What is going on in Wisconsin?  Nursing homes that receive Medicare and Medicaid are required by federal law to report all instances of alleged mistreatment, neglect or abuse, including injuries of unknown origin, to the state health department’s Division of Quality Assurance within 24 hours.  A recent investigation by the Wisconsin Center for Investigative Journalism found facilities do not get punished when they fail to comply with the legal requirement and report incidents.  Most of the time they don’t even investigate the incidents themselves.

Families of residents complain that facilities’ failure to report serious injuries or deaths related to abuse or neglect is not uncommon, and the state health department only learns about incidents after a family member files a complaint.  In some cases, nursing homes file internal reports after a resident injury or death, but do not report the incident to the state, in hopes to cover up the incident.

The number of complaints the state received about Wisconsin nursing homes and assisted living facilities rose from 1,684 in 2000 to 2,562 last year — an increase of more than 50 percent.  At the same time, the Wisconsin health department has cut its staff of full-time nursing home surveyors from 100 in 2002 to 64 in 2012 despite an aging baby-boomer population. A state report found that Wisconsin will have 1.3 million residents over 65 by 2030, compared to about 777,000 residents in 2010.

Meanwhile new laws to help nursing homes avoid accountability prevent juries from hearing about state investigation reports of nursing homes even in criminal cases which means that more neglect or abuse will go undetected and unpunished. Critics say the law removes a useful tool for ferreting out abuse and neglect, noting that attorneys cannot use state inspection reports to affirm allegations or impeach witnesses.

Representative Jon Richards, a Democrat from Milwaukee, says the new law is making it harder for families to win their cases in court. “The bill was passed, nominally, to produce job creation, but I don’t see how letting abusers off the hook creates a single job. That is a real problem.”



Articles at HaywardWI.com, GreenBayPressGazette, and Wisconsin in Watch.


An Ohio news station, NBC 4, reported that a local nursing supervisor have been found guilty of attempted neglect at a Woodsfield nursing home.  What the heck is “attempted” neglect?

Kathy Schwaben was employed at Monroe County Care Center when she neglected to assist an injured resident.  The resident was injured when she was a passenger in a MCCC van and the driver swerved recklessly, throwing the 81 year old out of her wheelchair.  An investigation discovered that the resident was not properly secured in her wheelchair at the time of the incident. There was no lap or shoulder restraint in use.  Instead ,she was crudely restrained by a bungee cord that was stretched across the arms of her chair. After the incident Schwaben failed to preform a physical assessment so the victim did not receive any immediate medical treatment following the incident. The elderly lady suffered several fractured bones as a result of the incident.

Schwaben was sentenced to a mere 10 day in jail that was suspended and only has to pay fines and court costs.  It is sad that the neglect of a family’s loved one is not taken more seriously and the punishment does not reflect the severity of the damage done.

Kansas City’s KCTV5 reported the lawsuit filed about the alleged crime and cover-up at Brandon Woods at Alvamar.  Predictably, Defendants say there is no merit to the lawsuit, but the allegations in a 32-page court document are detailed and disturbing.  The suit was filed by the family of Jean Allen who was living at Brandon Woods at Alvamar in hospice care with dementia and almost entirely immobile.

The report of a possible sexual assault by a nursing aide was upsetting to the family, but the outrage stems from how the facility responsible for Allen’s care handled that report.

"The lawsuit against the owners and staff says the daughter of Allen’s roommate called the head of nursing on Oct. 21, 2010.  "The telephone message starts out, ‘Something awful may have happened,’" said Skepnek.  Skepnek says the head of nursing, Sharon Mulqueen, did not contact Allen’s family, did not suspend the nursing aide, did not call police and did not send Allen to the hospital. The next day, he says, Mulqueen suspended the aide and sent Allen to Lawrence Memorial Hospital – not for a sexual assault exam, but for a routine Medicare exam."

The nursing home staff refused to file a police report until hospital staff threatened to do so themselves.  In the interim, the nursing home staff had bathed Allen and washed her clothes, destroying whatever DNA evidence might have been available.  As for Allen’s exam, the suit says a specialized sexual assault nurse reported cuts and scrapes that left her with "no doubt" that Allen had been sexually abused.


