Articles Posted in Nursing Home Abuse & Neglect

Data shows that in more than one in five nursing homes in the United States, antipsychotics are administered to a significant percentage of residents, despite the fact that they do not have psychosis or related condition that warrants their use. Antipsychotic drugs, which are intended to treat severe mental illness such as schizophrenia, can leave people in a stupor. Both the FDA and the Centers for Medicare and Medicaid Services say it’s not appropriate in most cases for patients suffering from dementia to be prescribed antipsychotics. The FDA has given these drugs black-box warnings, the agency’s most serious medication alert, about potentially fatal side effects when antipsychotics are taken by patients with dementia, saying they can increase the risk of heart failure, infections and death.

Federal law has long prohibited the use of antipsychotics and other psychoactive drugs for the convenience of staff, a practice known as “chemical restraint.” The Nursing Home Reform Act, passed more than 27 years ago, gave residents the right to be free from “chemical restraints.” The law also says that nursing home residents should only receive antipsychotics if the drugs are medically necessary. However, in 2012, despite the law being on the book for almost three decades, the government finally started a campaign laying out new stricter guidelines and harsher penalties for the overuse of antipsychotics to urge nursing homes to cut back on their use of these drugs that are so dangerous for patients with severe illnesses. Unfortunately, according to a recent report by NPR, it appears these new regulations have had little success curtailing the practice, largely because they are rarely enforced.

The penalties for giving residents unnecessary medication can range from a “plan of correction,” to civil fines, to being kicked out of the Medicare and Medicaid programs. However, the NPR report found that when penalties are actually assessed the harshest penalties are almost never used when nursing home residents are given unnecessary drugs of any kind. As a result, antipsychotics continue to be overused in nursing homes across the country.

Today, many families entrusting a skilled nursing facility with the care of a loved one may be shocked to find out the low number of registered nurses and other medical professionals that are actually providing care inside nursing homes at any given time. The controlling federal law intended at one time to improve the country’s nursing homes, the Nursing Home Reform Act of 1987, actually requires only one registered nurse on-site eight hours a day, regardless of the size of the facility.

Additionally, often times, advocates and experts believe that the data is skewed by nursing homes to make it look as if there are a greater number of medical staff available at all times in their home due to government data relying on self-reporting by the owners of the nursing homes. Data on the publicly available Nursing Home Compare website, which is promoted and operated by the government for comparison shopping, reflects staffing levels self-reported by nursing homes during a two-week period before annual federal inspections. Advocates say many homes work hard to prepare for those visits, and, as a result, critics say, those staffing levels may be artificially inflated. The Centers for Medicare and Medicaid Services (CMS), the federal agency responsible for overseeing nursing homes, has since 2001 discussed the problem of the inaccuracy of self-reported data. Unfortunately, these self-reported staffing levels are a crucial metric in the federal government’s broader quality rating of nursing homes on their Nursing home Compare website, which is heavily relied on by the public.

The discrepancies between the inflated numbers and the actual numbers can lead family members to believe their loved ones are receiving one level of care, when they may be receiving much less. This is troublesome as close to 100 peer-reviewed, academic studies have shown that the amount of care, particularly that provided by registered nurses, is most strongly connected with residents’ quality of care. Lower levels of care are associated with a higher likelihood of injury, abuse, neglect and even death.

A recent study by the Columbia University School of Nursing reported that the rate of infections in nursing homes is increasing. Regrettably, the trend will likely continue unless and until better care and hygiene practices are implemented.

The author of the study, Carolyn Herzig, stated, “Infections are a leading cause of deaths and complications for nursing home residents…We found a significant increase in infection rates across the board.” Data submitted by nursing homes to the Centers of Medicare and Medicaid Services (CMS) between 2006 and 2010 was analyzed by the author and her team. The data revealed increasing rates of urinary tract infections, pneumonia, wound infections, and septicemia, also known as blood poisoning. Septicemia is a serious, life-threatening infection that can worsen quickly. It arises from other infections throughout the body, often when such infections are either untreated, improperly treated, or treated too late. The Columbia University study also found increased rates of drug-resistant bacterial infections like methicillin resistant staphylococcus aureus, also known as MRSA. Of the above-referenced infections, urinary tract infections and pneumonia were the most common in nursing homes.

One of the more common types of cases that we see in our nursing home litigation practice are decubitus ulcer (pressure sore) cases. These wounds develop when the nursing home staff fails to turn and reposition a resident to relive pressure on a bony area, such as the sacrum, hips or heels. When a pressure sore occurs in the sacral area, it often becomes infected, especially if the nursing home resident is incontinent of bowel or bladder. If the wound infection is untreated or treated too late, the resident can develop septicemia (sepsis), which can, in turn, lead to death. That is why early intervention, proper treatment and proper hygiene practices are so important.

