Quality of Care

ProPublica’s Nursing Home Inspect: Bringing Light to Elder Abuse in Your Area

September 11, 2012 | by Yeroushalmi Law

Elder abuse and neglect within America is very common in nursing facilities, but is a largely ignored issue. However, a new online tool has recently been introduced that promises to change the way elder patient safety and abuse is monitored and understood. Created by ProPublica, Nursing Home Inspect now allows anyone with an internet connection the ability to check the nursing homes in their surrounding area for their most recent government inspection reports, with the statistics compiled together. Also included is a tipsheet on how to use Nursing Home Inspect to the best of its ability. It differs from the records found on the official U.S. Center for Medicare and Medicaid Services (CMS) website, as it allows you to search by keyword, city, and home’s name and also allows you to search all of the government reports at one time. Overall, the website is very convenient and user friendly. These government inspection forms are important, as they note potential abuse and neglect found through documentation of deficiencies within specific nursing homes.

The ProPublica database conducts its searches such that it allows the user to look for a pattern of problems that might exist in the nursing homes within his of her area. This is extremely useful to those doing research on the nursing homes within their area to see what kind of situations they might be placing their loved ones in. There are many common problems that exist within nursing homes, most of which can be linked to understaffing or lack of proper training within a nursing facility. Both lead to the substandard care of the elderly, which in turn cause diseases and injuries that could have been preventable in the first place.

One such problem is the development of pressure ulcers, which are open wounds that form when constant pressure cuts off a patient’s blood supply to a certain area of the body. Usage of the Nursing Home Inspect database to search for the phrase “pressure sore” turned up over 2,000 results, which is an alarming number of incidents considering that pressure sores are preventable. The inability of a facility to prevent pressure ulcers from development and aggravation usually is a clear indication of neglect occurring within the nursing home.

The Existence of Rituals of Abuse in Nursing Homes

September 7, 2012 | by Yeroushalmi Law

It has been estimated that with the “baby boom” generation now approaching retirement age, nearly 25% of the elderly population aged 65 years or older will spend part of their life residing within a nursing home. While the elderly should both expect and receive excellent, loving care at a facility where they will possibly spend the remainder of their life in, most patients are instead abused and neglected. They are treated not with dignity and compassion, but with contempt and ridicule. With such a large influx of potential patients looming on the horizon, nursing homes desperately need to change the means by which they function and treat their patients.

In the Journal of Women and Aging, a book review was recently conducted on a source concerning the ritual of abuse that currently exists within nursing home systems. The studies actually found that abuse suffered by the elderly most often occurred through four different ways: medical abuse, personal abuse, emotional negligence, and verbal abuse. Many caretakers within the study saw their nursing home residents as “‘unemotional work products’ rather than people in need”. More often than not, this abuse occurs because of a nursing home’s <a href="”>understaffing problems or lack of adequately trained staff. When a facility is understaffed and incapable, they cannot provide the proper amount of care or attention that a resident might need which could result in the development of pressure sores, falls, and even death. The elderly are also more susceptible to dehydration and malnutrition and need to be properly monitored to ensure that they keep up their daily intake.

What is extremely frustrating is that with enough attention and proper care, all of these diseases and health issues can be preventable. The correlation drawn between adequate staffing and the prevention of diseases from developing is not pure conjecture, but has been proven in various studies. One such study highlighted that if nursing home workers are actually trained through a mandatory program, overall communication is improved and hospitalizations can be prevented from occurring in the first place. There is a general consensus that America’s elder care industry is currently broken by the blatant abuse that occurs every day in nursing homes.

The Patients’ Bill of Rights claims that any skilled nursing facility has the obligation to provide their residents with a safe living environment, and to treat them with respect and consideration. It is a grossly unfair situation to the residents of such nursing homes that unfortunately cannot protect themselves from being neglected.

Lack of Training in Nursing Home Staff Can Lead to Preventable Emergency Hospitalizations

August 21, 2012 | by Yeroushalmi Law

In every calendar year, roughly 25% of all the patients in a nursing home are transferred to a hospital or emergency room. There have been recent concerns within the healthcare community that transfer rates are higher than what they should be. A recently published study looks at the frequency of hospitalizations in New York nursing homes and what impact education programs can have on preventing transfers.

