Quality of Care

Study Shows that C. Difficile Infections Are Ten Times More Prevalent in Los Angeles Nursing Homes that Are Understaffed and Unable to Uphold Safe Infection Control Policies

February 1, 2012 | by Yeroushalmi Law

Clostridium difficile, abbreviated as C. difficile, is just one of the many infections that are common in nursing homes. Caused by inflammation of the colon, some symptoms include diarrhea, nausea, vomiting, loss of appetite, fever, and cramping. Because residents of skilled nursing facilities live in such close quarters, infections are able to spread rapidly. Therefore, it is crucial that the nursing home staff take extensive measures to prevent the spread of infection. An article, titled “High Prevalence of Clostridium difficile Colonization among Nursing Home Residents in Hesse, Germany” and published in the January 2012 issue of Plosone Journal studies the outbreak of C. difficile infections in skilled nursing facilities.

After observing and analyzing various nursing homes for the presence of C. difficile the survey moved to study the general population. In comparison, the result of the study revealed that the prevalence of C. difficile was ten times higher in skilled nursing facilities than in the general population. This statistic was consistent with similar studies of C. difficile in the United States and the United Kingdom. This shows that although the study was conducted in Germany, the dangerous spread of infectious diseases in nursing homes is an issue that occurs internationally, including within our own local Los Angeles skilled nursing facilities.

The study cited antibiotic use as a common factor among nursing home residents that increased the prevalence of C. difficile. Certain antibiotics are known to kill the bacteria in the intestines that regulate C. difficile bacteria and ultimately prevent C. difficile infections from occurring. Because the use of antibiotics in skilled nursing facilities to treat various infections is so common, elder adults become more susceptible to contracting C. difficile.

Incontinence is another condition that increases the risk of the rampant spread of C. difficile in nursing homes. Patients who suffer from fecal incontinence must be monitored frequently and changed immediately, especially those also infected by C. difficile bacteria. According to the study, even up to several weeks after the disappearance of infection symptoms, 15 to 20 percent of patients are still at risk of a recurring infection and therefore still able to infect other residents. Because mere contact with the bacteria is enough to cause an outbreak of the infection among other residents of the facility, hand hygiene of nurses is an extremely important prevention technique. The facility, especially bathroom surfaces and other shared common areas, must be kept sanitized, in accordance with state and federal health codes.

Furthermore, the study alleged that although C. difficile was ten times more prevalent in skilled nursing facilities than in the general population, an entire 27 percent of the nursing homes studied failed to instigate specific infection control and management guidelines. Often, this is because the preventative measures and techniques outlined above are difficult and nearly impossible to execute effectively when the nursing home facility is understaffed.

However, it is the responsibility of the skilled nursing facility to not only employ an adequate amount of staff to sufficiently care for its residents, but also to ensure that this staff is qualified and able to recognize and accurately diagnose infections early on, and to instigate infection control measures when necessary. Failure on behalf of the nursing home to fulfill this duty is an egregious act of neglect and elder abuse that violates your loved one’s rights as a patient.

Los Angeles Nursing Homes Manipulating Patients’ Medical Conditions for Their Own Personal Gain

January 16, 2012 | by Yeroushalmi Law

Recently, as reported by The Baltimore Sun on January 12, 2012, certain health care groups have been engaging in a practice called “upcoding.” This increasingly prevalent practice involves healthcare providers reporting more serious medical conditions to the government, in order to receive higher reimbursement rates. In this specific case, an orthopedic company was accused of manipulating patients’ files to make it seem as though patients had a serious form of malnutrition, called kwashiorkor. The company denies these claims and is fighting back.

However, malnutrition is a serious problem that must not be underestimated. The most obvious sign of malnutrition is weight loss. Malnutrition has many health implications, including pressure ulcers, infections, pneumonia, and falls.

Usually, malnutrition is a direct result of understaffing. When there are not enough nurses working during mealtimes, residents do not receive the proper food and nutrition that they need. Furthermore, mealtime should be a time for positive social engagement, which must be initiated and encouraged by nurses. Often, nursing homes appear to be fully staffed during day shifts, but during night shifts and mealtimes they are actually inadequately staffed. When choosing a skilled nursing facility for your loved one, make sure to visit during mealtimes so that you can get a first-hand experience of what your loved one’s mealtimes will be like. If possible, try a sample of the food your loved one will be eating, and check if a dietician is present. You should also make sure that your loved one is not suffering from dehydration, which often accompanies malnutrition.

