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The long awaited Supreme Court verdict on the Patient Protection and Affordable Care Act (dubbed Obamacare), has come back in mainly favor of the new law. In a close ruling, five Justices, including Chief Justice John Roberts, upheld Obamacare with the remaining four dissenting. Although the majority of the law was accepted, Chief Justice Roberts quashed certain aspects as unconstitutional, in violation of the balance of federal and state power. The ruling upheld the new law as an acceptable use of congressional power to “lay and collect taxes”. But the provision for the government to withhold Medicaid funds from non-compliant states was rejected. Under the ruling, Congress will only be able to withhold extra funds meant to ease the exchange to the new system, but not take away the existing state Medicaid budget in its entirety.

The effects of the Supreme Court ruling on the healthcare industry are being debated. Pundits are already acknowledging the important role this will play in the upcoming presidential election, but it is really too early to tell what the implementation of the law will mean for healthcare agencies, patients, and insurance companies in the long run. The full provisions of Obamacare do not come into play until January 1st, 2014, but some effects are already being felt. The court decision has affected the stock prices of the healthcare industry, with hospitals up but insurance and pharmaceutical company prices dropping. There are some new developments that the healthcare industry can be sure of. Medicaid will be expanded, with a larger percentage of the population now being financially eligible. It is expected that 50 million uninsured people will gain access to insurance under this act. Medicare is also greatly affected, as many expensive prescription medications will now be covered and available as well as an elimination of co-payments for many types of medical procedures. This is of benefit to many of those in nursing homes, who are commonly on Medicare benefits.

With the requirement for all Americans to be insured, insurance companies are now required to accept in people with pre-existing conditions, who would commonly have been rejected, and not charge a premium for the coverage. While this is certainly beneficial for individuals, the financial toll this could take on insurance companies could be great. Some analysts contend that the law will actually end up benefitting insurance companies, but most agree that the price of healthcare will continue going up and future reevaluations and budget changes will probably be necessary.

As with the implementation of any new system, it is likely that many institutions will have a difficult period during the transition. The effect of 50 million newly insured people on the healthcare system could be a strain. For nursing homes, having to house and care for the additional numbers of patients could lead to problems in overcrowding and understaffing. The next few years may be an unsteady time for the quality of nursing home care. Medicare and Medicaid are integral in funding skilled nursing facilities, so the new changes to those programs are bound to have reverberating impacts.

With the many changes to the healthcare industry coming up under Obamacare, it is vital that nursing homes be monitored to ensure they are providing the health and wellbeing of their residents and upholding the Patient’s Bill of Rights. No matter what happens, all those residing in skilled nursing facilities should be free of avoidable infections, pressure sores, and injury from falling.

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Although it has always been required by law, many patients are unaware that health care facilities are required to provide them with access to their own medical records. The director of the Department of Health and Human Services Office of Civil Rights has recognized this problem and responded by releasing a right to access memorandum. This memorandum is a comprehensive one-page document that you can take to your doctor, hospital, or skilled nursing facility to retrieve your medical records.

Leon Rodriguez, director of the Office of Civil Rights, encourages patients to become more involved with their health care. His concern before issuing the memo was that too often, health care facilities used the Health Insurance Portability and Accountability Act (HIPAA) to prevent patients from having access to their own medical records. Some facilities act under false pretenses of protecting their patients’ privacy, while actually using HIPAA to their advantage to conceal and hold hostage their patients’ medical records.

You may wonder what incentives health care facilities have for concealing their patients’ medical records. Unfortunately, many California skilled nursing facilities today are guilty of nursing home neglect. When patients and their loved ones attempt to escape these abuses by taking legal action, nursing homes and their lawyers often use HIPAA to protect themselves by refusing to provide the patient with his or her medical records. Since the basis of a nursing home neglect case lies in the patients’ medical files, the inability of a patient to access his or her records can significantly hinder any lawsuit brought against the facility. For example, in certain class actions, attorneys will fight for years and are forced to take an excessive amount of steps and bring unnecessary motions just to send letters to other residents of the nursing home who may be potential class members.

