A Florida nursing home, Casa Mora Rehabilitation and Extended Care, will pay an $18,500 fine after neglecting a dying resident, and mishandling the resident’s death.  A nurse failed to administer life-saving attempts to a 58 year old woman who was unresponsive. The nurse thought the resident had requested not to be resuscitated, even though the woman wasn’t wearing a bracelet that identified DNR.

The resident’s daughter claimed that the facility hadn’t followed the necessary procedures to keep her mother alive.  The Florida Agency for Health Care Administration investigated her claim and agreed that the facility was negligent.  In addition to the fine, the facility will implement new procedures which will hopefully prevent incidents like these in the future.

See article at MySunCoast.

The Star-Tribune reported for the second time in less than a month, state officials have found evidence of neglect by a nursing home worker who failed to try to save a patient who was in distress and died.  In the latest case, a staffer at Benedictine Health Center did not administer cardiopulmonary resuscitation (CPR) after being called to the resident’s room by employees who saw the man, who could not talk, “blink and take a last deep breath,” according to the report released.

It was the second investigation made public recently where an overworked nursing home worker allowed a resident to die without trying resuscitation. Investigators found other problems in the employee’s actions in the Benedictine case. In addition to the failure to administer CPR, the neglectful staff member also failed to contact the man’s doctor about a earlier vomiting episode, as required for any change of condition.


The Star-Tribune had an interesting and scary article on a nurse who stopped giving CPR to a resident.  A registered nurse wrongly ordered a halt to CPR on a resident at Woodbury Health Care Center.  The resident was dead before emergency responders could take over. On arriving at the home they questioned why CPR was stopped.

The nurse, who was not identified in the report, had a history of disciplinary actions. "She is dead," the nurse told a fellow staff member soon after he began applying chest compressions on the resident according to a state Health Department report. The staffer kept up resuscitation efforts until the nurse repeated her command to stop by yelling at the staffer.

Clearly, this is a serious violation of a resident’s rights.  Residents have a right to any and all treatment that will prolong their life.

The nurse’s personnel file, included in the report, shows that she had been cited for needing to improve her job knowledge, professionalism and relationships with subordinates, residents and families. A doctor filed a formal complaint against her in 2007 for "improper conduct" and in 2009 she was disciplined for failing to follow wound-management protocol.

Until late last year, Woodbury Health Care Center was on the federal government’s list of about 200 nursing homes that get closer scrutiny, including semiannual inspections, because of a history of regulatory problems. Inspectors found 23 rule infractions in the home’s annual inspection in April 2008; that was down to the state average of nine a year later.

As a follow up to the recent posts on the great work the Star-Tribune did on their series on falls in Minnesota nursing homes, here is another article from the Star-Tribune about the tragic death of a resident caused by neglect and improper training.  The incident, described in a state report, sent state Health Department investigators to 122-bed Crest View, and has added fresh scrutiny to a facility already under special review because of past care infractions.

The call from the nursing home came at 5:30 a.m. on July 31: Your husband, admitted last night for a short rehab stay, has been found not breathing. By 7 a.m. the woman and other family members had gathered at Crest View Lutheran Home in Columbia Heights when they heard the sirens. The fire department rescue squad entered her husband’s room — two hours after he died — apparently called when the home’s day-shift supervisor started work.

The Health Department report gives this account:  The man, who is not identified in the document, was still warm, but not breathing and without a pulse, when the rehab unit manager found him.  The LPN and her nurse supervisor did not know that the man had orders for resuscitation, so they didn’t try to revive him. Even if they had known his "full code" status, the nurses did not know they were supposed to start CPR and call 911 even if no one witnessed his cardiac arrest — a point of staff confusion affecting that resident and potentially 14 others with "full code" orders. In addition, neither nurse had current CPR certification, neither had been briefed on emergency procedures and neither knew where to find the resuscitation kit — found during the inspection, but missing several pieces of equipment.

The home neglected the resident by not acting promptly to try to revive him, the department concluded, and was cited for three rule violations connected with the confusion, lack of action and lack of emergency training.