Interestingly enough, while some healthcare facilities are “upcoding,” others are “downcoding.” Although “downcoding” entails that the facility receives less funding from the government, nursing homes use this practice to lower their liability. For example, pressure ulcers are relatively easy to downcode because there are different levels of severity. Instead of accurately diagnosing a pressure sore as stage four, which is very serious, nursing homes often claim ignorance and diagnose these sores as being in their early stages of development. They allow patients to continue suffering until the problem is so serious that they must be sent to the hospital. At this point, nurses often claim that previously, the sore was not a severe one, and that it just recently developed into a stage four pressure ulcer. This allows them to attempt pass the responsibility on to the hospital or new care facility to which the patient is transferred. Once again, the development of pressure ulcers, as well as any other health ailments in nursing homes, is usually a direct consequence of understaffing. Regardless, nurses are fully responsible for the prevention of pressure ulcers, and must also be knowledgeable enough to accurately diagnose them, when necessary.

While the list of problems experienced in skilled nursing facilities is extensive, the main purpose of this blog is to emphasize how simple it is for healthcare facilities to manipulate their patients’ health records. For this reason, it is imperative that you are extremely cautious in allowing others to care for your loved one. Even if the facility makes claims and promises to you, it is important for you to ensure that the caretakers are following through with these promises. If you notice that something is wrong, or if your loved one is diagnosed with an illness, we advise you to get a second opinion. All too often, the elderly are taken advantage of and forced to suffer because skilled nursing facilities misdiagnose their patients. Do not allow this to happen to you or your loved one.

Nursing Homes and Pharmaceutical Companies Are Cheating Government Health Programs for Profit

January 13, 2012 | by Yeroushalmi Law

On January 10, 2012, Bloomberg News featured a story about Omnicare, a pharmaceutical company, that adjusted its billing records and reported false information to government health programs, such as Medicare and Medi-Cal, in order to increase its own profits. According to the report, the government may have lost millions of dollars from Omnicare’s fraud. Despite the story making it to news headlines, the truth of the matter is that health facilities cheat the government fairly often. Previously, Bloomberg News reported another situation that involved nursing homes that were incorrectly billing Medicare. To read more about that story, click here.

Incentives for cheating the government vary. In some cases, such as this most recent one, companies are simply seeking profit. In other situations, health facilities take advantage of Medicare by unnecessarily ordering drugs that were never prescribed by doctors. These drugs are usually used by nurses to chemically restrain patients. Antipsychotic drugs are the most common chemical restraints because of their power to sedate patients. However, these drugs that are intended to treat mental illnesses are more often used to treat patients with dementia. Because dementia patients are often subject to episodes of aggravation, nurses find it more convenient to subdue them with antipsychotics rather than to take the time to calm them down with behavioral techniques.

Specialists confirm that the best treatment for dementia-related aggravation is therapeutic, not pharmacological. Because aggravation is often caused by polypharmacy, or the excessive use of multiple drugs simultaneously, it only makes sense that adding more medications will only worsen patients’ conditions. Some types of treatments that have proven effective are pet and music therapy, as well as encouraging social interaction among patients, especially during mealtimes.

Beyond the ethical implications of using drugs to restrain patients, the improper use of antipsychotic drugs also poses many risks. Studies have shown that the use of antipsychotics in dementia patients more than doubles their chances of death. Additionally, patients are put at a higher risk for falls, depression, and isolation. You should also learn more about the dangers of physical restraints, and make sure that your loved one is not being restrained in any way by his or her nursing home, either physical or chemical.

Although the use of chemical restraints is an undoubtedly cruel act, nurses sometimes feel that they are left with no other choice. Nursing homes are often so understaffed that caregivers must take shortcuts in order to provide enough time to tend to each of their patients. Unfortunately, this abbreviated care is never sufficient in providing your loved one with the quality of care that he or she needs.

Understaffing and Lack of Resources in Los Angeles Nursing Homes Leads to Improper Prevention and Treatment of Pressure Sores and Puts Patients at Risk for Wound Infections

January 3, 2012 | by Yeroushalmi Law

In the January issue of the Journal of American Medical Directors Association, an article titled “When is a Chronic Wound Infected?” studies various methods of determining when a chronic wound is infected and judges which of these methods is most accurate. The article begins by explaining that the skin is a major barrier against infection, and therefore, the risk of a wound becoming infected is extremely high when skin starts to break down. The criteria for a wound to be considered infected requires that bacteria be present in the wound, and that this bacteria is producing tissue damage. There are many different types of wounds, but this particular article studies chronic wounds, such as pressures sores.

