a nursing home’s failure to prevent a resident from falling and then failing to intervene or inform the family. 

The family was never told that their 60-year-old mother had broken both legs in a fall and died of complications.  Eventually,  the family discovered the horrific details. Their mother, Linda Ober, had been dropped by staff at the nursing home where she lived and left to moan for help in her bed for five days.

Employees tried to cover up the injury by giving her pain medication and telling her that her memory of being dropped as they moved her out of her wheelchair was simply a bad dream.  The family is haunted by the thought that her mother spent her final hours wondering why her daughter didn’t come to see her. According to the suit, the resident  told hospital staff that they didn’t need to call her daughter, because nursing-home employees said they would. Cunningham, who lives a mile from the nursing home, said she was not told.

"I wasn’t there to hold her hand," said Cunningham, breaking into tears. "All I needed was a phone call."

Thomas D’Amore, the attorney representing Cunningham and her siblings, said Ober’s death was the result of having too few staff and not adequately training them to care for the center’s residents. According to the U.S. Department of Health and Human Services, a review of the Gateway nursing home about the time of Ober’s death found that the number of nurse-hours per resident was below the state average by 33 percent.

She was critically injured Oct. 29, 2006, when two employees dropped her after improperly wrapping a sling around her torso to move her from her wheelchair to her bed, according to the suit.   X-rays show Ober’s badly broken legs. In one X-ray, her femur is jutting away from its normal position by 45 degrees. According to a summary of a state investigation that D’Amore provided, staff who treated Ober at Mount Hood Medical Center said Ober’s pain was "off the scale" and that "you could feel the bones in her legs moving in your hands, and they were crunching."