Alarms to prevent falls is standard in the nursing home industry since the federal government limited the use of physical restraints in the early 1990s. Many nursing homes rely on alarms to warn them if a resident who is at risk for falls is getting up. However, a new trend is emerging for alarm free facilities. Many nursing homes now claim that alarms are not effective to prevent falls. A study last year in the Annals of Internal Medicine that was based at a Tennessee hospital found that alarms did not statistically reduce fall rates. The most effective safety measure is adequate staffing and supervision. Connecticut’s The Day had an interesting article on this controversial issue.
“Kimberly Hall South is among a handful of nursing homes in Connecticut that have gone “alarm-free,” meaning residents at risk of injury, usually from falls, are no longer outfitted with detectors on their mattresses, chair pads and clothing that emit a warning signal when they try to get up and move around.”
Most experts say alarms are an important fall-prevention measure, especially for residents with dementia or poor safety awareness who may try to get out of bed at night unsupervised. The alarms remind the residents that they should not move, while also summoning staff to assist. Nursing staff must be more diligent in monitoring patients but the lack of noisy alarms lowers anxiety for residents, especially those with cognitive problems, and improves the quality of thier life.
According to data from the U.S. Centers for Disease Control and Prevention, about 1,800 elderly nursing home residents die each year from injuries sustained in falls. Thousands more suffer serious injuries, such as broken hips. In Connecticut, nursing homes overall report that 3.1 percent of long-stay residents experience one or more falls with major injury, slightly lower than the national average.
Other preventative measures include frequent checks on residents who are at risk of falls; additional staffing, safety vests, lap cushions, siderails, hip protectors, detailed assessments of residents’ needs, to identify when and why they get up and try to walk, including their toileting needs; and consistent assignments of nursing staff to particular patients.
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The Duluth News Tribune reported that a Minnesota nurse was recently found to have stolen hundreds of painkillers from 34 residents of a Ecumen nursing home and short-term rehabilitation center. The thefts, which occurred undetected over a five-moth period, included the high power painkiller, oxycodone, among other drugs and totaled over 760 pills. The stealing was only brought to the attention of the facility after a resident who was not administered her oxycodone complained that she was “having extreme pain” without it. It was found that the nurse who was taking the pills was signing out the pills without ever administering them to her residents.
It is maddening to think that almost three dozen residents could have suffered in pain without their medicine while this selfish human being stole their pills. This absolutely calls into question the quality of employees nursing homes are employing and management’s supervision. Even worse, this incident of pill philfering is just one among many as can been seen by the increase in the number of drug thefts in Minnesota. In hospitals and nursing homes across the state the number of reported cases has increased by twice the rate they were in 2005. “The trend reflects what experts say is a nationwide surge of prescription drug abuse — in many cases by the very people entrusted with caring for patients.”
CBS 11 News reported that a recent state investigation of Estates Healthcare and Rehabilitation Center, a Texas nursing home, confirmed that the facility’s neglect caused a resident’s death. On July 8th Luis Martinez, a resident went missing. Upon hearing the news his family feared the worst since Martinez suffered from Alzheimer’s disease and relied on a cane to walk. For 7 long days, Martinez’s wife and children anxiously searched for him until his son stumbled on the sickening sight of his own father’s decomposing body a mere four blocks from the facility.
Sadly the investigation reveled that Martinez’s tragic death was completely preventable, had the facility simply done their job. Martinez was assessed as being high risk for elopement and often expressed to staff that he planed to leave the “prison.” Because of this, he was placed on a special floor with added safety precautions. However, Martinez was removed from the floor, without assessment, due to overcrowding. Then Martinez, a know “flight risk”, was placed alone in a new room with a door leading to outside. Incredible!
The only steps the facility took to ensure Martinez’s safety was placing a wander-guard that would alert them should he leave the facility. Clearly, that was not enough since a wander-guard was found in the trash the night he disappeared. The administrator of the facility showed no remorse for the incident, commenting that she initially was not worried because she though the family had taken Martinez and even admitting that she knew the wander-guard alert system was “not fool-proof.” She even bragged that her staff did a “fine job” dealing with Martinez’s disappearance.
