Quality of Care

Studies Show Correlation between Pressure Ulcers and Skin Changes that Occur with Age

October 10, 2013 | by Yeroushalmi Law

Recent research has been conducted to explain why the elderly population may be at higher risk for pressure ulcer development. Our skin functions as a defensive barrier against physical and chemical trauma and disease. However, research has uncovered correlations between skin changes that occur with age which may serve as risk factors for pressure sores. This is because various changes in the skin’s structure occur with time, impacting the skin’s ability to heal wounds quickly and leaving it more vulnerable. The skin of elderly individuals has increasingly fewer epidermal cell layers thus deteriorating its ability to serve as an effective barrier. Additionally, as people age, subcutaneous fat will deteriorate. This will have the effect of decreasing support of one’s skin from underlying bone. In addition, skin will generally respond with less vasodilation when there is external pressure, furthering the likelihood for pressure sore development.

Because of these changes, elderly individuals in nursing homes are highly susceptible to the development of pressure ulcers. Despite the fact that it is highly preventable, statistics reveal that about 2.5 million people develop pressure sores every year in the United States alone. Of these individuals, up to 24% develop pressure sores in long term care facilities, while 38% develop pressure sores during their stay at acute care hospitals. Pressure sores not only diminish an individual’s quality of life but may also lead to death. Thus, early identification and treatment are critical in preventing the development and worsening of sores, and the complications that may result due to their development.

Government Shutdown and its Impact on National Healthcare

October 4, 2013 | by Yeroushalmi Law

A government shutdown took place Tuesday morning on October 1, 2013, due to Congress’ failure to pass a 2014 spending measure before the midnight deadline on Monday. The shutdown has resulted in about 800,000 federal employees being furloughed, allowing only for ‘essential’ government workers to continue performance of their duties. While the shutdown coincided with the launch of the Affordable Care Act, the opening of the new health insurance marketplace was able to move forward as planned.

The government shutdown will have various effects on federal agencies, including the healthcare industry. Federal agencies have provided information stating that Medicare will operate without disruption for the immediate future. Additionally, Medicaid funding was made available for states on October 1. The Administration on Community Living has reported that it will continue to support its Aging and Disability Resource Centers, along with the Health Care Fraud and Abuse Control program through the provision of mandatory appropriations. However, the ACL will cease providing funding for senior nutrition programs, elder abuse and neglect prevention services, and the long-term care ombudsman program due to the shutdown. The Department of Veterans Affairs will continue in operation, meaning that all VA medical facilities will remain open and in operation. Therefore, nursing home care will continue to operate within these facilities.

Investigation Reveals Mass Dismissal of Elderly Abuse Cases

September 18, 2013 | by Yeroushalmi Law

A recent investigation by the Center for Investigative Reporting revealed that the California Department of Public Health dismissed about 1,000 pending cases in 2009 which alleged caretaker abuse and theft, without taking any action. This hurried dismissal of cases occurred to alleviate the Department’s extreme backlog of cases. These closed cases involved caregivers accused of assaulting or abusing their patients, some of which involved elderly patients. The closing of these pending cases has allowed for these caregivers to retain their licenses, thereby allowing them to continue to work in nursing homes, hospitals, and other health care facilities throughout Southern California. These abuse cases have been reported from facilities in Los Angeles, Riverside, San Diego and Santa Barbara, ranging from abuse and neglect to suspicious deaths. Therefore, we must remain vigilant in ensuring that instances of abuse against the elderly in such facilities go reported and ensure such caregivers are removed from their positions to prevent further harm.

The investigation found that the Department of Public Health rarely took action against these caregivers, despite clear evidence of allegations of abuse, and that the number of caregivers removed from their jobs for their wrongful actions has declined. Specifically, investigators found that about 81% of cases were closed in 2012 without taking any action against an accused caregiver. What is even more worrisome is that there was also an extreme drop in the number of cases involving suspicious deaths from abuse that were sent to law enforcement to be investigated and prosecuted. It should be noted that this decline in action is not due to a decrease in complaints, but rather, is correlated with the hurried removal of the Department’s backlog of pending cases. As a result, even though accused caregivers and their employers may have engaged in wrongful conduct, they are still licensed to work and care for vulnerable patients and are not being held accountable.