In other instances, nursing homes have been found guilty of manipulating patient records or carelessly documenting certain conditions, while neglecting to document other important information. Inaccurate documentation can lead to improper assessments, withholding of treatments, and polypharmacy, all of which can lead to death. Because a nursing home staff may not be properly documenting your health condition, it is important that you use your right to access to obtain your own records and review them yourself.

Withholding of this information is especially egregious because patients have a legal right to access their own records. We hope that this article has been informative and will allow you to play a more interactive role in the care that you receive from any skilled nursing facility.

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A recent article in the Journal of Clinical Nursing, titled “Use of Physical Restraints in Nursing Homes and Hospitals and Related Factors: a Cross-Sectional Study,” studies the risks of using physical restraints in hospitals and nursing homes. The article defines a physical restraint as any device that limits the freedom of an individual’s movement. For example, bedrails, belts, geriatric tables, mechanical devices, straps, and vests are just a few of the different types of physical restraints that are commonly used in skilled nursing facilities.

By examining seventy-six nursing homes, the study aimed to identify the various factors that are related to the use of restraints in skilled nursing facilities. The study also considered the usage of physical restraints in hospitals as a basis of comparison in drawing conclusions about the reason that the use of physical restraints is so prevalent in nursing homes. While only 9.3% of hospital patients were found to be restrained, 26.3% of nursing home residents who participated in the study were subject to restraint at some point during their residency. Some shared characteristics of the patients who were restrained include disorientation and the presence of cognitive disorders, such as dementia, that may have caused the patient to wander. However, of the patients who were physically restrained, those who resided in nursing homes were usually determined to be at a lower risk of falling than those in hospitals.

Nurses in healthcare facilities often restrain patients unnecessarily. Usually, this phenomenon can be explained by understaffing. A previous study has shown that 37% of nursing homes used restraints because of shortages in staffing. As nurses are assigned far more responsibilities than they can single-handedly accomplish, they often feel that they are left with no other option than to restrain their patients. However, it is the duty of the skilled nursing facility to hire an appropriate amount of staff to sufficiently provide your loved one with the individualized care that he or she deserves and requires.

The patients who were physically restrained in nursing homes were also found to be more incontinent than those in hospitals. Incontinence is actually one of the consequences of restraint usage, so therefore, it makes sense that incontinence rates are higher in skilled nursing facilities, since use of physical restraints in nursing homes is so prevalent. Incontinence can lead to serious psychological problems, such as feelings of loss in dignity that no human being should ever have to experience. Some other psychological problems related to the use of physical restraints in general include embarrassment, feelings of confinement, aggression, social isolation, and anxiety. Furthermore, additional health complications include pressure ulcers, aspiration and breathing problems, agitation, constipation, decreased cardiovascular endurance and balance, and increased dependency in activities of daily living.

The study asserts that physical restraints fail to decrease the occurrence of falls, and that when falls do happen, the consequences are actually worsened by the presence of a physical restraint. There have been instances when fractures and suffocation directly caused by restraints have led to death. A direct quote from the article sums up the danger of using physical restraints effectively and concisely: “Physical restraints restrict persons in their human rights, do not protect them from harm, but are always harmful and should be avoided.” The use of physical restraints is ethically and legally wrong. It is extremely important for you to ensure that your loved one’s rights are not being violated, and that his or her physical and mental well-being is not at risk.

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On February 8, 2012, Bloomberg News reported that fourteen hospitals in New York are paying $12 million to settle the allegations that they made false claims to Medicare. Beginning in 2000, and for eight years thereafter, these hospitals overcharged Medicare for kyphoplasty surgeries that were performed on osteoporosis patients with spinal injuries.

As shocking as this may sound, similar fraud against Medicare occurs quite often. Just recently, a total of about forty hospitals have paid $39 million for similar cases of overcharging Medicare. Sometimes, these false claims are referred to as “upcoding” because the healthcare facilities upcode their patients’medical conditions, so that they can report a higher reimbursement rate.