Physicians and wound care specialists use colony forming units (CFU) per gram of tissue to measure the presence of bacteria in a wound. They have established the “10^5 Rule,” which asserts that in the surgical closure of ulcers, spontaneous healing will occur at bacteria levels lower than 10^5 CFU. This rule implies that once spontaneous healing occurs, the possibility of infection is diminished and caretakers can conclude that the chronic wound is not infected. However, according to the American Medical Directors Association, the “10^5 Rule” may be inaccurate because there are factors other than the quantitative measure of bacteria that contribute to the development of infections. One such factor is the virulence of the bacteria. For example, certain infections, such as staphylococcus aureus, pseudomonas aeruginosa, and Bacteroides fragilis are so virulent that even at levels below105 CFU, infection is highly likely and requires treatment.

The article determined that a tissue biopsy is the most accurate method of determining whether or not a patient is suffering from an infected wound. However, most skilled nursing facilities do not perform biopsies. Instead, they obtain a surface swab of the wound and test the sample for the presence of infectious bacteria because this process is less costly and much simpler than a tissue biopsy. Despite its practical benefits, the use of surface swabs to determine if a wound is infected can be misleading. Often, the infection is incorrectly diagnosed and consequently, patients do not receive proper treatment and are unable to make a full recovery.

However, laboratory tests are not completely at fault when an infected wound is incorrectly assessed. In nursing homes that are understaffed, as well as in those that employ unqualified nurses, infected wounds are often overlooked, ignored, or inaccurately diagnosed. In fact, pressure sores are usually preventable and it is therefore the responsibility of the nursing staff to take these preventative measures, so that your loved one may avoid the pain and suffering that is caused by an infected wound. In the case that a pressure sore becomes infected, it is the duty of the nursing staff to ensure proper treatment. In addition to the usage of medications, some treatments include pressure relieving techniques, such the use of special mattresses and the repositioning of the patient, as well as the cleaning and dressing of the wound.

Study Shows That Nearly Half of All Medical Homes Fail to Meet National Standards of Quality

December 28, 2011 | by Yeroushalmi Law

On December 22, 2011, The Seattle Times published an article, titled “Medical; Patients, Doctors Differ on High-Quality Care,” about patient-centered medical homes. Although a survey on the satisfaction of patients showed that they were generally satisfied with their physicians, a recent study conducted by the Health Service Research Journal reported that 46 percent of medical homes fail to meet national standards in quality of care to even qualify them as medical homes.

Patients in medical homes are expected to have a team of nurses, doctors, and technicians to constantly be caring for them. Unfortunately, many skilled nursing facilities are understaffed and instead, this “team” of nurses, in reality, is actually just a few nurses who also has to attend to many other patients. In such environments, it is nearly impossible for residents to receive the one-on-one attention that they need. Quality of care is directly dependent on adequate staffing. If a facility is understaffed, it will not be able to provide high-quality care to your loved one. When searching for a nursing home, it is very important that you place quality of care as a priority and ensure that the facility is adequately staffed.

Understaffing leads to an array of injuries in California nursing homes, especially when the facility in appropriately utilizes restraints. When nurses are unable to meet the needs of all their patients, they often use physical or chemical restraints to subdue their patients, making them easier to handle. In addition to being a direct violation of Patients’ Rights, the use of restraints also leads to pressure sores, incontinence, and chronic depression.

The study also found that a lack of resources and infrastructure also contributed to a decline in quality of care in medical homes. In a ranking of the top hospitals of 2011, Leapfrog Group listed technological resources as one of the most important determining factors of quality of care in medical facilities. Make sure that your loved one’s nursing home has a strong infrastructure and offers the latest in technology and resources to provide your loved one with the care that he or she deserves and to prevent any avoidable suffering.

New Medicare Program to Improve Quality of Care in Los Angeles Nursing Homes

December 21, 2011 | by Yeroushalmi Law

A new Medicare program is aimed at reducing medical costs, while improving quality of care for the elderly, The Arizona Republic reported on December 20, 2011. Instead of paying doctors after each patient visit, the new health initiative gives health providers a budget within which they must work. The only way to increase this budget is by proving that they provide a high quality of care for their patients. Unfortunately, no such program exists for skilled nursing facilities, so they are often guilty of operating at quality levels much below standard. The quality of care that a nursing home provides is reliant upon its staff’s ability to meet the needs of its patients. Inadequate staffing refers not only to the amount of staff available, but also to the quality of care that they provide.