The Journal Sentinel of Milwaukee Wisconsin had a story about numerous advocates criticizing Wisconsin’s attempt to take away the right to a jury trial and cap noneconomic damages to an arbitrary limit and prevent punitive damages.

Family members of those residents abused and neglected oppose the caps.  One family member said "The idea that our lawmakers now want to shield nursing homes from full responsibility for their neglect is the worst kind of public policy at the worst of times."

 AARP, the Coalition of Wisconsin Aging Groups, Disability Rights Wisconsin, Alzheimer’s Association of SE Wisconsin, Mental Health of America of Wisconsin, the Wisconsin Alliance for Retired Americans, an affiliate of the AFL-CIO, and other advocacy groups also oppose the bill.

They opposed not only the caps on damages but also provisions that would shield the information in an incident report required by federal and state law whenever a resident is injured, preventing certain state reports from being used in court.

When a resident has been injured, he or she can sue for economic, noneconomic and punitive damages.  Economic damages, which are tied to lost earnings and medical expenses, can be relatively limited for residents in nursing home and assisted living centers.  f the injury results in death, adult children can sue for wrongful death. Those awards by state law are capped at $350,000 for adults.  The cap on punitive damages, designed to deter or punish a defendant, could be the most significant change.  The caps on noneconomic and punitive damages would limit plaintiff attorneys’ leverage in negotiating settlements because nursing homes and assisted living centers wouldn’t have to fear multimillion-dollar awards if the lawsuit went to trial.

Families can be compensated for funeral and out-of-pocket medical expenses. But awards for medical expenses stemming from the injury, such as hospital costs, typically reimburse Medicare, Medicaid and insurance companies.

Medicaid is fully reimbursed when a resident or his or her estate is awarded damages for negligent care. And the Coalition for Wisconsin Aging Groups estimates that Medicaid pays for 62% of all nursing home residents in Wisconsin.


The Denver Channel reported the police investigation into another suspicious incident at a nursing home. Police have launched a criminal investigation into an incident at an Adams County nursing home after a patient suffered deep lacerations to her face and a fractured eye socket.

"They said she was walking and fell into a wall," explained Kayla Gonzalez-Poblano while describing the injuries suffered by her 57-year old mother Angela Guerra.  Gonzalez-Poblano told 7NEWS that the Administrator of the Woodridge Park Nursing and Rehabilitation Center, Angela Aragon-Herrera, had told her, "[Guerra] ran at the wall, but two nurses were there to catch her… so she didn’t get any trauma to the head."  "Then that story completely changed to ‘no one was around but the maintenance man and that she was running full speed at the wall, hit the wall and fell down,’" said Gonzalez-Poblano.

Administrator Aragon-Herrera will not show the family the nursing home’s internal incident report created from the investigation by the nursing home which is required to be done pursuant to the rules and regulations of all nursing homes for any and all incidents at a nursing home.

Guerra has spent several days in the hospital with severe lacerations to her face, a fractured eye socket and may lose vision in her eye.  According to Gonzalez-Poblano, the social worker told them, "the surgeon says the wounds on her face do not match up to the story they are saying of her hitting a wall."

The Woodridge Park Nursing Home and Rehabilitation Center was the subject of a CALL7 Investigation in November which reported that Aragon-Herrera was under investigation after complaints that she was ordering patients medication be altered without a doctor’s approval.

The CALL7 Investigators also found the state Health Department had substantiated a series of complaints against Woodridge including, failure to provide adequate supervision of patients, insufficient food, and lack of proper sanitation procedures.

"The health department did come in and investigate and did find deficient practice with [administrators] not having enough supplies in the facility," said Kay, a former nurse manager at Woodridge who asked that we not reveal her last name. And the nurses said that when they called the corporate hot line to complain, Aragon-Herrera would intervene.