Just a month ago, the federal government investigated another case in which pharmaceutical companies were manipulating their financial statements in order to profit from government health programs. You can learn more about this case and the incentives pharmaceutical companies and other healthcare businesses have to cheat Medicare by reading this California Nursing Home Abuse Blog.

Some skilled nursing facilities cheat government health programs for reasons other than to profit. For example, some facilities use Medicare or Medi-Cal money to order antipsychotic drugs that were never prescribed by a physician in the first place. These drugs are usually used as chemical restraints, to sedate dementia patients who have episodes of aggravation. However, studies have shown that the use of chemical restraints actually worsens aggravation and also makes patients twice as likely to die from an overdose. Furthermore, the use of restraints can not only lead to death, but is also a direct violation of the Patients’ Bill of Rights. The use of restraints is most commonly found in nursing homes that are understaffed and unable to personally attend to each patient and provide him or her with the individualized care that he or she needs.

In an attempt to stop fraud against the United States government and to encourage witnesses of such fraud to speak up, the federal government passed the False Claims Act, which states that whistle-blowers can sue on behalf of the government and receive a share of any claims that are made. This further proves how serious fraud against the government is, especially when the lives and well-being of nursing home residents are being put in danger.

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On February 2, 2012, the International Wound Journal published an article titled “Wound Outcomes in Patients with Advanced Illness.” The article studied elderly adults who were sustaining serious wounds, in addition to suffering from advanced illnesses, such as cancer. The patients had various types of wounds, including pressure ulcers, malignant wounds, skin tears, inflammatory wounds, and venous leg ulcers, arterial leg and foot ulcers. The goal of the study was to observe the potential for wounds to heal completely, despite the presence of an advanced illness.

The study split the participants into four groups based on the length of time that they were able to live with the wound before passing away. The divisions were as such: 7 days or less, 8 to 30 days, 31 to 91 days, and 92 to 182 days. The wound type that occurred most often in the patients studied were pressure ulcers. The results of the study showed variations in the complete healing of pressure sores, depending on their level of severity. Most pressure ulcers that had only progressed to the first or second stage were usually able to heal successfully and completely. However, only one stage three pressure ulcer in the entire study was able to heal completely, while no stage four ulcers were observed to have healed completely.

The results of the study merely emphasize the importance of identifying and diagnosing wounds early on in their stages of development. Many prevention techniques are available and are generally very successful in preventing the development of pressure sores. However, in order for any of these prevention techniques to be carried our properly and achieve their full effectiveness, facilities must be adequately staffed, as each technique requires careful attention to each individual patient.

Although the article defined an advanced illness as one that would cause the patient to die within six months, the study succeeded in disproving the common assumption that dying patients cannot fully recover from wounds. Unfortunately, many skilled nursing facilities leave patients to suffer in the last days of their lives because they are misinformed that there is no point in trying to heal the wounds of patients who are on their deathbeds. In choosing a nursing home for your loved one, make sure that the staff is knowledgeable and willing to provide your loved one with the best care possible, up until the end of his or her life. Any refusal on the part of the skilled nursing facility to provide your loved one with the care that he or she needs in order to achieve the best quality of life is considered an act of nursing home neglect.

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A recent study titled “Emergency Hospitalizations for Adverse Drug Events in Elder Adults” available in the November 2011 issue of The New England Journal of Medicine has discovered four drugs that are directly responsible for two thirds of all hospitalizations and overdoses in elder adults. Interestingly enough, these drugs are not considered by physicians to be risky, but rather are very commonly used, especially in elder adults. These drugs include blood thinners and medications for diabetes.