Reduction in Polypharmacy is Beneficial for Both Nursing Home Residents and Health-Care Providers

June 13, 2013 | by Yeroushalmi Law

It is not uncommon for the elderly to need the assistance of multiple medications to maintain their health. However, as the number of medications being taken increases, so does the risk involved. A study conducted by the Division of Geriatric Medicine at the Saint Louis University School of Medicine finds that incorporating more inter-professional education in nursing home caretakers’ training can help reduce polypharmacy in their facilities. Such discovery is significant when it is taken into account that up to 28 percent of nursing home residents are hospitalized due to adverse drug reactions (ADR). An ADR’s mortality rate is significantly increased when the patient is taking over six medications.

The need to decrease polypharmacy is not only evident in residents’ high rate of hospitalizations, but it is also reflected in the incredible cost created by it. The study cites a cost analysis which proves that for every dollar spent on medications in nursing homes, another dollar and thirty three cents are spent on treating adverse drug reactions. It is abundantly clear that nursing facilities should have a greater interest in reducing polypharmacy in order to increase the quality of care of their residents, and to decrease the cost of care for themselves.

Enhancing communication amongst nurses, doctors, resident’s families, and staff can help them track the resident’s medications, and detect any deterioration due to polypharmacy. This allows for all those involved in the resident’s care to be more fully informed about how they can best help him or her. The study also suggests that hand counting all medications prescribed to patients from the physician’s order sheet is a more reliable way to avoid any mistakes from using an electronic log. Although this may seem more time consuming for pharmacists, it reduces the time spent on having to solve adverse drug reactions resulting from negative drug interactions later. Additionally, minimizing the number of medications prescribed also reduces medication administration time, which allows staff more time to dedicate to providing proper care and attention to each resident. Furthermore, a resident that is less medicated has a decreased risk for falls, weight-loss, and even death.

This new information-based initiative is simple and can only be made possible through the cooperation of pharmacists and nursing home staff. The Omnibus Budget Reconciliation Act of 1987 (OBRA) included a clause which demands that all certified nursing homes have pharmacy services available on location at their facilities. Therefore, all certified nursing homes already have an infrastructure of professionals which facilitates the spread of knowledge in order to promote a decrease in polypharmacy. There is also an incentive present for nursing homes to decrease medication use in order to save money and time, and increase the quality of care for their residents. This need to increase the quality of care of their residents should outweigh their desire for convenience. Sedating patients so that fewer staff is needed to care for them is a common practice at many nursing homes that value convenience over their residents’ well-being, and it constitutes a form of elder abuse.

Re-hospitalization of Nursing Home Residents Related to Licensed Nurse Retention

June 7, 2013 | by Yeroushalmi Law

It is no secret that taking care of the elderly in a nursing home is an incredibly important role that carries with it responsibilities of magnanimous proportions. In addition to offering physical aid to avoid falls and encourage mobility through physical exercises, nurses must also build rapport with their residents so that they may offer them emotional support through their caretaking process. However, the daily routine of caring for several residents often becomes exhausting for these nurses, leaving them burned out. Such exhaustion often results in a nurse leaving the facility and the relationships he or she has built with the residents. This common phenomenon among nursing home caretakers causes either a high turnover rate amongst nurses, or leaves the facility constantly understaffed.

A recent study published by The Gerontological Society of America explores the relationship that exists between nurse turnover and nursing home resident re-hospitalization. They find that many hospital readmissions may be prevented if the quality of nursing home care is improved through the hiring of more licensed nurses and licensed practical nurses. As it stands, they estimate that about 28% to a staggering 40% of re-hospitalizations may be avoided. In order to improve the quality of care, nursing homes must hire enough licensed nurses and keep them for long periods of time so that the care may be consistent. The study found that higher licensed nurse staffing correlated with lower licensed nurse turnover rates. More importantly this showed that increasing a nurse retention rate by 10% would reduce hospital readmission rates by 19%. This occurs because a long term stay at a nursing position fosters specialized knowledge which better equips nurses to provide a higher quality of care for residents.