When an elderly person suffers a hip fracture, the injury is sometimes referred to as a “death sentence.” This is particularly true for elderly individuals who are residing in nursing homes. Studies going back to the 1980s showed that 27% of elderly persons who suffer a hip fracture die within one year following the injury. Even when elderly persons survive a hip fracture, they are usually left with decreased mobility and often require assistive devices to walk again. Falls and fall-related injuries can cause a loss of confidence and a fear of future falls, which can also lead to decreased mobility. This lack of mobility can, in turn, lead to other medical complications, such as the development of pressure sores, pneumonia and other serious health conditions.

More recent studies have reaffirmed the potentially devastating effect that a fractured hip can have upon an elderly nursing home resident. Researchers at the Perelman School of Medicine at the University of Pennsylvania examined 60,000 nursing home residents who were hospitalized after suffering fractured hips between 2005 and 2009. What they found was alarming. Their study revealed that within six months of being hospitalized for a hip fracture, 1/3 of the nursing home residents had died. The study also found that of those nursing home residents who survived a hip fracture for longer than six months, 28% remained immobile and became dependent upon caregivers to move around. When the researchers extended the time period to one year for individuals who suffered hip fractures in nursing homes, a staggering 50% of the nursing home residents had died. Statistics for those who were living outside of the nursing home when they suffered a hip fracture were markedly different, as only 20% died within one year of the fracture versus the approximately 50% of nursing home residents.

Risk factors for falls in nursing homes include the resident’s age, mental status, means of voiding, a history of falling within the previous six months, visual impairment, confinement to a chair or bed, gait and balance problems, and medications. The most common causes of falls in nursing homes include failing to properly to assess the resident’s risk of falling, inadequate supervision of the resident, hazardous conditions within the nursing home (slippery or cluttered floors, inadequate lighting, inaccessibility to call lights, improper use of assistive devices), improper height of beds, failure to use bed and wheelchair alarms, and failure to consider the effects of medications which increase a resident’s risk of falling. These common causes of falls in nursing homes almost always boil down to staffing issues; either understaffing or inadequately trained staff, both of which are the responsibility of the owners and operators of the nursing homes.

Elopement, sometimes referred to as wandering, is defined in the context of the nursing home setting, as a cognitive-challenged resident leaving the facility and exposing themselves to potential dangers. Individuals who are the most at risk for wandering in nursing homes are those who suffer from dementia. It is estimated that approximately half of all nursing home residents suffer from some form of dementia, most commonly Alzheimer’s disease. Those residents who suffer from dementia often experience severe anxiety that is associated with not knowing where they are, what they are supposed to be doing, who the people are around them and perhaps not even their own name, which can lead to wandering/elopement.

Unfortunately, the risk of elopement endangerment in nursing homes is on the rise. Over the last several years, the number of reported cases of elopement has increased by 38 percent. When a nursing home resident elopes and leaves the nursing home grounds unattended, they put themselves, and others, at risk of injury. Residents who have eloped may be exposed to extreme heat or cold, suffer a fall when walking over uneven or unfamiliar territory, or suffer severe injuries or death as a result of wandering into traffic or bodies of water.

Elopement by nursing home residents is generally preventable, and usually is a consequence of the nursing home staff failing to meet two specific areas of care: supervision and security. Nursing homes are required by law to provide each resident with the appropriate level of supervision to address elopement and wandering behaviors. Proper supervision by nursing home nurses employees is a critical component to a safe nursing home facility. Moreover, there must be a proper care plan in place to address the security needs of each resident. The ideal care plan is resident-specific and adapts to any changes in a resident’s condition that would impact the safety of the resident. To ensure the care plan meets a resident’s changing needs, the plan must be continually evaluated.

According to a study released this week by Medicare’s Inspector General, one in three patients in skilled nursing facilities suffered a medication error, infection or some other type of harm related to their treatment. A “skilled nursing facility” is defined as a facility that provides specialized care and rehabilitation services to patients following a hospital stay of three days or more. There are more than 15,000 skilled nursing facilities nationwide, and about 90 percent of them are also certified as nursing homes, which provide longer-term care.

Researchers found that 22 percent of patients suffered events that caused lasting harm, and another 11 percent were temporarily harmed. In 1.5 percent of cases the patient died because of poor care, the report said. During August 2011 alone, the study estimated that 21,777 patients were harmed and 1,538 died due to substandard skilled nursing care.