For the past nine months, the nonprofit Crest View has been one of four Minnesota nursing homes on a federal Special Focus Facilities list — about 156 homes nationally with exceptionally troubling rule violations.  Crest View was placed on the list March 2. During three inspections since January 2008, the home was cited for 58 violations. (The state average is nine infractions per inspection). Complaint investigations added four more citations, including those from the incident in July.


The L.A. Times reported that State officials have fined two nursing homes in Orange County for providing care so inadequate that it caused the deaths of two patients.

In one case, a woman died from dehydration.  This is clearly a preventable death.  The nursing home failed to give a resident sufficient fluids, causing her to suffer dehydration and acute kidney failure.   A doctor ordered that the patient’s fluid intake and urine output be monitored during every shift.  A review of the patient’s intake and output of fluids was blank or illegible.  The woman’s condition had deteriorated so much that she was transferred to a hospital, where she was diagnosed with a urinary tract infection, dehydration and an "altered mental status."  

The patient died six days later, on Christmas Day.  Alamitos West Health Care Center in Los Alamitos was fined $100,000

 In the other, staff failed to provide CPR to a man suffering a heart attack because they mistakenly believed he was under orders not to be resuscitated.  A registered nurse supervisor did not call 911 as a patient was dying "because she thought the patient had orders" not to be resuscitated. In fact, the patient’s medical record included an advance directive form from a family member on which was marked the option, "I DO WANT C.P.R." in an emergency situation.  A licensed vocational nurse called to inform a family member that the patient had died. The nurse told the family member that the patient was dead and that paramedics were not called because the facility had orders not to resuscitate the patient.  The family member told the nurse to hang up and call 911.  By the time paramedics arrived, they found the patient in bed with no heartbeat. He was covered with a sheet with no signs that CPR had been initiated.

State officials levied an $80,000 fine on the Huntington Valley Healthcare Center in Huntington Beach.


Lexington Herald-Leader had an article about nursing homes that caused at least 6 deaths due to their ignorance and negligence.  Incredible. State investigators have cited 4 nursing homes for failing to perform lifesaving measures on residents who had requested that they be resuscitated.

The errors alleged by the state provide ammunition for those who are pushing for a new law or regulation that would mean all nursing homes would use a purple wristband to identify residents who had signed a do not resuscitate — or DNR — order.

Kentucky has no uniform regulations regarding how to inform staff members of DNR orders at the bedside at nursing homes or hospitals.   Three different groups of nursing home and hospital officials are meeting in the next several weeks to determine whether Kentucky should join other states that have adopted a color-coded system.

Five of the six facilities sanctioned received Type A citations, the most serious the state can give. In all six cases, the individuals died.

■ Kenton Healthcare in Lexington was cited in September 2007 after the staff allegedly did not initiate lifesaving measures on a resident despite a doctor’s orders that everything possible be done to save the patient.

■ Hillcrest Health Care Center in Owensboro was cited in December 2008 after cardiovascular pulmonary resuscitation was not performed on a resident who wanted to be resuscitated.

■ In April 2007, staff members at Christian Health Center in Bowling Green did not immediately resuscitate a resident, despite a doctor’s orders that lifesaving measures should be used.

Staff members told state investigators that the facility did not have a system that allowed immediate access to the code status of a resident.

■ Woodland Oaks Nursing Home in Ashland is appealing a citation it received in January. Officials there deny failing to perform CPR on a dying patient who had requested lifesaving measures.

■ On the other end of the spectrum, Green Meadows Health Care in Mount Washington received a citation in March 2008 for trying to revive a resident who had signed a DNR order. Green Meadows officials did not return a telephone call seeking comment.

■ In March, Jefferson Manor in Louisville was cited after 95-year-old Eva Karem was resuscitated in February 2008 despite a DNR order. (It received a citation that was not as serious as a Type A.)

The Karem case prompted a series of meetings of lawmakers, nursing home officials and others who are looking at the use of wristbands.