The study recorded that 33% of hospitalizations were caused by a blood thinner called Coumadin. Insulin was responsible for 14% of hospitalizations, with other blood thinning drugs following closely at 13%. The last type of drug, called a hypoglycemic agent, is an antidiabetic drug that is taken orally. It was found to be responsible for 11% of hospitalizations of elder adults. These four drugs all have one thing in common: a narrow therapeutic index. This means that the line between a recommended dosage and a fatal dosage is very thin. Therefore, close monitoring of every individual is required in order to attain an ideal dosage that is both safe, as well as effective.

While taking blood thinners and antidiabetic drugs, it is highly recommended and often required for patients to undergo periodic blood tests. Their blood must be monitored closely to ensure that the drugs are not having any negative side effects on the patient. Additionally, it is important for the patient to have routine check-ups in the case that he or she is eligible for a dosage decrease. Because the therapeutic index of these drugs is so narrow and the risk of overdose is so high, it is especially important that your loved one’s dosage is closely monitored and maintained at a safe level.

Although it may be a tedious task to monitor someone taking one of these drugs and ensure that they are constantly receiving blood tests and necessary check-ups, it is crucial to their health and safety. Therefore, if your loved one resides at a nursing home, it is important for you to make sure that the home is adequately staffed and that the caregivers are well-trained and closely monitoring your loved one.

Another factor that must be monitored when an individual is taking one of the four aforementioned drugs is nutrition. Food can interact with these drugs and alter their effectiveness. This may lead to a necessary change in dosage as a precaution against overdose or hospitalization. Therefore, it is essential that your loved one is not a victim of malnutrition because in addition to its obvious health-related repercussions, malnutrition may also contribute to an inappropriate dosage amount and possibly hospitalization and overdose.

It is also important that your loved one’s nursing home is organized. Every resident should have detailed and extensive medical records. If your loved one’s records are unsubstantial, he or she may be at higher risk for polypharmacy, which is the excessive use of multiple prescribed drugs simultaneously. Because these drugs already put your loved one at higher risk of overdose, taking more than one can be especially dangerous. Therefore, it is important that the nursing home keep track of all medications that their residents are taking so that their physicians are aware that they are taking these drugs before prescribing other ones. While keeping records of all residents’ health should not be a difficult task, it is indeed an important one because a lack of organization may have serious consequences such as overdose and even death.

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In today’s scientifically advanced world, determining whether or not a nursing home resident displays symptoms of depression can be done quite simply and accurately. A more prevalent issue relating to depression involves the quality of treatment in nursing homes. A recent study titled “Antidepressant Prescribing Patterns in the Nursing Home: Second-Generation Issues Revisited” conducted by the Journal of American Medical Directors Association takes data from ten different nursing homes and analyzes how different factors influence the use of antidepressants among nursing home residents. The results of the study show a significant correlation between quality of treatment and pertinent documentation provided for this treatment.

In order to provide your loved one with the best possible care, it is important first to know exactly what his or her rights are. The Omnibus Reconciliation Act of 1987 requires that nursing home staff provide detailed records and regular assessments regarding the use of psychoactive drugs, including documentation of reasons for use and periodic attempts at dose reduction. This law was enacted for a specific reason. It is a health risk for nursing home residents to be using antidepressants without proper documentation of the patient’s depressive symptoms, the original reason for the prescription, as well as the reason for continued use of antidepressant drugs, and any side effects that these drugs may have.

In their study, the American Medical Directors Association found that 33% of nursing home residents who used antidepressant drugs had no documentation of actually being diagnosed with depression. Although in some of these cases antidepressant drugs were being used to treat other illnesses, many lacked any reason for the prescription of these drugs in the first place.

In the charts of those patients who were documented with a diagnosis of depression, the specific symptoms that led to this diagnosis and the subsequent prescription of antidepressants was missing. There were many patients who were diagnosed with depression and prescribed antidepressants, but later discontinued their treatment and 85.7% of such charts did report the reason. However, these reasons were found by the American Medical Directors Association to be vague, with “little explicit information…provided regarding the reason behind treatment changes.” While documentation is generally a sign of sufficient monitoring of a patient, the quality of this documentation is even more important. Documentation must be substantial and patient-specific in order to really be of any use to the patient and his or her future caretakers.