In order to promote higher nurse retention rates in nursing homes, these facilities must invest time in constructing strategies to encourage long-term job retention. A nursing home’s priority must be to provide the highest quality of care to their residents. This includes ensuring that their residents’ needs to be hospitalized are minimized by maximizing the assistance they receive from professional nurses at the facility. In addition to the benefits conceded to residents from increasing nurse retention, there is also an economic incentive derived from it. Many nursing home administrators mistakenly believe that staff turnover is a money-saving strategy. However, nursing homes with higher performance levels on staff turnover, retention, and avoidable hospitalizations receive extra money from the CMS Nursing Home Value-Based Purchasing. Additionally, those that have an increased rate of Medicare hospital readmissions are actually sanctioned by receiving lower Medicare payments.

Nursing Home Dementia Patients: Link Between Pain and Disruptive Behavior

June 5, 2013 | by Yeroushalmi Law

A 2013 study conducted by BioMed Central Geriatrics found that there is a strong positive correlation between pain and disruptive behaviors displayed by the elderly suffering from dementia. It explains that such behavior is often expressed through aggression or agitation, which increases these patients’ risk for injuries and hospitalizations. In fact, agitation is a common behavioral symptom which occurs in up to 80 percent of nursing home patients suffering from any type of mental deficiencies, not simply dementia. However, because dementia is characterized by a decreased ability to verbalize pain due to memory impairment, it causes the sufferer’s pain to manifest itself through destructive behavior.

This discovery is significant because it emphasizes the need for nursing homes to address troublesome behavior by dealing with the root of its cause, rather than simply attempting to manage the symptoms. Many nursing home caregivers often attempt to deal with these symptoms by using psychoactive restraints which not only lead to falls and decreased mobility, but also offend the personal dignity of the elderly. Such practices are common because a sedated patient does not need to be checked on for long periods of time, allowing a chronically understaffed nursing home to continue running with their limited staff. Therefore, this unethical practice bolsters understaffing, which is an important cause of elder neglect.

The BMC Geriatrics study also found that 30% of the cost of care associated with dementia is attributed to the cost of controlling disruptive behaviors. In other words, learning how to adequately cope with elderly pain would significantly help to reduce the overall cost of caring for dementia patients. This cost reduction should serve as an incentive for understaffed nursing homes to hire and train more qualified caregivers, ensuring a higher quality of care for their residents.

In addition to uncovering the root of a serious issue, this study highlights the extent to which many nursing homes are ill prepared to aid their residents. Without proper and extensive training of their staff, nursing homes will continue their unethical practices of medicating their disruptive patients in order to calm their agitation or aggression. Using psychoactive restraints to sedate patients into a state of compliance is a gross violation of the elderly’s Patient’s Rights. Their cognitive and communicative deficiencies subject them to a torturous silence which must be broken. It is the nursing home’s responsibility to not only care for the patient’s physical well-being, but to ensure their emotional and mental comfort as well.

For-Profit Nursing Homes Found to Be Overcharging and Underperforming

January 11, 2013 | by Yeroushalmi Law

According to an article in Bloomberg News, the for-profit private nursing home industry overbills Medicare by 1.5 billion dollars a year by conducting unnecessary procedures and therapy on their patients. This, however, is not the only way that for-profit nursing homes have been using unlawful methods to increase profits. Nursing homes frequently engage in the understaffing of their facilities in an attempt to cut payroll costs and essentially place profits over people. Between the years of 2008 to 2012, federal prosecutors have brought 120 civil and criminal cases against nursing home facilities and other related people that have now been resolved. That is twice the number of cases that were brought in the five years prior to 2008.

One of the most egregious offenders was Skilled Health Care Group Inc., a company that operates 75 nursing homes in the United States. The company was charged with 11 counts of elder abuse at a nursing home in Eureka, California. Prior to the criminal charges being brought forth, Skilled Health Care Group settled six wrongful death civil suits between 2005 and 2012 in California’s Humboldt County. The criminal charges were stemming from incidents occurring at a skilled nursing facility in Eureka, California. This nursing home was one of the 22 company sites that was indentified by the court to be suffering from chronic understaffing and the jury returned a 677 million dollar judgment which was later brought down to 63 million dollars in a settlement. According to documents from the class action suit, patients were left unattended for hours at a time, soiling themselves and not being changed, and being denied meals, which led to suffering and dehydration and malnutrition.

