In an article from the Charleston Regional Business Journal, South Carolina’s medical disciplinary actions are compared with the rest of the nation. The Journal finds that SC’s disciplinary actions for medical professionals are the lowest in the nation.  SC has been the most lenient on disciplinary actions for medical professionals.  Whatever the reason, the fact remains that SC is the easiest state on medical professionals who have committed serious offenses requiring disciplinary action. Sometimes, less isn’t always more. Sometimes it’s just less, and it’s unsatisfying and unjust. Below is a good example of why the system needs to change.

Dr. Steven A. Matzinger first started using cocaine in 2006. From then on, he continued to use the drug until 2007 when he checked himself into rehab. He continued to see patients throughout his drug use, and he even saw patients during his stint at rehab.  Dr. Matzinger had several malpractice lawsuits brought against him from procedures during this time. He was also accused in a harassment case with a former employee.

The SC Board of Medical Examiners investigated Dr. Matzinger. They found out about his cocaine use and the multiple medical malpractice lawsuits. The Board gave him a fine of only $5,000, required him to stay in a program for recovering professionals, and suspended his license. However, the Board stayed the suspension when he paid the fine and administrative costs. Dr. Matzinger now works in Myrtle Beach, where he has been the recipient of another medical malpractice lawsuit.

ProPublica investigated why so many people do not report medical errors.  “Many of the people who suffer harm while undergoing medical care do not file formal complaints with regulators. The reasons are numerous: They’re often traumatized, disabled, unaware they’ve been a victim of a medical error or don’t understand the bureaucracy.

It’s a collective problem because patient safety flaws that remain hidden, if they are not corrected, may be repeated.  Propublica has collected a staggering number of people harmed while undergoing medical treatment.  “A review of medical records by the U.S. Health and Human Services Department’s inspector general found that in a single month one in seven Medicare patients was harmed in the hospital, or roughly 134,000 people.  “An estimated 1.5 percent of Medicare beneficiaries experienced an event that contributed to their deaths,” the IG found, “which projects to 15,000 patients in a single month.”

A July report by the HHS inspector general’s office found that only 12 percent of harmful events identified by the office even met state requirements for reporting them. Compounding the problem: Hospitals themselves only reported 1 percent of the harmful events.

 

The website MedicalXpress had an article discussing the new study called, "Nurses’ Perceptions of Error Reporting and Disclosure in Nursing Homes," published in the January 2012 issue of the Journal of Nursing Care Quality.   The majority of registered nurses who responded said error disclosures are difficult to process in nursing homes.   In NHs, nurses more routinely interact with patients with complex needs, which in turn increases the chance of errors occurring. Nursing errors refer to a nurse’s action that adversely affected, or could have adversely affected, a patient’s safety, quality of care, or both. Examples of nursing errors include lack of prevention (eg, breach of infection control precautions), inappropriate judgment or attentiveness, misinterpreting a physician’s order, or documentation errors.

NYUCN Assistant Professor of Nursing, Laura M. Wagner, PhD, RN, GNP-BC said  "Our research highlights the need for nursing homes to improve communication processes and policies, ultimately rendering a culture of safety in nursing homes."  The authors found that multiple barriers exist that might inhibit disclosure; almost one-third of the respondents were less likely to disclose if they believed they might be sued or reprimanded.

"Although there is increasing attention to disclosing harmful events, there is a significant gap between what is expected and what actually occurs in current practice. The process of disclosing is an ethical and legal obligation that provides essential information to patients and families."

The cover up is always worse than the initial mistake made by the caregiver.
 

KansasCity.com had an article reporting the guilty plea of one of two women accused of physically and sexually humiliating nursing home residents for months in Albert Lea, Minn., to three of the charges against her in a case that has heightened attention to how aides are chosen and supervised.  Brianna Broitzman was an aide at Good Samaritan, the nursing home that was the focus of state investigations and widespread publicity about the case in early 2008.  Her guilty plea covers gross-misdemeanor disorderly conduct involving three victims.