The accuracy of documentation is another area of concern. Although 65% of patient charts claimed that they were being monitored by psychiatrists, their quarterly reviews did not include documentation of any monitoring for depression symptoms. It is important to extensively investigate your loved one’s nursing home to ensure that his or her caretakers are actually following through on their documented promises.

The lack of monitoring and documentation of nursing homes is often a consequence of understaffing. In their study, the American Medical Directors Association discovered that nursing homes with low licensed nursing staff were less likely than those with higher licensed staff to document the presence or absence of depressive symptoms.

Although clear documentation does signify better organization and closer monitoring of patients, it may seem unimportant in comparison to other priorities of nursing homes. However, lack of documentation can lead to very serious consequences that often result in death. Nursing home residents often take multiple drugs for various reasons, putting them at risk of polypharmacy. In addition to the danger of simultaneously using more drugs than recommended by professionals, polypharmacy also places an emotional burden on elderly adults who have too many pills to take. Additionally, unless a patient is being closely monitored, it is impossible to determine whether or not he or she requires a change in drug dosage.

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If your loved one resides in a nursing home and has dementia, you should work with the medical staff to ensure that your loved one lives in conditions that facilitate a good quality of life.

According to the recent article titled Quality of Life of Nursing Home Residents With Dementia: A Comparison of Perspectives of Residents, Family, and Staff, published in The Gerontologist, since dementia currently has no cure, quality of life (QoL) is recognized as a meaningful indicator of the course of illness and the effectiveness of interventions. It is possible for a resident to receive good care at a long-term care facility, yet not experience good QoL.

Measuring QoL is inherently subjective–it is defined in terms of individuals’ perceptions on their well-being in the context of the culture and values in which they live compared to their goals, expectations, and standards. For residents with dementia, measuring QoL is more complex because the residents’ self-assessment may be affected by cognitive impairment, including issues involving memory and reasoning, and noncognitive ailments, such as depression and psychosis, which are not uncommon in individuals with dementia. Because of these cognitive and noncognitive concerns, measuring QoL for patients with dementia involves a consideration of the views of both the patients and proxies, including the family and nursing home staff.

The authors discuss a study conducted in Spain where the views of nursing home residents with dementia with regard to QoL were directly compared to the views of family and nursing home staff. To measure QoL, residents, family, and staff completed a questionnaire where the individual completing the questionnaire rated various factors comprising QoL in the nursing home environment, including physical health, energy, memory, family, and staff.

Nursing home residents with dementia view their QoL more favorably than their family members and nursing home staff. Residents view many aspects of QoL more favorably than family and staff: energy, mood, friends, ability to keep busy, ability to take care of oneself, ability to do things for fun, ability to make choices in one’s life, ability to live with others, and their life overall. Among all the participants in the study, the people working in the nursing home rated the highest, and memory was rated the worst. For family members and staff, the resident’s abilities for independence and making choices rated among the worst.

Family members and nursing home staff tended to rate the residents’ QoL similarly, but less favorably than the residents, including mood, memory, and physical health. Several reasons for this less favorable assessment include (1) the role that the subjective view of residents play in assessing QoL, (2) the lack of understanding of dementia in family members and staff, (3) the residents’ partial awareness of their declining capabilities, and (4) the external observers’ tendency to weigh negative information more heavily than positive information when forming opinions about other people.

In evaluating the outcome of care, it is challenging to determine whether the proxies’ viewpoint or the residents’ viewpoint into QoL is more valid. However, the study suggests that the residents’ assessment of their QoL should be considered because it provides a different perspective from that of the proxies. Thus, it is increasingly recognized that QoL should be a primary outcome of interest in the care given to residents with dementia.

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Methicillin-resistant Staphylococcus aureus (MRSA) is a harmless type of staph bacteria that lives on the surface of the skin. It does not become problematic until it enters the body through an open wound, breathing tube, or catheter. Because MRSA is resistant to certain antibiotics that are commonly used to treat and cure staph infections, it can become an extremely serious problem, especially in skilled nursing facilities. MRSA colonized residents are more likely to develop infection than noncolonised ones, and thus have increased risk of death. (For more information, visit the Centers for Disease Control and Prevention.)