Even more maddening, the facility faced no consequences for their neglect and simply had to submit a plan of correction for things to return to normal. The lack of concern and remorse the facility showed and the absence of consequences in such a senseless tragedy is extremely disheartening.
An article in the Robinson-Moon Patch reported that an Ambridge, Pennsylvania woman admitted to law enforcement that she stole blank checks from a nursing home resident’s room and then attempted to defraud him out of over $1,500.
Caren Anne Austin forged the resident’s name and attempted to cash the stolen checks at two local banks. Staff at Manorcare Health Services, where the victim is a resident, contacted authorities when the checks were discovered missing. Austin admitted to police that she stole the checks when she was visiting her boyfriend, who was the victim’s roommate, at the nursing home. Austin is charged with forgery and two count of theft by deception.
Austin pleaded guilty in 2002 to multiple counts of forgery and theft by deception, and pleaded guilty again in 2010 to burglary and receiving stolen property in connection to a Moon Township incident.
The Hartford Courant had an article on the tragic death of a nursing home resident who choked on a peanut butter and jelly sandwich. It was well known that the patient needed assistance while eating. Because of short staffing, the resident was left unattended with the fatal sandwich.
State inspectors said staff members at Torrington Health and Rehabilitation Center, whose parent company is Spectrum Healthcare Torrington, were required to carefully monitor the elderly patient, who suffered from mental illness and pulmonary disease. The staff was instructed by doctors to encourage the resident to eat slowly and take small bites, and to cue the resident to chew and swallow. Food had to be cut up in small pieces. Despite this treatment plan, inspectors reported, "staff failed to supervise the resident when the resident was left unattended with a peanut butter and jelly sandwich.”
The patient was found unconscious. Medics performed CPR and the ambulance report indicated the resident’s airway was completely blocked with peanut butter. The patient died at a hospital of cardiac and respiratory arrest, and choking, according to the state Department of Public Health inspection reports.
A $5,800 daily fine has been imposed against Bristol Nursing Home in Tennessee. New admissions were suspended for a couple of days but for some reason was reinstated. The state also imposed a one-time $3,000 fine. The federal fine of $5,800 was to be imposed until violations discovered in March have been corrected. The Tennessee Department of Health suspended admissions effective April 13 but it only lasted 4 days.
A complaint investigation and annual survey conducted at the licensed 120-bed facility between March 26 and March 31 revealed serious violations in the areas of, "administration, performance improvement, nursing services and resident rights."
At the center of the substantiated complaint is a mentally impaired and vulnerable male patient who fights with other men and has been accused of sexually assaulting female patients. The staff complained that it was difficult to supervise him because of inadequate staffing. He was admitted to the nursing home Aug. 9, 2011, and became violent and more focused on female patients after his ex-wife died sometime in November 2011. At times, he mistook several of the female patients as his ex-wife and complained that she was running around with some male patients.
The report cited:
Two violent men who have punched, pushed and kicked at patients;
Failure to draft a plan of intervention or increased supervision for the two violent patients;
A lack of incident reports, investigations or interventions related to incidents involving the most violent man;
Failure to notify a patient’s doctor of elevated blood sugar and need for psychiatric help
“The facility’s failure placed all the residents on the … unit in an environment which was detrimental to their health, safety, and welfare,” the report states.
Oak Park nursing home failed to supervise two patients with histories of aggressive outbursts before a fight that left one dead, according to a report released by the Illinois Department of Public Health. Anibal Calderon died Feb. 14 of head injuries from a fight two days earlier at Oak Park Healthcare Center. After hearing yelling, nurses found Calderon lying on the floor and bleeding from his head while a 66-year-old resident stood beside him, the report states. It characterized the attack as "unprovoked," and the Cook County medical examiner’s office ruled it a homicide. According to employees, normal staffing for that area was one nurse and two certified nursing aids. One of the CNAs should have been in the dining room monitoring residents there and the other should have been in a chair near the dining room doorway monitoring residents known to wander in the unit. Said one certified nurses aide, “That is why we have a (certified nurses assistant) seated in the hallway to monitor.”