Understaffing occurs when nursing homes fail to meet the legal standard that requires them to provide patients with an adequate amount of staff to meet all their needs, which California law has quantified as a minimum of 3.2 nursing hours per patient, per day. Inadequate staffing is directly linked to quality of care because when a facility is understaffed, its quality of care declines significantly.

Nurses are often forced to work extended shifts when their skilled nursing facilities are understaffed. These longs shifts increase nurses’ chances of memory lapses, confusion, and slowed judgment, according to a recent study. Consequently, staffing errors occur, putting the lives of the residents in danger, as these mistakes are often fatal. When a care facility is directly responsible for the death of a patient, a Wrongful Death claim can be made by the patient’s successors as compensation for personal loss and suffering.

In other cases, nurses, pressed for time, may shortcut their caretaking procedures and resort to practices that constitute elder abuse. Such practices include, but are not limited to, the use of restraint, which can be either physical or chemical. They are used for the purpose of subduing patients and making them easier to care for. However, regardless of the justification that nurses give in support of restraints, the use of restraints, whether chemical or physical, is a direct violation of Patients’ Rights, which state that patients may only be restrained for medical purposes, but, in any case, are always entitled to refuse treatment.

Inadequate Staffing in Los Angeles Nursing Homes Forces Nurses to Work Long Hours and Increases the Chance of Fatal Errors

December 18, 2011 | by Yeroushalmi Law

On December 14, 2011, Modern Healthcare reported the dangers of extended hours and long shifts in healthcare facilities. While the correlation between exhaustion and increased error may seem obvious, many nurses have difficulty accepting this truth and determining the point at which their fatigue may lead to fatal consequences. The effects of fatigue include, but are not limited to, confusion, memory lapses, and impaired judgment. Many healthcare facilities fail to comprehend the seriousness of the consequences that can be caused by staffing errors. Often, these careless errors are fatal and lead to the death of a patient.

Nurses are often forced to work long hours because health facilities are understaffed. Even when they are well-rested, nurses who work in inadequately staffed facilities are more likely to make careless errors because they are constantly pressed for time, as they need to attend to more patients than they are able to handle alone. Factoring in exhaustion, in addition to the problem of understaffing significantly increases the chance of error, while decreasing quality of care of patients.

Inadequate staffing has many consequences including an increased risk of falls and incontinence, as well as dehydration and malnutrition. In both cases, patients require one-on-one assistance and individualized care plans. However, when nursing homes are understaffed, nurses simply do not have the time to meet the specific needs of each resident. Not only is understaffing a serious problem because of the health and safety risks it poses, but it is also illegal.

When staffing errors or inadequate staff lead to the death of a patient, a Wrongful Death claim may ensue. If nursing home neglect is directly responsible for a resident’s death, the successors of the patient may demand compensation for the personal losses that they have suffered.

Man Sent to Recover in Care Facility Dies by Suffocation Because of a Staffing Error: Nursing Home Neglect at Its Worst

December 16, 2011 | by Yeroushalmi Law

On December 11, 2011, the Detroit Free Press published a series of articles investigating nursing home neglect. The first article, titled “Nursing Homes with Good Staff, Stopgaps Can Still Fail”, reports the accidental death of a man as a direct result of nursing home neglect. After having an accident, James Culbert was sent to a care facility to recover. Instead, he died a painful, devastating death by suffocation because the night staff had forgotten to connect his ventilator and check his vital signs. By the time the staff realized their error, it was much too late. Unfortunately, deaths as a result of careless errors are a common occurrence in nursing homes. In the second part of its series, titled “Troubled Nursing Homes Aren’t Closed,” the Detroit Free Press discusses how care facilities are able to remain open, despite major violations of state and federal codes, and incidents, such as James Culbert’s, that often result in death. Finally, the last portion, “Nursing Homes: A Caring Staff Makes All the Difference,” emphasizes the importance of an adequate, highly-qualified staff.

Staffing is the fundamental problem directly linked to all other issues that may occur in nursing homes. While care facilities are legally obligated to meet the minimum of 3.2 nursing hours per patient per day, they are also held accountable for providing high-quality care for their patients. In your search for the best nursing home for your loved one, the Detroit Free Press cautions against automatically correlating quality of care to the physical appearance of the facility because looks can be deceiving. Surprisingly, the Detroit Free Press found that the newest facilities that market luxurious living and provide generous accommodations are sometimes ranked lowest in quality of care. Instead, the article emphasizes the importance of an adequate, qualified staff.