Shockingly, the study revealed that 59 percent of the errors and injuries were preventable. Most of the injuries and deaths were caused by substandard treatment, inadequate monitoring, delays or the failure to provide needed care. Many of the deaths involved problems such as preventable blood clots, fluid imbalances, excessive bleeding from blood-thinning medications and kidney failure.

According to the website Nursing Home Inspect, multiple nursing homes located throughout the States of Georgia and South Carolina lead the country in the amount of fines paid for violations of regulations that govern their operation. Nursing homes are inspected periodically by regulators (sometimes called “surveyors”) as a matter of routine. Additionally, when the Government receives a complaint from a family member about a nursing home, the facility will be inspected as part of the Government’s investigation of the complaint. If it is determined that the nursing home failed to comply with regulations that govern their operation, they are issued what are known as “deficiencies.” Simply stated, these are citations for failing to follow the rules.

Nursing Home Inspect was designed to make it easier for consumers to do research online and compare nursing homes based upon the number of deficiencies and penalties that were issued against them during the past 3 years. A non-profit investigative news organization known as ProPublica continually updates the information on the website. When nursing homes are repeatedly cited for deficiencies, they can face penalties, including fines. According to Nursing Home Inspect, the most fined nursing home in America over the past 3 years is Unihealth Post-Acute Care – North Augusta, a nursing home located in North Augusta, South Carolina. That facility paid a total of $737,000 in fines over the past 3 years. The second most fined nursing home in America is Cobb Healthcare Center, located in Comer, Georgia. That facility paid a total of $592,000 in fines over the past 3 years. Sadly, of the 20 most fined nursing homes in America during this time period, 3 were located in the State of Georgia. In addition to Cobb Healthcare Center, a nursing home known as Willowbrooke Court at Lanier Village Estates in Gainesville, Georgia and a nursing home known as Bethany Nursing Center of Vidalia in Vidalia, Georgia were among the 20 most fined nursing homes. Two nursing homes located in the State of South Carolina were also in the top 20, Unihealth Post-Acute Care – North Augusta and Heartland of Columbia Rehab. and Nursing Center in Columbia, South Carolina.

Not coincidentally, the most fined nursing home in America over the past 3 years, Unihealth Post-Acute Care – North Augusta, was also designated as a “Special Focus Facility,” which is a nursing home cited for having a history of serious quality issues. Of the 20 nursing homes across the U.S. listed as having the most serious deficiencies, 5 of those facilities are located in South Carolina. In addition to Unihealth Post-Acute Care – North Augusta, the other South Carolina nursing homes cited were Magnolia Manor – Columbia in Columbia, Brookeview Healthcare Center in Gaffney, Unihealth Post-Acute Care – Aiken in Aiken, and Camp Care in Inman, South Carolina.

According to the Wall Street Journal, nursing homes are overbilling Medicare $1.5 billion dollars annually. A majority of nursing home residents are Medicare recipients, making Medicare a key payor for nursing homes throughout the United States. When residents are admitted to nursing homes, the nursing home is required to prepare a report known as a Minimum Data Set (MDS), detailing the type of care to be rendered to the resident and the degree or intensity of care, which is also referred to as the acuity. The amount of Medicare’s reimbursement to a nursing home is based on the acuity level. The greater the acuity, the larger the reimbursement. Increased care rendered to residents in nursing homes includes things such as speech therapy, physical therapy and occupational therapy.

The recent study by the Government, as reported in the Wall Street Journal, revealed that some nursing homes have been guilty of what is known as “upcoding,” a process in which they inflate their bill to Medicare by claiming that more intensive services were provided than were actually performed. For example, a facility may claim that physical therapy was rendered to a resident regularly when, in fact, little or no therapy was performed. In other cases, the study determined that nursing homes were providing inappropriate or unnecessary care for the sole purpose of inflating their bills to Medicare and receiving greater reimbursements.

Ironically, while nursing homes have been overbilling Medicare to the tune of $1.5 billion dollars annually, their lobbyists are asking Congress to enact a bill, HR 5, which would limit the recovery by a victim who has been abused or neglected in a nursing home. While nursing homes are defrauding the Government (and taxpayers), they are asking the Government to pass laws that would shield them from liability for negligently injuring residents. Keep in mind that many of these residents are part of the so-called “great generation,” comprised of men and women who fought for our country in World War II and other wars, built factories that provided jobs for thousands of citizens, and were tax-paying citizens themselves.

A study published recently in the Journal of the American Geriatric Society concluded that 1 out of 5 newly admitted nursing home residents falls within one month of their admission. The study also found that the higher the levels of staffing with certified nursing assistants (CNAs), the lesser the risk of falling. The study examined data from both Medicare and Medicaid on more than 230,000 new residents admitted to approximately 10,000 nursing homes throughout the United States. 21% of those residents sustained at least 1 fall during their first 30 days in the nursing home. The authors of the study also examined risk factors that contribute to falls, and found that fewer falls occurred in those nursing homes with higher ratios of CNAs to residents.

