In an investigation by Quebec coroners, their findings say that many nursing home deaths are avoidable. The coroners investigated 27 suspicious deaths from nursing homes between 2006 and 2011. An article by The Montreal Gazette looks specifically at 12 of the cases, which tell a gruesome and sometimes horrifying tale of abuse, negligence, and avoidable and wrongful death. The most common causes of death were burns suffered as a result of scalding hot bath water, asphyxiation because of restraints and bed rails, and exposure to the elements because of unlocked doors and windows.  I don’t recommend reading the article if you’re squeamish.

The Legal Examiner reported on the astounding number of medication errors occurring in nursing homes. Researchers from the Journal of the American Medical Informatics Association observed nursing home staff administering medication to 127 residents and found 428 errors, totaling an alarming 21.2 percent of all medication administrations.  Another study reaffirmed these startling findings, showing that the repeated errors in nursing homes were a “common occurrence”and, obviously, were more likely to cause harm to residents than non-repeated errors.

Medication errors including giving the wrong dose of medication, giving it at the improper time, or incorrectly following doctor’s orders while administering the medication. While the amount of errors in long-term care nursing homes are alarmingly high, the American Journal of Geriatric Pharmacology found that rates are even higher in assisted-living facilities. This can be attributed to the fact that improperly trained, non-nursing staff is given the responsibility of administering medications. In another study the Journal of General Internal Medicine found that these errors “were the rule rather then the exception” and that many errors involved risky drugs such as hypoglycemic agents and anticoagulants.

Paul Woodley of Saratoga Springs, NY experienced the consequences of medication errors when his wife, who was a resident of Maplewood Manor Nursing Home, was mistakenly administered a dose of insulin intended for her roommate. As a result she suffered from dehydration, pneumonia, and an urinary tract infection until she died sixteen days later.

The American Association of Retired Persons reports that on average Americans age 75 and older typically take over 11 medications each day. With this many medications it is very important that nursing home staff are especially vigilant and correctly trained. Sadly, the current number of medication administration errors is very preventable and likely attributed to the under-staffing and lack of training provided to staff.

The Consumer Voice published an interesting response to a recent study by AON Risk Solutions which argued that nursing homes are facing increased liability costs at the same time their revenue is being strained by funding cuts, particularly from a Medicare reimbursement reduction that went into effect October 1, 2011.  The industry hacks then said tort reform and pre-dispute mandatory arbitration agreements will somehow decrease health care costs.  As the Consumer Voice reports:

“Here’s what they do not tell you:

 This report is published with the American Health Care Association – the largest trade association representing the interests of many nursing homes.

For the second time in FY 2012, publicly traded nursing home companies reported “profits that exceed expectationsi,” “surging operational incomeii” and “performance that outran fairly aggressive projections.”

Medicare reimbursement rates for skilled nursing facilities are 3.4% higher in FY 2012 than in FY 2010 – even with the reduction effective October 1st, 2011.

 Seven states were chosen by Aon for the report. Why were these states chosen and not others? Does the report only examine states with the results Aon wants? How can the report be a “national study” if the information comes from just 7 out of 50 states?

 The report says it distributed a request for data to for-profit and non-profit providers. It does not state that the request for data was sent to all providers in the country or even all providers in the seven states highlighted in the publication. Did only certain providers receive the data request? Were those providers cherry-picked?

 The report fails to identify the providers from which claim data was collected and how
many providers were included from each state. Consequently, data from a state could
conceivably be drawn from a single provider with a poor history of care and therefore not
be representative of the state as a whole.

 According to the report, approximately 19,500 non-zero claims were aggregated.
However, the report’s definition of a claim is any demand. A demand is not always a
formal lawsuit and claims of all kinds, including lawsuits, may be dropped. How many
of the 19,500 claims were actual lawsuits that were settled or went to trial?

 The report’s own data contradicts the contention that tort reform has reduced costs.
o West Virginia enacted tort reform in 2003. However, the loss rate has shown “a
strong upward trend
” (page 30).
o Georgia enacted tort reform in 2005, yet both the frequency of claims and the loss
rate has increased
(page 18) since that year.

 According to the report, the data comes solely from 8 of the 10 largest providers in the
country. However, the size of providers varies across the U.S., and the average size
nursing home is only about 108 beds.v How can the report claim to represent the
“perspective of all long term care providers” when it does not include data from small
and medium-sized providers?

 “Claims” include very serious harm and injury to residents, and even cases of resident
death. Examples include pressure ulcers down to the bone, malnutrition, dehydration,
sexual assault, broken bones, falls, and severe infections.

 Tort reform is touted as a way to reduce healthcare costs. However, medical malpractice litigation is not responsible for rising healthcare costs: between 2000 and 2011, the value of medical malpractice payments fell 11.9 percent while healthcare spending nearly doubled, increasing 96.7 percent.  Furthermore, in Texas – the state the report cites as “the example for effective tort reform” – researchers have found that tort limitations have not saved money.