"It is very important to accurately identify patients’ preferences regarding resuscitation, while also protecting their privacy, which is a factor we will be taking into careful consideration when making our decision," she said.

Defendant nursing homes in litigation often attempt to confuse the jury regarding DNR orders.  Nursing homes always claim that a DNR allows them to ignore and neglect residents because "the family signed the order and must have wanted him/her dead".  Ridiculous.


McKnight’s had an article about the increased use of advance directives.  Many of our clients feel pressured into signing these directives.  I believe it is a way for the nursing homes to avoid liability.  When the nursing home neglects a resident or fails to deliver timely care and the delay in treatment causes a wrongful death, the nursing home points to the advance directives as a way of explaining their negligence. most CNAs and LPNs do not understand the purpose of advance directives. They believe that advance directives allows them to ignore the condition of the residents and permits letting the resident suffer and die in cases where simple treatment could have avoided the death.

The article states that advance directive documentation is on the rise in the nation’s nursing homes, according to a recent report from the Institute for the Future of Aging Services, a research arm of the American Association of Homes and Services for the Aging.

Nearly 70% of all nursing home residents over the age of 65 have at least one advance directive document in their records. That is up from 53% in 1996, according to the report. The documents were more common for married, white and female residents.

Advance directives provide written documentation of a patient or resident’s end-of-life choices. "Both residents and families must continue to engage in the discussions needed to accurately document end-of-life choices," said Helaine Resnick, Ph.D., director of research at IFAS, adding that providers, as well, must continue to stress the importance of advance directives.

Santa Cruz Sentinel has an article about the tragedy that is all too common for many nursing home residents.  Nursing homes fail to train on what DNR status means, and far too often simple care is not provided that would save a resident’s life.  Below are excerpts from the article.

The Tragedy: On Sept. 11, 2007, a 71-year-old woman with cancer was transferred to Pacific Care Manor, a nursing home in Capitola. Just prior to her admission, the woman’s doctor noted that her patient was lucid and responsive and "could have years to live." Most importantly, the patient had also expressed a desire to live.

Shortly after her admission, the woman began refusing food, water and any treatment. Within two days, she was screaming and combative. On day three, the nursing staff suggested that lab work be ordered to determine the cause of the resident’s distress. The facility’s director of nursing overruled the suggestion because "once we know what is going on then we will have to treat her." Instead, the nursing director asked the facility doctor to prescribe pain medication and a "do not resuscitate" order. The doctor complied and, despite the woman’s documented opiate intolerance, he prescribed a Fentanyl patch, Haldol, morphine. He also wrote an order for "no CPR, no hospitalization." His patient cried out "you are all going to kill me" after the forcible administration of the prescribed medications. On Sept. 16, just five days after her admission, the resident died. 

All residents of nursing homes have the right to grant or withhold consent to any proposed treatment.  Residents have the right to refuse or consent to treatment and to receive all information relevant to making their treatment decisions. Providing such information is part of any responsible nursing home’s assessment and care planning process. Federal regulations also reaffirm residents’ rights to informed consent and to refuse treatment.

Regardless of a resident’s mental capacity, no facility may administer treatment unless the resident has agreed or has been specifically adjudicated incompetent by a state court judge. Even after a court has determined that a resident is incompetent, it must make additional findings before terminating a resident’s right to refuse treatment. Without a court order, the provision of any treatment over a resident’s express refusal is a violation of several residents rights and is criminal battery.

Similarly, doctors cannot order "Do Not Resuscitate" orders without the written authorization of their patients. For DNR orders, designated health care agents may sign for the patient. However, doctors may not unilaterally impose DNR orders without a resident or resident representative signature.

Nursing homes throughout California are accustomed to interposing their notions of a resident’s best interests over the expressed wishes of their residents. The Department of Public Health and resident advocates have been generally weak in preventing this illegal conduct. Hopefully, the tragedy in Capitola will serve as a warning to both facilities and advocates about the deadly consequences of disregarding residents’ critical rights to direct their own treatment.

Anthony Chicotel is an attorney for the California Advocates for Nursing Home Reform in San Francisco.