"This is literally what [Herrera] would say: ‘Every time you call that number, they call me. So please don’t call that number. If you have an issue, bring it to me.’ If you brought the issue to her, two weeks, three days, whatever the time frame was, you were gone," said Jennifer.

In November, A state ombudsman explained that Woodridge is not unique and in this current economy there are many nursing homes with similar or worse issues.



The Madison-St. Clair Record had an article about the recent lawsuit filed against The Lincoln Home Inc. and Weiss Management Group Inc..  The Lincoln Home is a long-term care facility in Belleville. Weiss Management is responsible for overseeing the day-to-day operations at the nursing home.

Lillie Avant accuses Defendants of breaking her leg multiple times and then failing to do anything about it.  Avant says the incident began the morning of May 31, when Lincoln Home staff members attempted to turn and reposition her onto her right side in bed. At least three employees allegedly heard loud popping sounds and saw Avant immediately grab her leg and cry out in pain during the move.  Avant says the popping was the sound made by her femur and knee fracturing as staff repositioned her. Despite the obvious signs of broken bones and her complaints of severe pain, Avant says no one notified her doctor or her legal representative about the incident.

Avant’s son arrived at Lincoln Home later that afternoon and saw his mother "moaning and groaning in pain." Avant’s daughter went to the nursing home about five hours later but found that her mother had still not received any medical care for her leg.

Avant says an order for x-rays on her hip and leg were received late that night. The next morning, the woman says she refused to go to her kidney dialysis treatment because she was in so much pain. Despite her continued complaints about pain in her leg, Lincoln Home staff allegedly gave her pain medication and noted she got "no relief" from them.

According to the complaint, Avant was transferred from Lincoln Home to Memorial Hospital the night of June 1 to be treated for multiple leg and knee fractures. On the same evening, a representative from Lincoln Home allegedly sent a representative to Avant’s hospital room to get her to sign a statement about the incident at a time when the patient was heavily medicated.

Avant accuses Lincoln Home and Weiss Management of more than 20 negligent acts and violations of the IIllinois Nursing Home Care Act. She is asking for more than $50,000 from both defendants.

Attorney Paul W. Johnson of Belleville is representing Avant. They demand a jury trial.


The Middletown Press in Connecticut reported that the Genesis Healthcare owned nursing home Bishops Corner Skilled & Nursing Rehabilitation where a patient with dementia rolled down a hill and died last week has a “below average” rating, according to information on Medicare.gov.  Both the state and the West Hartford Police Department are investigating the death of Percy Sumner, an 88-year-old patient who rolled down an embankment in front of the Bishops Corner nursing home.  According to http://www.medicare.gov, a one out of five star rating was given to the facility by health inspectors, or “much below average,” with a one rating being the worst score possible.

Overall, the Bishops Corner home has a two out of five rating, according to the site. Both the nursing staff and “quality measures,” information that is self-reported by nursing staff, received a four out of five star rating. An investigation conducted about four months ago said the Bishops Corner facility failed to ensure its facility is accident-free. The home scored a three out of four, with four being the highest level of harm, but the problem had been corrected by June 25, according to the report. The three rating means a patient actually was harmed by a problem indentified by inspectors, the website said.

West Hartford police said Sumner rolled 44 feet down a hill, through a picket fence and over a 3-foot wall before hitting his head on the concrete. Sumner was transported to St. Francis Hospital and later died from the head injury.

Earlier in the morning, the nursing home was placed on notice that Sumner was trying to leave the facility as he was seen trying to exit through the front door of the 130-bed facility.  He was brought back to his unit and put on a 15-minute check by staff.  Some time later, Sumner exited the building by himself, sounding the alarm.  None of the staff seem to have responsed and the incident occurred. When nurses saw what happened, they immediately called 911.

The News-Gazette had an article about the state investigation of an incident in which a female patient at Champaign County Nursing Home suffered an injury that went undetected (or covered up) and died several days later.  The incident has led to a chain reaction of investigations, reports and findings that have resulted in $50,000 in fines against the nursing home, the loss of some Medicare and Medicaid funding and the potential loss of all Medicare and Medicaid funding.