However, the IDPH report said while there is evidence of prior inappropriate behavior by both men, it was not communicated to staff through any treatment plan. “(The nurse) said there was no supervision or monitoring in place for (Calderon or his assailant),” the IDPH report states. The nurse told state investigators she was “unaware of any unusual behaviors displayed by (the assailant).” She said unless such behavior is noted on the patient’s plan of care, she would not be aware of it.
Nursing home records indicate both became increasingly prone to "wandering, verbal outburst … signs of forgetfulness" and "aggressive disorder," according to the report. Despite several recommendations made to change the care plan, staff did not follow through, the report states. Also, the report found many staffers were unaware of the behavioral issues and did not supervise the men adequately when the fight occurred.
Incredibly, the facility did not have a policy or plan to address coping with physically aggressive behavior according to the report. The assailant was involved in an altercation with another resident whom he pushed to the floor, but his current comprehensive care plan did not note any methods to address the incident.
The victim’s family filed a lawsuit asking for reasonable compensation for their father’s wrongful death. The lawsuit alleges that Oak Park Healthcare Center violated federal and state nursing home regulations by failing to protect Calderon from abuse and neglect. The complaint further alleges that the facility failed to provide Calderon with appropriate supervision and failed to employ sufficient staff to properly supervise and monitor residents.
The lawsuit also alleges that the facility failed to promptly report suspected incidents of abuse and ignored complaints regarding residents and staff at the facility.
The Grand Rapids Press had a story about the tragic incident involving Matthew Ambrose. On Sept. 12, Matthew Ambrose perched at the edge of his bed at the Grand Rapids Home for Veterans. Staff knew Ambrose was a high risk for falls because he suffers from Alzheimer’s disease, has a poor sense of balance and could not be left unattended when he was in a position where he could fall.
A privately contracted nurses aide sat the World War II veteran on the side of his bed and left the room to retrieve a lift apparatus to transport him from his bed into a wheelchair. When she returned, Ambrose was on the floor with his neck broken. "The Ambrose lawsuit claims the contracted nurses aide should have known Ambrose was a risk to leave alone. According to the suit, Ambrose has dementia, Parkinson’s disease and "a history of falling," worsened by prescription medications that make him "even more prone to falling." Ambrose now resides in a Grand Rapids nursing home, where Eskola visits him virtually every day. After his fall, Eskola said, her father had surgery at Metro Health Hospital in which a surgeon inserted a metal screw to stabilize a neck bone broken by the fall."
His daughter, Janice Eskola, believes her father’s fall represents more than one unfortunate incident at the home. It is about putting budget priorities ahead of the welfare of men and women who served their country. "State officials insist budget pressures afford them little choice but to trim expenses because of a $4.2 million cut in state funds to the home and stalled plans to replace 170 union nurses aides with non-union contract workers. "
Gov. Rick Snyder intends to extend privatization in the 2012 budget for the home, at an estimated savings of up to $5.8 million a year. State funds to the home were cut by $4.2 million in anticipation of that move.
Oklahoma’s Aden Evening News on Officer.com reported that thousands of pain pills are missing from Calloway Nursing Home. Police have launched an investigation. Between 2,000 and 3,000 Lortab pills were discovered missing during a routine state audit. Why didn’t the nursing home know it was missing the narcotics?
Several employees are suspected of stealing and distributing the drug, but no employees have been arrested.
The Daily Pilot reported that the Newport Nursing and Rehabilitation center is fighting a $100,000 fine that the California Department of Public Health has issued after a woman died on September 6, 2011 because of a preventable fall after she was left alone and unsupervised in the bathroom. Several nurses noted that the woman needed constant supervision.
The Department of Public Health found that the nursing home failed to properly supervise the woman causing the fall. The nurse who was responsible for supervising the resident in the bathroom left her alone to go take a break. Why wouldn’t she wait to take her break? Where was the charge nurse?
Another employee of the nursing home found the woman face down on the floor. Medics were able to briefly revive her but she remained brain dead and had a fractured spine.