The rise of for-profit institutions in the health care industry, especially with regard to skilled nursing home facilities has led to the cutting of costs that are absolutely necessary to run an efficient and well-maintained nursing facility that provides a high quality of care. At the same time, overbilling and the conducting of unnecessary or even dangerous medical procedures on residents has been on the rise. In the past three years, the U.S. justice department has settled civil fraud complaints against eight hospice companies that enrolled or retained patients that were in improving health and were not dying.

What this means for you and your loved ones is that sometimes, the care and well-being of patients are not being prioritized over low costs and profits. This, in turn, leads to a culture of cutting corners and lack of training, which can result in neglect, elder abuse, and even death. When for-profit nursing homes cut costs by understaffing, they are putting your loved one’s life at risk. Nearly all injuries that occur in skilled nursing facilities can be prevented with proper staff and training. Such injuries include pressure ulcers, malnutrition, dehydration, and those that result from falls.

Implications of Hurricane Sandy for California Nursing Homes

December 18, 2012 | by Yeroushalmi Law

Although Californians fortunately were not directly affected by Hurricane Sandy, the disaster poses many implications for disaster preparedness in the health care industry. A recent article published by the New England Journal of Medicine titled “Disaster Resilience and People with Functional Needs” discusses strategies that can be used by the health care industry to minimize the adverse effects of natural disasters on medical patients. The article emphasizes the importance of maintaining an established day-to-day system of organization within the facility, even in the absence of a natural disaster. In nursing homes, for example, it is the responsibility of the Administrator and the Director of Nursing to ensure that the facility is operating smoothly, with sufficient staff to meet patient needs.

One strategy recommended by the article is the adoption of an electronic system of maintaining health records. In the midst of a disaster, paper records are often destroyed, leaving health care facilities unorganized and without information on their patients. The Department of Health and Human Services, recognizing the utility of electronic health records, has started to use payment incentives under the Health Information Technology for Economic and Clinical Health (HITECH) Act to encourage health care facilities to make the transition from paper to electronic records. In terms of day-to-day use, electronic health records will serve to improve care provided to patients with functional needs, who are frequently transferred back and forth from hospitals to nursing homes.

Numerous studies in the past have concluded that poor documentation of a patient’s condition can lead to serious injuries, including pressure ulcers. Nurses frequently make inaccurate and contradictory assessments when staging their patients’ pressure ulcers, which is detrimental to the healing of a pressure ulcer since different stages warrant different treatments.

Another study links poor documentation to the improper administration of antidepressant drugs, which can lead to injury, and even death. It is extremely important that skilled nursing facilities carefully document every drug that is administered to its residents, especially since nursing home patients are usually on several drug regimes at once, putting them at a high risk of polypharmacy.

Unfortunately, nurses in understaffed facilities are forced to take shortcuts, and quite often, the provision of accurate and detailed documentation is one of the first duties to be breached. Failure to maintain detailed and organized medical files leads to poor communication among nurses working different shifts, physicians, and future caretakers. Consequently, quality of care and the health of the patient suffers.

Performance-Based Payroll Programs Can Improve Quality of Care and Reduce Mortality

November 30, 2012 | by Yeroushalmi Law

Nursing homes and hospitals around the world have long operated on experience-based pay scales. Only recently, however, have various hospitals begun adopting performance-based payroll systems to improve the quality of care. The results are especially crucial for American health providers, who will move towards pay for performance in 2013 when it is officially introduced by Medicare. Although opposition to pay for performance has cited that little evidence exists connecting performance-based incentives to patient wellbeing, a more recent report published by the New England Journal Medicine (NEJM) reveals a strong correlation between pay for performance programs and reduced mortality rates. These findings pave the way for further research into better incentives for health care providers.

A common denominator among deaths in hospitals and nursing homes is understaffing. Most injuries and deaths are preventable through competent and sufficient caretakers. Understaffing refers not only to a lack of qualified staff available but also to the amount and quality of care and lack of effective staff. It is crucial that healthcare workers provide optimal attention to all patients and follow all policies and procedures to uphold a high standard of care.