In the world of long term care, hospitalizations are not generally beneficial to the patient. Such events not only indicate a deterioration in patient health, but the actual act of transferring can put great strain on a person’s body, mind, and health: transportation, change in environment and people, miscommunications about treatment and care plans, etc. Communication between nursing facilities and emergency personnel/hospital staff is an area where much can slip through the cracks, resulting in worse care for the patient. An article that was published last year delves into the issues surrounding the lack of thorough communication involved in hospitalizations. The authors recommended that a more comprehensive documentation system be put into place and that verbal communication, to augment and explain written forms, be mandatory. In the present state of affairs, much information is lost between facilities as people fail to completely fill out transfer forms or are unable to understand the notes of the other facility. In such cases it is the patient’s quality of care that suffers and the already stressful process of transferring from facility to facility is made worse.

Considering the toll hospitalizations can take on the health of those in long-term sub-acute care, it is important for skilled nursing facilities to attempt to reduce any unnecessary or preventable transfers. The recent study of New York nursing homes reported that in using an education and training system, they were able to observably lower the rate of hospitalization. The program used is called INTERACT, “Interventions to Reduce Acute Care Transfers”. The main principles of this system are educating nursing home staff in early detection of problems and how to communicate and handle these issues in a timely fashion, before they become severe enough to need transfer to an emergency facility.

The lynchpin on this program is the education of employees in how to recognize problem symptoms and the correct responses to any such problems. The efficacy of the INTERACT program, which has been through multiple successful trials, speaks to the fact that good training systems for staff are not currently in place. The failure of a nursing home to adequately train staff violates the patient’s right to be cared for by knowledgeable and qualified care-givers, set down in Health and Safety Codes. Factors that can commonly contribute to failure to provide proper training to employees are understaffing and fiscal meanness.

In the situation discussed in the referenced study, untrained staff can lead to increased hospitalizations and miscommunications between facilities, which can have a great negative impact on the patient. And there are many other harms that can be inflicted upon residents in understaffed nursing homes. Conditions such as pressure sores are preventable with enough care and attention, but can become severe and very painful if a patient is not well-looked after or if the proper preventative measures are not carried out. Infection control is also greatly affected by staff numbers and education. Studies have shown that a great number of nursing home staff are not educated in basic infection prevention techniques, such as proper hand washing and sterilization. Lack of training in this area, along with low staffing levels, has been correlated with higher rates of preventable infections, such as scabies and methicillin-resistant Staphylococcus aureus (MRSA).

Failure of Nurses to Wash Hands Greatly Increases Spread of Infections

August 6, 2012 | by Yeroushalmi Law

A recent study published in the Journal of Hospital Infection looks at the transmission of bacteria in long term care facilities. The researchers reported the results of their experiment in “Effect of an infection control programme on bacterial contamination of enteral feed in nursing homes”. The study measured the spread of methicillin-resistant Staphylococcus aureus (MRSA), a prevalent healthcare associated infection, between patients with enteral feeding systems and nursing staff.

Enteral feeding is used on nursing home and hospital patients who, for whatever reason, cannot feed themselves. A tubing line is threaded down the esophagus to the stomach or inserted directly into through the stomach wall. These patients are given a liquid milk based diet. Because the method of feeding delivers food directly into the body, proper hygiene when dealing with the feed or equipment is very important as such patients are more susceptible to infection. This study found that contamination of enteral feed and equipment was quite prevalent in nursing homes. The most frequent vector of spread was the hands of nursing home staff, which had not been adequately washed and decontaminated as they moved from patient to patient.

The researchers found that establishing an infection control procedure (ICP) in the home greatly reduced contamination and infection. The ICP consisted of educating the staff about enteral feeding and how to clean equipment, but most important was teaching about proper hand-washing and hygiene techniques. The simple act of making sure that employee hands were cleaned between patient visits had a great impact on reducing infection threats.

As part of the Patients’ Bill of Rights,every nursing home resident is entitled to reside in a hygienic environment, without the threat of constant infection or injury. It is the responsibility of the home to provide this. As this study shows, just the simple act of hand washing can have a huge impact on infection spread. Nursing homes need to spend the time to educate their employees in infection control procedures and other general safety measures.

Beyond the lack of knowledge of infection control measures, many nursing homes do not employ enough staff to fully carry them out. When nursing homes are understaffed, those nurses who are caring for all of the patients are more hurried and stressed, which can lead to lapses in judgment, lax adherence to infection control measures and other healthcare guidelines, and burnout syndrome. This directly imparts a negative impact upon nursing home residents. Laxity in infection control increases infection rates in homes, which can at minimum cause the patient a great deal of discomfort and at worse result in their premature death. The MRSA contaminations observed in the study discussed are correlated with at least a 2.5 fold increase in mortality.