Two other visits to the nursing home by public health inspectors – one on April 2 and another on April 29 – found more problems at the facility. In the April 2 inspection, it was determined that the nursing home did not follow its own policy in handling an allegation lodged against an employee.

Also that day, the inspector determined that the nursing home staff "failed to provide appropriate treatment and services to maintain or improve abilities in toileting and transfers" for four residents.

The April 29 inspection found that nursing home staff failed to use proper equipment when transferring three patients. In the most serious case a 91-year-old patient suffering from dementia broke her hip after she stood up from her wheelchair and fell. The woman was supposed to have had a personal safety alarm on her wheelchair.

In the incident which set off the series of investigations, a patient identified only as R7 slipped out of a chair while in a lounge area, but apparently was caught by a certified nurse aide.

"CNA slid under (R7) and pulled her onto her lap … (R7) denied pain .. did not hit head … did not hit w/c (wheelchair) or w/c pedals. (R7) talking and laughing with staff … able to move arms and legs without a problem or pain … Body check done with no areas of redness noted," said a report identified as a "late entry," and dated Jan. 25. It is not clear whether the incident occurred that day or earlier. There was no other documentation of the fall before Jan. 25.

By Jan. 29, however, nurses noticed bruising on the woman’s right leg and right hand. A physician ordered the woman be taken to an unidentified hospital. There, an emergency department attendant said the woman’s "right leg has progressively increased in size with diffuse ecchymosis (bruising) … It does appear (R7) struck her head." There was an "incredible amount of blood lost in the leg," an emergency department physician said. It "took a lot of fluid and blood to fix (R7’s) anemia/shock which resulted in CHF (congestive heart failure)."

The woman died on Feb. 4. The Public Health investigation of the incident, dated Feb. 25, found the nursing home neglected to properly care for the patient in at least four ways:

– "By failing to implement existing policies on Falls, Lab and Diagnostic Test Results, Laboratory Testing, Orders for Anticoagulants, Anticoagulants and Change in Resident’s Condition or Status;"

– "By failing to notify the physician in a timely manner of high laboratory values, neglected to identify a fall, to notify the Physician/Nursing staff of the fall and implement post fall monitoring;"

– "By failing to assess and monitor significant bruising as a side effect of anticoagulant therapy and a fall;" and

– Neglecting "to notify the Physician of the significant bruising in a timely manner, but continued to administer anticoagulants to R7."

The nursing home has allegedly instituted changes in response to the public health findings. For example, training will include special attention to reporting falls. "An episode where a resident lost his or her balance and would have fallen were it not for staff intervention, is a fall. In other words, an intercepted fall is still a fall," said a memo.

And when employees are accused of mistreatment of residents, a memo says they "will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator or designee. Employees accused of possible mistreatment shall not complete the shift."


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.


Florida’s "right to know" constitutional amendment that allows patients to check records of medical mistakes by health care providers doesn’t apply to nursing homes according to the Florida Supreme Court.

The decision in Benjamin v. Tandem Healthcare, Inc. came in a lawsuit over the death of Marlene Gagnon, a nursing home resident who choked to death on food specifically served to her against her doctor’s orders.

The decision allows the nursing home to hide relevant and material information from her estate.  This includes the nursing homes nondisclosure of an incident report on Gagnon’s death.  The amendment itself says it covers "health care facilities" and "providers" as defined in general law.

The high court arbitrarily decided that state law doesn’t include nursing homes among health care facilities.  "They basically said nursing homes do not provide health care," said Jeffrey Fenster, a lawyer for Gagnon’s five children. "This strips constitutional rights from the elderly. … This is just an invitation to more elder abuse."

The amendment never was intended to apply to nursing homes because it refers to "patients" and people in nursing are considered "residents" under state law, said Tony Marshall , association senior vice president.

The amendment was put on the ballot through a petition drive sponsored by consumer advocates. It was one of three initiatives dealing with medical malpractice adopted in 2004, including one that bars doctors with three malpractice judgments from practicing. The third, promoted by the Florida Medical Association, limits how much lawyers can collect in fees.