 Arbitration completely strips the resident or the resident’s family member of their constitutional right to a trial by jury. Arbitrators are private individuals who may be chosen by the nursing home – not publicly elected or appointed officials like judges. Arbitration can be very costly and is usually far more expensive than court.  Residents and families not only have to hire a lawyer, they generally have to pay a part of the arbitrator’s fee – which is like having to pay the judge. And once a decision is issued, consumers typically cannot appeal it like they can in the court system.”
 

On July 23rd, I posted an article about the Brown University study on feeding tubes and pressure ulcers.  The well-respected expert on geriatric pressure ulcers, Dr. Jeffrey Levine wrote the below article in response to the study that you can find on his website.  See link here.

The medical literature concerning patients with advanced dementia has consistently shown that feeding tubes provide little benefit.  Complications of feeding tubes can include aspiration pneumonia, diarrhea, agitation, need for physical and chemical restraint, and insertion complications such as wound infection. A new article has shown that feeding tubes can increase risk for pressure ulcers, and do not promote healing of pre-existing ulcers. This article will fuel discussion not only of risks and benefits of tube feeding, but the avoidability or unavoidability of pressure ulcers. However there were issues not addressed by this paper, such as the adequacy of nutritional content once the tube is inserted.

The paper was entitled Feeding Tubes and the Prevention or Healing of Pressure Ulcers and it was published in the Archives of Internal Medicine. The authors studied whether feeding tubes inserted directly into the stomach (PEG tubes, acronym for percutaneous endoscopic gastrostomy) are associated with pressure ulcer development and/or healing in nursing home residents. Using a very robust data set, they found that feeding tubes were not associated with prevention or improved healing, and that PEGs were associated with increased risk for pressure ulcers.

Pressure ulcers are costly, often preventable, and can result in infections, painful surgical procedures, prolonged rehabilitation, disfigurement, and death. The controversy over the avoidability of pressure ulcers has escalated over the last several years, particularly since the 2008 Medicare rule which placed hospital acquired pressure ulcers on the “no pay” list. The National Pressure Ulcer Advisory Panel jumped into the fray by issuing a consensus statement saying that not all pressure ulcers are avoidable. New theories have been developed accounting for the unavoidability of some pressure ulcers, particularly the expert consensus statement called SCALE, or Skin Changes at Life’s End.

One important variable that was not studied in the feeding tube paper was the adequacy of tube feeding content. Tube feeding delivers nutrients that include protein, calories, and vitamins, and if feeding is inadequate a state of malnutrition will ensue, and pre-existing nutritional deficits will worsen. The research evidence to support nutrition as a factor in pressure ulcer prevention has been inconclusive, but that does not mean that this relationship does not exist.  Indeed most experts and clinicians, including myself, will say that malnutrition is an important factor in pressure ulcer occurrence, and nutritional support is critical for wound healing. The commonly accepted caloric requirement for wound healing is 30-35 Kcal/Kg – a factor not considered in the Archives paper.

It makes sense that tube feeding increases the risk for pressure ulceration. Patients with tube feedings must be positioned with the head of the bed elevated to lower the risk for aspiration pneumonia – but this increases shear forces and decreases the ability to turn, thereby increasing risk of developing pressure ulcers over the buttocks or sacrum. Once a tube is inserted however, the patient must receive adequate protein and calories as determined by a competent nutritionist and ordered by a physician who understands the issues. In all cases of end of life decision making, the risks and benefits of tube feedings must be thoroughly explored, and patients and their families need to make informed decisions. The growing body of research shows that tube feeding in persons in advanced dementia offers very limited benefits.

 

The Los Angeles Times and The New York Times reported on recent findings that states, by adopting an expansion in Medicaid coverage, could lower their death rate by up to six percent. The study by Harvard researchers found that when Medicaid was expanded to give more people health insurance less people delayed health care and, overall, less people died.  Sounds like common sense. The study was published in the New England Journal of Medicine.

This study reflects efforts by researchers to provide policy makers with the information needed to make informed, “evidence-based decisions” as they choose to accept the hundreds of billions of dollars the Affordable Care Act will provide or decline the federal funding and continue on with limited Medicaid eligibility.

Karen Davis, the president of the Commonwealth Fund, a nonpartisan research foundation explains, “Actual mortality studies are few and far between. This is a well-done study: timely, adds to the evidence base, and certainly should raise concern about the failure to expand Medicaid coverage to people most at risk of not getting the care that they need.”

The study looked at data from three states; New York, Maine, and Arizona, who have expanded their coverage and compared them to similar neighboring states that have not expanded their coverage. The three states that expanded their coverage to include people that previously were uninsured, mainly low-income adults without children and without disabilities that otherwise would not be covered, saw an average of 2,840 fewer deaths for every 500,000 people that were added. “Policymakers should be aware that major changes in Medicaid, either expansions or reductions in coverage, may have significant effects on the health of vulnerable populations,” the authors of the study wrote in their conclusion.