Prevention of falls and pressure sores are also within a nursing home’s purview. Training and time on the part of staff members is integral in avoiding such injuries. And at times lack of staffing resources can spur employees to use drastic measures to cope with overwork, such as the excessive application of restraining devices in the stead of direct care, supervision, and assistance. Such acts can not only increase the patient’s risk for further injury, but also constitute an infringement upon every nursing home patient’s rights.

Recent Study Links Osteoporosis Medications to Incidents of Thigh Fractures

May 24, 2012 | by Yeroushalmi Law

Osteoporosis is an common bone disease, especially in women over the age of fifty. While many medications have proven to be effective in the treatment of osteoporosis, recent studies link a class of drugs called biphosphonates to thigh fractures. Two examples of biphosphonates that are used to treat osteoporosis are Fosamax and Actonel. The University Hospitals of Geneva conducted a study that was published by the American Medical Association to determine the risks of taking biphosphonates.

The Wall Street Journal reported that the study included 477 osteoporosis patients over the age of 50. Of these patients, 39 were inflicted with thigh fractures that are associated with biphosphonate drugs. These thigh fractures are particularly unusual because they occur upon minimal to no impact. For instance, some patients experienced these types of fractures from stepping off a curb. Of these 39 patients, 32 were taking a biphosphonate drug and 11 had fractures in both legs. The study concluded that although biphosphonate drugs are effective in treating osteoporosis, after three to five years, patients should consult their doctors about continuing on this drug regime. At this point, the risks of using biphosphonate drugs may outweigh the benefits.

This new information on medication for osteoporosis highlights the need for skilled nursing facilities to continually train and educate their staff. A nursing home with high quality care must take a broader approach to care of their patients. Although Registered Nurses (RNs) play an extremely important role in the care of nursing home residents, other types of staff are necessary as well. For instance, in this specific case, nursing homes need to employ bone specialists, dieticians, and physical therapists that have the most current information on osteoporosis treatments and can provide osteoporosis patients with the care that they require.

The involvement of multiple parties and disciplines in the care of an individual, however, also requires effective communication. Documentation of medical conditions becomes even more important because doctors, nurses, specialists, and therapists need to have accurate information about a patient’s health condition in order to provide the most effective care. When medications are involved, as is the case with these osteoporosis drugs, it is particularly important to accurately document a patient’s health condition. Often, when caregivers are not aware of other medications already being prescribed to the patient, polypharmacy occurs. Although polypharmacy may seem unrelated to this case with osteoporosis treatments, this new research on biphosphonate drugs definitely highlights the importance of communication and collaboration among the various fields of medicine.

Medicare’s ‘No-pay’ Rule Has Lead to Improvements in Infection-Control in Health Care Facilities

May 20, 2012 | by Yeroushalmi Law

When it was first adopted, Medicare’s ‘no-pay’ rule was a controversial topic in the world of healthcare. Under the ‘no-pay’ rule, healthcare facilities are not eligible to receive Medicare funding for treatment of conditions acquired within the facility. However, this rule has actually proven to be beneficial to improving quality standards of healthcare facilities, as hospitals and nursing homes now have a greater incentive to prevent infections and other conditions from developing under their watch.

While many different conditions are can be facility-acquired, the three most common were various types of infections related to surgical procedures and the use of catheters. Some other examples of common infections include Methicillin-resistant Staphylococcus aureus (MRSA), scabies, Clostridium difficile (C. difficile), and sepsis. In a recent study by the American Journal of Infection Control, reported by American Medical News, it was found that 70% of professionals now claim that they are spending more time educating their staff on infection prevention techniques as a result of the ‘no-pay’ rule.

This is not the first incentive program that Medicare has implemented, however.
For example, another recently enacted Medicare program makes the amount of funding provided to a healthcare provider directly contingent upon its quality rating. Meanwhile, the Department of Health and Human Services will award healthcare agencies up to $216 million in funding for reducing preventable injuries.

While they have proven to be beneficial, the necessity of incentive programs highlights the many conditions that can develop as a result of nursing home neglect and understaffing. Some nursing homes will even “downcode” serious conditions in order to relieve themselves of liability and continue to receive funding from government healthcare agencies. This dangerous practice further decreases your loved one’s chances of receiving the care that he or she requires. Because nursing homes and other healthcare facilities have incentives to hide conditions from government health agencies, it is important for you to be extremely attentive of your loved one’s health. Rather than blindly accepting the nursing home’s assessment of your loved one’s health condition, you should often examine your loved one yourself. It is important for you to be aware of all these abuses before choosing a nursing home for your loved one.