Unfortunately, many nursing homes lack such a staff. The Detroit Free Press investigated various deaths that occurred in nursing homes and found that many of them could have been prevented with a more attentive staff. Falls were among the most common causes of death, simply because a patient would fall down and hours would pass before a staff member even noticed, often much too late. Another common staffing error involves medications. The Detroit Free Press reported one death in which a man was given another patient’s diabetes medication. When patients’ lives are on the line, it is crucial that caregivers avoid making such careless mistakes. In some serious cases, caregivers even forgot to feed patients, who eventually starved to death. This raises the issue of malnutrition and dehydration, which provides clear evidence of nursing home neglect, even when it does not directly lead to death.

Families of Los Angeles Nursing Home Patients Must Be Cautious of Nurse Tampering with Patients’ Drugs

December 15, 2011 | by Yeroushalmi Law

On December 11, 2011, the Associated Press reported that three nurses were convicted of tampering with their patient’s drugs. All three nurses had been previously convicted of various drug-related crimes and yet were still able to secure jobs at skilled nursing facilities. One nurse, previously convicted for forging prescriptions, was convicted once again, this time for diluting five of her patients’ morphine solutions. Another nurse who stole her patients’ drugs at her previous job was found guilty of adding tap water to one of her patient’s painkillers. The last nurse, fired from her previous job for drug discrepancies, was caught stealing syringes of morphine and replacing them with a dangerous sodium chloride solution. The most disturbing truth about these crimes is that they occur in nursing homes nationwide and are often a cause of pain, suffering, and death in nursing home patients. In this specific situation, blame can be placed on the nursing home for failing to implement background checks on its employees. By simply being a bit more thorough in their hiring processes, nursing home management has the ability to significantly improve quality of care in skilled nursing facilities.

Staffing is the root cause of most problems in nursing homes. While the term ‘inadequate staffing’ is most often associated with quantity, people often overlook that it must also be applied to quality of care as well. A nursing home staff can be inadequate if it fails to provide a high standard of care or if its members are not qualified for the job. Similar to the situation reported above, management of nursing homes often fail to hire nurses who are best qualified to provide the care that your loved one requires. It is important that you emphasize both quantity and quality of care when choosing a skilled nursing facility for your loved one.

Diabetes: An Increasingly Prevalent Issue in Nursing Homes that Requires Immediate Attention

December 12, 2011 | by Yeroushalmi Law

The prevalence of diabetes is increasing exponentially in the American population. In nursing homes alone, it has been found that 20 percent of adults between the ages of sixty-five and seventy-five suffer from diabetes, and that 40 percent of adults over the age of eighty suffer from this common illness. Because of its widespread nature, the Journal of American Medical Directors Association featured an “Update on Diabetes in the Elderly and in Nursing Homes” in its November 2011 issue.

The article reported that in the elderly, diabetes often manifests itself as weight loss, fatigue, and nocturia. Because these issues are often attributed to old age, 25 to 41 percent of elderly adults remain undiagnosed. Therefore, it is important that your loved one’s nursing home is adequately staffed with trained professionals who recognize that these may in fact be signs of diabetes, rather than automatically blaming old age as the underlying cause.

Understaffing also becomes a major issue in the treatment of diabetes. Elderly adults who are diabetic suffer a great burden of disease. They are constantly being transferred in and out of hospitals, and are at higher risk of hypertension, heart failure, kidney disease, visual impairment, and foot problems. Due to the various ailments that often accompany diabetes, adults who suffer from this illness require additional staff assistance for activities of everyday living. Therefore, if your loved one suffers from diabetes, it is crucial for you to ensure that his or her nursing home facility is providing your loved one with the care and assistance that he or she requires as a diabetic.

Caregivers must also be very alert and observant because diabetic residents are also more susceptible to falls. Studies have shown that diabetic residents suffer more fractures than residents who do not have diabetes. This is a significant issue because falls can have serious implications, including death, that can often be avoided with an active and attentive staff.

Regarding the treatment of diabetes, the article emphasizes the importance of individualized care plans, especially in patients with dementia. There is evidence to show that patients with cognitive impairments are less likely to be put on a special diet. Because diabetes is an illness that is directly linked to nutrition, it is essential that every patient’s nutritional needs are met, whether or not they have dementia.

According to the Journal of American Medical Directors Association, the goals of diabetes treatment should be to decrease pain and nocturia, while limiting cognitive impairment. Because diabetic patients are more vulnerable to infections, such as pressure ulcers, the influenza, methicillin-resistant staphylococcus aureus (MRSA), scabies, clostridium difficile (C. difficile), and sepsis, another goal of treatment is to decrease the likeliness of contracting any of the above infections. Additionally, caregivers should strive to improve incontinence and prevent falls in diabetic patients.