These findings support what those of us who represent victims of abuse and neglect in nursing homes have known all along; that is, almost all injuries in nursing homes can be linked to staffing. The majority of the time, problems in nursing homes can be traced to not having enough staff to adequately care for the number of residents in the facility. Other times, problems can be traced to inadequately trained staff. One explanation for fewer falls occurring in nursing homes with higher staffing ratios is the fact that CNAs provide many of the hands-on resident care during activities where the risk of falling is high, such as dressing, toileting, and generally moving around. Most nursing home residents need, at least, some assistance with these so-called activities of daily living. Often, nursing home residents will press “call” buttons to request assistance. When the staff does not respond promptly, the residents attempt to perform these tasks on their own. This can lead to falls and fall-related injuries, especially in individuals who are living in a new place and are not yet familiar with their surroundings.

Many newly admitted nursing home residents are there for short-term rehabilitation with the ultimate goal of sending them back home. A fall and resulting injury, such as a fractured hip or closed head injury, can delay or prevent altogether the resident from ever being able to return to his or her home. Falls can result in disability, functional decline, a decreased quality of life, and increased mortality. A fall or series of falls can lead to a fear of falling, which can cause more loss of function, depression and social isolation, all of which are detrimental to a person’s overall well-being.

The Boston Globe recently published a series on the overuse of antipsychotic medications in nursing homes. Those of us who represent victims of abuse and neglect in nursing homes refer to this as a form of “chemical restraint.” Many nursing homes use antipsychotic drugs to control combative behavior and agitation in nursing home residents who have not been diagnosed with a condition for which such drugs are recommended.

The Boston Globe’s investigation yielded a number of findings including:

(1) In 21% of U.S. nursing homes for the year 2010, at least one-fourth of the residents received antipsychotic medications despite the fact that they did not have illnesses or conditions for which such medications are prescribed.

(2) The use of antipsychotic medications was linked to staffing levels within the nursing homes. The facilities that used antipsychotic drugs for conditions not recommended by physicians had lower staffing levels than facilities who did not rely heavily on the use of antipsychotic medications.

(3) The use of antipsychotic medications by nursing homes tended to correlate with facilities whose residents were deemed by the nurses and staff to have behavioral problems, such as being verbally or physically abusive to staff, resisting care, or wandering.

Antipsychotic drugs are typically used to treat some of the most severe mental illnesses, such as schizophrenia. They are powerful sedatives with potentially harmful side effects. The U.S. Food & Drug Administration (FDA) has issued so-called “black box warnings” about the dangers of giving antipsychotic medications to patients with dementia or Alzheimer’s disease. These drugs can increase the risk of infections and cardiovascular complications in elderly individuals. Additionally, they can cause a sudden drop in blood pressure, dizziness, and blurred vision, any of which can lead to falls and serious, fall-related injuries.

Antipsychotic drugs are overprescribed in nursing homes because the nurses and staff either don’t have the time to deal with a resident’s behavioral problem, or they don’t take the time to investigate the underlying cause of a resident’s combative behavior. A resident with Alzheimer’s or dementia, for example, can become confused, frightened or anxious simply because of a change in their environment. By redirecting these residents to an area or environment that is more familiar or comforting to them, the anxiety or combative behavior can often be lessened or eliminated. However, it can take longer to redirect the resident than it takes to administer a sedative or antipsychotic drug that will knock the resident out for hours at a time.

Efforts are underway to encourage nursing homes to care for residents with Alzheimer’s or dementia without resorting to the use of antipsychotic medications. Nursing homes are encouraged to have lots of activities and try various types of interventions rather than using the quick fix of prescribing an antipsychotic. Federal regulations that govern nursing homes provide inspectors the authority to issue citations, known as “deficiencies,” if nursing homes are found to have engaged in “unnecessary medication use.” Additionally, federal regulations require nursing homes to try to gradually reduce the resident’s dose of antipsychotic drugs at least once a year, but facilities sometimes neglect to do so.

If you believe that a loved one in a nursing home is being given unnecessary antipsychotic medications or is being overmedicated, you should ask for a list of all medications that are being administered to the resident and the doses. A simple internet search or a review of sources commonly found in public libraries, such as the Physician’s Desk Reference, will provide you with the information you need regarding the medication, including what it is used for, the recommended dose, and potential side-effects. If you believe that the administration of antipsychotic drugs is causing or contributing to a decline in the resident’s condition, report your concerns to the nursing home administrator and ask to speak with the nursing home’s medical director.
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