How You Can Avoid Burnout and Still Care for Your Aging Parents

May 7, 2012 | by Yeroushalmi Law

Many couples nowadays work simultaneously and take care of both their aging parents and their children. Coined the “sandwich generation”, these couples may experience a burnout as they have to focus on their job, care for their children, their marriage and the health of their aging parents. A study published in the Social Psychology Quarterly looked at what factors attributed to these burnouts and coping methods for successful couples. In interviews from the study, one of the most frequently mentioned stress factor was caring for aging parents, which was reported to be even more difficult than caring for young children.

The couples who were interviewed pointed out that much of the stress that comes from taking care of elderly parents comes from watching their decline in health each visit, and that having the support from their partner helped them immensely. The study found that lower rates of couple burnout correlated with lower rates of job burnout, and that one of the most important coping methods associated with reducing couple burnout was visiting their parents together. Visiting their parents together therefore strengthened their marriage, and reduced the stress of seeing their loved ones in a compromising situation.

Coping with the difficult task of watching the health of your loved ones decline is only one of the many stresses that families have to deal with. Families that decide to choose a nursing home for their parents are presented with a whole new array of stresses. With the wide array of choices, it becomes difficult to decide which facility will provide the best care with the most convenient location. As the article suggests, an important part of making the decision is making it together. It is also important, before making the decision, to visit the facility together to ensure that the facility has all the needs of your loved one, and staff that will offer professional care.

If you or your loved one is seeking a nursing home, the main issue to keep in mind is ensuring that the nursing home is not understaffed. In order to provide the proper care, one of the most basic requirements is that the nursing home has enough staff to give attention to each resident. Understaffing can lead to a wide array of problems, including malnutrition at mealtimes, an increased amount of falls, increased likelihood of pressure ulcers, and possible misuse of physical restraints.

Recent Study Links the Lack of Direct Care from Registered Nurses to an Increase in Pressure Sores in Los Angeles Nursing Homes

February 24, 2012 | by Yeroushalmi Law

A recent article titled “Observing How RNs Use Clinical Time in a Nursing Home: A Pilot Study” observes how RNs allocate their time between direct and indirect care of their patients. While direct care generally involves physical and psychological care and the administration of treatments, indirect care is more administrative, including documentation and reading of medical records and care supervision and management of nursing aides and certified nursing assistants.

The results of the study showed that RNs spent 59% of their time in indirect care, and only 31% in direct care. The remaining 10% was classified as unproductive time, including breaks and mealtimes. Of the time spent in direct care, the majority, 94.6%, was spent in executing general care procedures. The remaining 5.4% was spent in clinical care, which involves the direct care of pressure ulcers, pain management, and nutrition and weight loss. Because direct care from RNs is so valuable, the study encouraged RNs in skilled nursing facilities to allocate their time between direct and indirect care more wisely.

Despite common misconceptions that direct care is more beneficial than indirect care, previous studies have actually shown that both types of care are important. One study has proven that poor supervision, which is a type of indirect care, is actually related to an increase in cases of pressure ulcers, as well as job dissatisfaction and turnover. On the other hand, direct care is also associated with reduced pressure ulcers, as well as a decline in other adverse outcomes including urinary tract infections, catheterization, and weight loss, while improving the use of nutritional supplements and the maintenance of activities of daily living.

While the implementation of direct versus indirect care each has its own results, under both types of care, the development of pressure ulcers is affected. This is due to the fact that prevention of pressure ulcers is highly dependent on RN staffing levels and quality of care. In fact, pressure sore prevention is so reliant upon the nursing staff, especially RNs, that the prevalence of cases of pressure sores is actually considered to be an indicator of quality of care that a nursing home provides.

Not only does there have to be an adequate amount of staff, however, but this staff must also be well-trained on how to prevent, diagnose, and treat pressure ulcers. While prevention is a completely feasible and necessary part of patient care plans, when pressure sores do begin to form, it is key for nurses to be able to recognize these wounds in their early <a href="stages of development before they progress into more serious stages that can often result in death.

Patient Dumping: A Common Practice in Los Angeles Healthcare Facilities

February 21, 2012 | by Yeroushalmi Law

Recently, the Los Angeles Times reported on a hospital that has been accused of patient dumping. Jesse Bravo, a patient at White Memorial Medical Center here in Los Angeles was admitted to the hospital for treatment of schizophrenia. When he was discharged, Bravo’s wife was not notified and instead, he was dropped off in front of a rehabilitation center. Bravo reportedly never actually went inside and spent several days on the street before police found him and brought him home his wife, who had filed a missing persons report. The couple is now suing the hospital for elder abuse, hospital negligence, and false imprisonment.