A recent study, titled “MRSA: A Challenge to Norwegian Nursing Home Personnel” and published in Interdisciplinary Perspectives on Infectious Diseases, highlights how the spread of MRSA creates challenging tasks for nursing home staff because of the increased workload associated with cleaning, disinfection, and sanitation of the environment and of the MRSA-infected residents. The study also found that problems related to the control of MRSA are associated with “old buildings standards not suitable for modern infection control work with lack of isolates, single rooms and bathrooms, [and] a low rate of professional healthcare staffing and education in infection control work.”

To decrease the risk of transmission of MRSA within nursing homes, nursing home owners and operators need to avoid overcrowding the facility and must provide adequate staff to effectively implement infection control and preventative measures. Without adequate facility space to isolate the infected residents or carriers for treatment and decolonization of MRSA, staff, visitors, and other patients are exposed to the infection and the likelihood of an infection outbreak increases significantly. High quality care by well-educated and well-trained staff, who are capable of following MRSA control guidelines, is absolutely necessary to successfully controlling and treating MRSA infections.

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If your loved one currently resides in a Skilled Nursing Facility (SNF) or nursing home in Southern California, and has problems receiving adequate nutrition, you may have considered whether your loved one should use a feeding tube.

According to a recent article titled Enteral Nutrition for Older Adults in Nursing Facilities, published in the June 2011 volume of Nutrition in Clinical Practice, older adults (those 85 years of age and older) residing in nursing facilities tend to have multiple health conditions and an increased need of assistance with activities of daily living, such as eating. Approximately fifteen percent of residents of nursing facilities need constant assistance with eating. Thirty-two percent of residents have sensory impairments, including problems with teeth, which hinder eating.

It is the responsibility of the healthcare practitioners at nursing facilities, including physicians, nurses, and dieticians, to ensure that residents receive adequate nutrition. One of the methods used to ensure that residents are receiving adequate nutrition is for those residents to rely on feeding tubes. If a feeding tube is used, the registered dietician (RD) often determines the nutritional requirements of each resident and ensures that each resident’s nutritional needs are met. Failure to monitor the nutritional intake of residents can lead to malnutrition, which in turn can lead to weight loss, pressure ulcers, and other fatal problems. These injuries are often signs of neglect.

According to federal regulations, use of a feeding tube should not automatically be the preferred option for residents not receiving adequate nutrition. Before a feeding tube is placed, the nursing facility must ensure that 1) the use of a feeding tube is unavoidable for those who have been able to eat with or without assistance, and 2) residents receiving nutrition through feeding tubes receive attention and treatment to prevent complications, such as aspiration pneumonia, vomiting, and dehydration, and to restore normal eating abilities, if possible. (42 C.F.R. § 483.25(g).)

The authors of the article state that the resident’s wishes regarding the use of a feeding should be respected. The resident may have expressed his or her preferences when admitted to the nursing facility, in an advanced directive, or a living will. If no preferences can be determined, then a decision has to be made on whether use of a feeding tube is worthwhile. Feeding tubes are appropriate in various situations, including 1) when a return to previous quality of life is expected, 2) when a resident has a permanent problem swallowing or has a damaged esophagus, and 3) for people with head and neck cancer or acute stroke with dysphagia as a possible method to prolong life.

In a nursing facility, the RD is responsible for assessing the nutritional needs of residents, tailoring the formula residents receive through the feeding tube based on those needs, and changing the tube feeding orders as needed. The RD, along with the healthcare team, should continually monitor the effectiveness of the tube feeding, including formula administration, tolerance of the feeding, nutrition status, and overall health and well-being. Proper monitoring will reduce the incidence and severity of complications as a result of tube feeding, including clogging, aspiration pneumonia, and diarrhea.

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