The charges against Broitzman said she admitted to police that she poked one resident in the breast. The teens who were implicated accused Broitzman of numerous other actions, including spitting in a resident’s mouth, jabbing the breasts of several residents and putting "her bare butt" on a resident’s face.

According to the complaint against Larson, she admitted to police that she inserted her finger into the rectum of a resident. She said she was trying to trigger a bowel movement but acknowledged that this was not part of her training. The complaint said she also acknowledged getting into bed with a resident and making a humping motion, patting the buttocks of one resident and trying to get another angry and then laughing at her.

The allegations became public in August 2008, when state Health Department inspectors concluded that aides, to make their work "fun," had abused 15 residents suffering from Alzheimer’s and other forms of dementia. The state said some of the residents were combative, easily agitated or blind.

Six aides, high school friends at the time, were charged – Broitzman and Ashton Larson as adults and the four others as juveniles who were found responsible for not reporting the abuse as required by state law. The women were accused of abusing seven residents who suffered from dementia.

Sexual abuse cases in nursing homes during the 1980s and ’90s led to laws requiring reports of suspected abuse and criminal background checks of those who work with vulnerable adults.

Broitzman will be sentenced in Freeborn County District Court on Oct. 22.  A presentence investigation recommends that Broitzman spend up to a year in jail, pay a $3,000 fine or spend two years on probation.

The case against Larson, 20, another former aide at the Good Samaritan nursing home, is proceeding toward trial. Broitzman and Larson were charged with fifth-degree assault, abuse of a vulnerable adult by a caregiver, abuse of a vulnerable adult with sexual contact, disorderly conduct and failing to report suspected maltreatment. All are gross misdemeanors.

 

 

News Channel 36 in Concord, North Carolina had a tragic story of a resident  who fell to her death at a nursing home.  State inspectors have launched an investigation at the Concord nursing home.

The 87-year-old woman was found with a massive head injury on the ground beside an outside loading dock.   The article mentions that a fence near the loading dock is brand new, clearly installed after the patient at Concords Five Oaks Manor Nursing Home was found on the ground.  She’d fallen 4 feet to the ground, hit her head and died after being rushed to the emergency room.

The nursing home administrator did not report the woman’s fall or death to the state.  A state spokesman says someone else reported it to them. Concord police told News Channel 36 the same thing.

Just last week Medicare ranked Five Oaks among the worst nursing homes in the country with just one out of five stars. Two state inspections from this year showed deficiencies. One cites accident and supervision problems, with one example where a patient "was on the floor" and staff had to be "disciplined."   Another said a patient was "outside the building."

 Channel 36 had a follow up to this story here.  In the follow up article, the family expressed concern that someone else could die there. The family says she had gotten out of the facility before.

Her daughter, Rosemary Ritchie, said she is worried about other patients at Five Oaks Manor. Doctors told her that her 87-year-old mother was brain dead because of a fall that the nursing home could have prevented.

She says her mom somehow got through a kitchen door that didn’t have an alarm or lock on it. That door led out to the back of the facility and a loading dock. "I put her there trusting they would keep her safe and then this happened. It’s not right," Ritchie said.

News Channel 36 tried repeatedly to get in touch with management at the nursing home and were told they would not comment.

A Perfect Cause is an advocacy group that pushes for reform of nursing home laws, regulations, and requirements.  Recently, they got the Oklahoma attorney general and the Oklahoma County district attorney’s office to support a push to make crimes against nursing home patients immediately reportable to police.

Jack Crow, who says he believes his wife was abused at a nursing home, is pushing to change the statutes.  Crow’s wife, who suffers from Alzheimer’s disease, was badly bruised in July. An investigation found that she suffered the injuries in a fall.

Crow disputes the findings and is working with A Perfect Cause to change the reporting procedures.

Current Oklahoma statutes call for someone with reasonable cause to believe abuse or neglect is occurring at a care center in the state, it should be reported to the Department of Human Services or the Sheriff’s department.  However, reasonable cause is subjective and no guidance is given to nursing homes as to what constitutes neglect and abuse.

The district attorney and attorney general’s offices believe police should be called first.

"When you have a crime scene, there is evidence," said Scott Rowland, of the Oklahoma County district attorney’s office. "There is witness testimony in these crime scenes."