According to the article, over the past few years, patient dumping has become a serious problem. In response to this issue, Los Angeles law enforcement authorities have been strictly regulating policies against patient dumping. Chief Deputy City Attorney William Carter said that “The message was sent in the city of Los Angeles that this kind of activity would not be tolerated and would be closely watched.” Unfortunately, similar cases of elder abuse and neglect occur regularly, not only in hospitals, but also in nursing homes and other long-term care facilities.

In skilled nursing facilities, especially those that are understaffed, duties are often carried out carelessly and recklessly. This inattentiveness often leads to errors that are detrimental to the health of patients and sometimes even death. Patients with cognitive disorders such as dementia and Alzheimer’s disease are at an especially high risk of nursing home neglect. While their conditions require additional attention and care, nursing homes often fail to provide for these needs.

In a recent case taking place in a nursing home, a patient with memory problems was allowed to wander out into a seven lane road in forty-eight degree weather, wearing only pajamas. Furthermore, it took the facility two hours to notice the patient’s disappearance before they reported him missing. In another nursing home, a woman with dementia suffered from hypothermia when she was found outside in twelve degree weather at 4:00 a.m.

Although skilled nursing facilities may seem fully staffed, we often find that there is a discrepancy between the staffing levels of different shifts. For example, in the case discussed above, while the facility may or may not have been fully staffed during the day, they were most likely understaffed during their night shift, since the woman was clearly not being closely monitored, as she was able to wander from her bed outside into the cold.

When healthcare facilities are understaffed and are failing to provide your loved one with the care that he or she needs, they are violating the Patient’s Bill of Rights and committing elder abuse. Under the circumstances that their carelessness and neglect directly contribute to the death of a patient, the successors of the resident may be able to make a Wrongful Death claim.

Recent Study Proves that Los Angeles Nursing Homes Need to Be More Careful in Administering High Dosages of Drugs

February 3, 2012 | by Yeroushalmi Law

A recent article, titled “Anemia in Nursing Homes: A Complex Issue,” was published in the Journal of American Medical Directors and studied the nature of anemia in skilled nursing facilities, including its causes and treatments. The article cited iron deficiency, protein malnutrition, frailty, and weight loss as some causes for anemia. In caring for anemic residents, the nursing home staff needs to be cautious because this condition not only leads to decreased muscle strength, mobile impairment, and an increased risk for falls, but is also very tricky to treat.

The study aimed to disprove the common misconception that taking a high dosage of iron, up to 200 milligrams daily, is a simple way to overcome anemia. Participants were divided into three groups, each taking a different dosage of iron daily. One group took 15 milligrams, the second took 50 milligrams, and the third group took 150 milligrams. The study was conducted over two months. At the conclusion, the researchers determined that regardless of the dosage amount, each group experienced the same increase in iron levels.

Ultimately, we can take from this study that in caring for our loved ones, it is best to maintain all medications at the lowest dosage possible. In the case of anemic patients, those who were taking a higher dosage of iron experienced side effects, including abdominal pain. They were also less likely to adhere to their prescription, taking only portions of their medication, rather than the entire dosage. The study asserted that a dosage as low as 30 milligrams is sufficient in effectively treating anemia. It was also noted that since iron interferes with the absorption of other drugs, it should not be taken in conjunction with other medications.

In order to best assure your loved one’s health, regular check-ups and updates to his or her medication prescriptions are recommended. Furthermore, proper documentation and updated records must be kept in an orderly fashion, so that current physicians can be aware of the patient’s medical history, as well as medications that the patient is currently taking, or has taken in the past. Keeping organized records of a patient’s medical history also facilitates physicians in lowering dosages, when possible, as the patient’s condition is treated and his or her health improves. Organization of medical charts has a significant impact on keeping your loved one’s drug intake to a minimum.

Often, disorganization and lack of documentation in skilled nursing facilities is a result of understaffing. When nurses are assigned too many duties and responsibilities, they tend to overlook or skip certain steps in the caretaking process that they deem unimportant. However, it is the responsibility of the skilled nursing facility to employ a sufficient amount of staff and ensure that every measure is being taken to maintain the highest practicable health and well-being of the residents.

Carelessness and improper documentation of prescribed drugs can lead to overdoses, adverse drug reactions (ADRs), and sometimes even death. In addition to monitoring your loved one’s iron intake, other drugs that are commonly abused or misused in nursing homes are antipsychotics. Drugs that are improperly used are considered chemical restraints. The use of restraints is both a threat to your loved one’s physical and mental well-being and a direct violation of the Patients Bill of Rights.