In 2008, the National Health Service introduced Advancing Quality, a pay for performance program, to northwestern English hospitals. Based on the Hospital Quality Incentive Demonstration program in the US, Advancing Quality was designed to promote better quality of care by rewarding good performance with additional pay. The system was organized in a “tournament” format, providing bonus payments to only the top performers according to a set of standards. Poor performers were not penalized. Altogether, $7.5 million dollars were awarded in the first 18 months.

The NEJM study focused on comparing hospitals under Advancing Quality to hospitals that had not yet adopted the program. It scrutinized the 18 months prior to and 18 months following the introduction of Advancing Quality, analyzing mortality rates due to acute myocardial infarction, pneumonia, and heart failure. Taking into account chances of death due to patient history, age, sex, and stage of ailment at the time of hospital admittance, the study compiled data on over a million patients. This was charted next to the hospitals’ Advanced Quality rankings, or lack of one. In this way, they tested the effect of incentives on mortality rates.

The results demonstrated that risk-adjusted mortality rates for the three conditions decreased significantly with the introduction of the pay for performance program. With an overall 1.3% decrease in mortality rates, this was equal to 890 fewer deaths out of 70, 644 patients over an 18 month period. This is an especially positive outcome as opposed to the other hospitals, which had little to no change in mortality rates before and after the introduction of Advancing Quality.
The introduction of performance-based pay systems in the world of healthcare is a tremendous step towards improving the quality of care provided. A lower mortality rate is a definite sign of better treatment and standards, achievable through financial incentives, as demonstrated by this study. Understaffed facilities suffer from carelessness and neglect, often due to a lack of vigilance on the workers’ parts. Quality of care is the top priority at nursing homes, and can only be achieved through motivated staff. Burnout occurs when staff members feel overworked and disconnected from their jobs, which often leads to reduced attention to care. Financial bonuses provide incentive for adhering to high standard of care in nursing homes.

It is important to note, however, that providing pay incentives may also have negative consequences, and we often find that nursing homes will place profits over people. For example, an administrator may receive a bonus if he or she works within a certain budget, and of course, the easiest way to stay within budget is to shortstaff. That being said, this report by the NEJM, if nothing else, serves to reinforce that fact that many injuries that occur in health care facilities are preventable – the real underlying problem is that caregivers are just unmotivated or do not have the time to make the effort to take these preventative measures.

A Report by the Care Quality Commission Reveals Universal Problems in Long-Term Care Facilities

November 27, 2012 | by Yeroushalmi Law

The Care Quality Commission recently published a report called “The state of health care and adult social care in England” that reveals problems that are universal to long-term care facilities. The report concluded that three factors can be linked to low quality of care in nursing homes: a culture where substandard care is the norm; care that is task based rather than specially tailored to meet individual resident needs; and high turnover rates or poor deployment of staff.

What these three factors have in common is that they all have to do with the nursing home’s staff. The quality of a nursing home’s staff is central to providing your loved one with the care the he or she needs and deserves. Unfortunately, however, the study found 25% of nursing homes to be understaffed. Although California law requires a minimum of 3.2 nursing hours per patient day, having sufficient numbers of staff cannot be so simply quantified. The study considered inadequate staffing to be any level of staffing that prevented the facility from providing a high quality of care to its patients.

This proposes an alternative approach toward staffing levels that is instead based on patient acuity needs. David Behan, chief executive of the commission, asserts that “Health and care services need to rise to the challenge of responding to the increasingly complex conditions suffered by our ageing population. That means delivering care that is based on the person’s needs, not care that suits the way organisations work.” In fact, it is your loved one’s right under Health and Safety Code 1599.1 (a) to reside in a nursing home that is staffed to meet the needs of all residents at all times. Any breach of this duty on part of the nursing home affects the allocation of staff and resources and negatively impacts the care provided to all residents of the facility.

The study focused on mismanagement of drugs as a result of understaffing, which occurred in 22% of skilled nursing facilities. This can include chemical restraints, polypharmacy, and the use of drugs for off-label purposes, which can all lead to dangerous adverse drug reactions.

Also considered when evaluating the quality of care of a nursing home was dignity and nutrition. Many residents were spoken to condescendingly, did not receive privacy, or could not reach their call lights. In fact, the study found that 15% of nursing homes did not employ staff that treated its patients with respect. Some other common injuries that can be indicative of poor quality of care in nursing homes are pressure sores, dehydration, and infections.