 

Kaiser Health News reported a new study from the New Hampshire Center for Public Policy Studies.  The study shows that there is “virtually no correlation between hospital [CEO] pay and either quality or cost” at nonprofit health systems.  Instead, the CEOs’ compensation packages correlated closely with the size of the institutions they ran, not the quality of the care provided. The bigger the system, the more the CEO generally made.

“Given these hospitals exist to provide quality health care and are required to provide community benefit and charitable care in light of their non-profit status, the lack of such a correlation is a significant concern,” New Hampshire Attorney General Michael A. Delaney said in a prepared statement. The New Hampshire Department of Justice regulates the state’s nonprofit sector.

The study found “a weak relationship” between CEO compensation and the amount of charity care a hospital provided.  The researchers also found that pay for the average New Hampshire hospital CEO has risen faster in recent years — up 18 percent from 2006 through 2009 — than compensation for the average private-sector worker or the average health care worker.

 

The website Counsel & Heal reported a new study about the dangers of falls for newly admitted nursing home residents.  Nursing homes should be aware of this study and watch new residents carefully to prevent falls.  The study was published in the Journal of the American Geriatrics Society.  Falls occur because the patients are in a new environment – unfamiliar to staff, identification and management, and lack of adequate staffing.

Of the more than 230,000 patients in almost 10,000 nursing homes in the United States, researchers from the University of Southern California and Brown University found that 21% of newly admitted nursing home residents sustained at least one fall during their first 30 days in the facility.

Staffing is important in decreasing the risk of falls. According to researchers, nursing homes with higher certified nursing assistants-to-patients ratio saw fewer falls “because CNAs provide much of the hands-on patient care during high-risk activities such as toileting, dressing, and ambulation.”

Lead author Natalie Leland, a research gerontologist and occupational therapist at the University of Southern California, explains “A fall can delay or permanently prevent the patient from returning to the community, and identifying risk of falling is essential for implementing fall prevention strategies and facilitating successful discharge back to the community.”

The Atlantic had an interesting article about the mitigating effects that feelings of a life purpose can have on slowing the progression of Alzheimer’s disease.  An ongoing study since 1997 has shown that an individual’s sense of life purpose can lessen the risk of later cognitive impairment.  In the study participants are asked to rate how well they relate to statements such as “I feel good about what I have done in the past and I feel hopeful about what I will do in the future” or “I used to set goals for myself but now that feels like a waste of time.” When the participants die their brains are autopsied to determine the amount of plaque accumulation in the pathways of the brain caused by Alzheimer’s.

The autopsies have shown that there is no physical difference between the brains of those individuals that rated high life on purpose and those without it. These finding show the feelings of purpose do not prevent the actual buildup of detrimental materials in the brain.  However, the participants that had a strong feeling of life purpose did have an overall 30% lower risk of cognitive decline. This means that the strong beliefs that one has a reason in life gives an individual a higher level of what researchers call a “neural reserve.” This reserve does not prevent plaque build up or brain damage but gives the brain the ability to sustain damage and respond to it much more efficiently.

Overall the study found that engaging work and purposeful living improves brain health and mitigates the harmful cognitive effects of Alzheimer’s, “It would appear that humans are hard-wired a bit like working dogs — we may dream about a life of ease aboard luxury yachts, but we are at our best when we are gainfully engaged in meaningful work.”
 

An article in Modern Medicine calls for new strategies to address the issue of Vitamin D deficiency in female nursing home residents. The article cites a study that has found large number of elderly female residents deficient in Vitamin D during the winter months. It reports increased risk of death in women already suffering from low levels of the vitamin.

Experts blame the deficiency on a combination of low exposure to sunlight, dietary causes as well as the inability of the aged skin to receive the vitamin. 25-hydroxyvitamin D (25[OH]D) concentrations are known to increase the risk of death in the general population. Researchers have now begun trace these deficiencies to the mortality of elderly females. In a study of 961 female patients from 95 nursing homes in Austria, 92.8% were found to have levels of 25-hydroxyvitamin D below the required amount. 269 deaths were noted 27 months later. Experts urgently recommend strategies to address the deficiency and advise supplementation in the elderly female population.

The L.A. Times reported that the price of drugs widely used by elderly Americans grew by almost double the rate of inflation from 2005 to 2009, according to a new study by the AARP.

The average retail price over the five-year period for the 469 drugs most often used by AARP members grew by 25.6%, compared to the 13.3% rise in inflation over the same period, according to the report.

The report also says that 406 of the 469 most commonly used drugs are used to treat chronic conditions and that the average cost of taking such medicines for chronic conditions was $1,152 higher in 2009 than it was five years earlier.