A Perfect Cause wants to make sure facilities follow that procedure by requiring them to report suspected abuse to police first, before anyone else.

The Philadelphia Inquirer wrote an article about how many errors in health care settings do not get reported.  These errors or mistakes, whatever you want to call them, need to be disclosed so we can figure out how to prevent them in the future.  These health care businesses are more worried about getting caught then preventing them.

The article describes several incidents where patients were not given proper care but the hospitals failed to report the problems such as two patients at Fox Chase Cancer Center in Philadelphia required additional surgery after objects were negligently left inside their bodies or three patients at Mercy Fitzgerald Hospital had to be sent back to the OR last year to stop excessive postoperative bleeding or  At Abington Memorial Hospital, an elderly woman recovering from surgery for a broken hip in 2005 was left on a bedpan for at least 41/2 hours. She developed two open bedsores as a result.

For several years now, hospitals in Pennsylvania and New Jersey have been required to report medical mistakes and serious complications to state agencies charged with reducing medical errors. But most hospitals aren’t complying, undermining efforts to improve patient safety.  In New Jersey, five of the state’s 80 hospitals failed to report a single preventable mistake last year. In Pennsylvania, some facilities didn’t report any serious events or even the near misses that might have harmed patients.

James Bagian, head of the Department of Veterans Affairs’ National Center for Patient Safety, said: "Anybody that is supposed to report close calls and has zero reports is clueless; Management is asleep at the switch and just waiting until they kill someone."  The public can only learn that a hospital isn’t reporting mistakes in those rare instances when the health department cites it for failing to comply with the law.

"There is still some underreporting, and we are working directly with the hospitals to understand why," said Eliot Fishman, policy director of the New Jersey Department of Health and Senior Services.  Consumer advocates want more transparency so patients can make better health-care decisions.

The numbers suggest underreporting is more than just a passing problem.   Calvin Johnson, the Pennsylvania secretary of health, said only people with their "head in the sand" would fail to see the problem of uneven reporting by hospitals. But he noted that with about 200 hospitals and millions of patient visits each year, it is impossible for the state to check every chart.

While it’s important to study each of those reports, it is at least as crucial to identify hospitals that are not participating at all, said Conway, of the health-care improvement institute.   "We cannot improve care unless we understand the problems," Conway said. "There can’t be safety without transparency."
 

I saw this article on another website discussing the recent Cornell University study on physical abuse between residents.  Resident on resident abuse is underreported and mismanaged in the nursing home setting and most likely caused

Physical abuse in a nursing home may include staff or other residents.  According to a Cornell University Study, resident-on-resident violence in long-term-care facilities is far more prevalent than previously thought.  The authors of the study admit nursing home abuse is  woefully understudied.

The new study, funded by the National Institutes of Health (NIH), is only the second published report to look at patient-to-patient violence. Cornell University examined the records of 747 nursing home patients over the course of the study. Of those, 42 where involved in 79 incidents at nursing homes that actually required police intervention. The finding surprised researchers, especially because the study was not even focused on nursing homes. Rather, it looked at overall community crime, and nursing homes where just one area that was examined. 

Many nursing home patients suffer from varying degrees of dementia, and this often plays a factor in the violence.  Common triggers can be unwanted touching or disputes over television.   It is often the byproduct of a neglectful staff. Conflicts are far more likely to escalate to physical violence when patients are unattended. However, attentive staff can take steps to separate feuding patients before the situation deteriorates.

The report also questions the wisdom of housing dementia patients together. This is standard practice in most nursing homes, which generally have a dementia ward. But, because dementia often triggers violence, the report suggests it might be better to incorporate these patients into the general population as much as possible. 

As many as one in 20 nursing home residents are victims of nursing home abuse. Because there is no uniform system for reporting nursing home violence, experts on elder abuse concede that current estimates are probably just the tip of the iceberg.   There is no requirement to report resident-on-resident violence. In fact, the Cornell researchers only looked at cases that involved police calls. There were simply no records available to them detailing physical confrontations between residents that did not escalate to this level of violence.