California Nursing Home Abuse Lawyer Blog

Four Medications Have Been Discovered to Cause the Most Overdoses in Elderly Adults

November 29, 2011 | by Law Offices of Ben Yeroushalmi

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.

Recent Study Shows that Use of Antipsychotics to Chemically Restrain Nursing Home Residents Directly Aggravates Dementia-Related Agitation

November 23, 2011 | by Law Offices of Ben Yeroushalmi

Studies show that one in five adults residing in nursing homes experience agitation, which can manifest itself as irritability, apathy, or depression. While agitation occurs in adults who are relatively healthy, it becomes problematic when adults who have dementia become agitated because these cases of agitation are more likely to progress into more serious phases. In a study titled “Dementia-Related Agitation,” available in the November 2011 Journal of American Medical Directors Association, John B. Morley studies the relationship between dementia and agitation in nursing home residents and proposes some solutions to this issue.

One cause of agitation is pain. Therefore, it is very important for nursing homes to have high-quality pain management programs such as music therapy, dance therapy, and pet therapy. Psychosocial interactions and exercise therapy have proven to be the most effective treatments for pain management. However, for any of these treatments to reach their full potential in terms of effectiveness, caretakers must be thoroughly educated in these areas and must be provided the tools and resources necessary to implement such programs by the nursing home’s owners and operators. For this and for many other reasons stressed in the series of articles published in this nursing home and elder abuse blog, It is critical for you to ensure that your loved one’s care facility is adequately staffed and that your loved one is being properly cared for by a knowledgeable and well trained staff. If you watch your loved ones like a hawk, you will instinctively know when a facility is not only understaffed, but also undertrained and not properly supplied with the resources it needs.

Malnutrition also factors in to the causes of agitation. A lack in nutrients can cause visual and oratory problems that may hinder the ability to see or hear and consequently increase the risk of agitation. Additionally, studies have proven that there is little evidence to support that the use of feeding tubes helps to improve nutrition in elderly adults.

A final common cause of agitation is delirium. It is often a consequence of polypharmacy, which is the excessive use of multiple prescribed drugs simultaneously. Since the use of drugs is a direct cause of delirium, and thus agitation as well, it is only logical to conclude that agitation should not be treated by using additional drugs. Specialists confirm that the best treatment for agitation is behavioral, not chemical.

However, some nursing homes may not have your loved one’s best interest at heart. Such facilities may be using drugs such as antipsychotics to chemically restrain elderly adults who suffer from agitation in order to subdue them and make them easier to handle. Furthermore, evidence has shown that use of antipsychotics may increase the risk of falls, mortality, and hip fractures. Not only is this is a direct violation of your loved one’s Patients’ Rights, but it can also be detrimental to his or her physical and mental well-being.

Recent Study Suggests Use of Physical Restraints in Nursing Homes Is Linked to Further Immobility and Dependence of Residents

November 21, 2011 | by Law Offices of Ben Yeroushalmi

The use of physical restraints in nursing homes is a very controversial issue because it presents a situation in which a person’s fundamental rights may be violated and elder abuse may be taking place. According to the Joanna Briggs Institute, a physical restraint is defined as “any device, material or equipment attached to or near a person’s body and which cannot be controlled or easily removed by the person and which deliberately prevents or is deliberately intended to prevent a person’s free body movement to a position of choice and/or a position of person’s normal access to their body.”

Caretakers argue that physical restraints are necessary to maintain the safety of the staff and other residents and are only used on residents who have a high risk of falling, display signs of cognitive decline, or are impaired in their activities of daily living. While some of these reasons may appear to be valid, evidence from past studies have shown that over an extended period of time, restraints actually do not have any effect on the prevention of falls in nursing homes.

There is also evidence that suggests restraint-free nursing homes, on average, do not have an additional amount of staff in comparison to those that use physical restraints. Therefore, the use of physical restraints in some facilities may be a result of a lack of motivation and training on how to properly supervise residents with high risks of falling on the part of the caretakers. This presents issues not only of adequate staffing, but also brings to light issues concerning quality of care.

A recent study in the February 2011 volume of the Journal of the American Geriatrics Society titled “Effectiveness of a Multifactorial Intervention to Reduce Physical Restraints in Nursing Home Residents” took residents from forty-five different nursing homes and examined three hundred and thirty three elderly adults, all of whom were using physical restraints. They divided the residents into two different groups. In the intervention group, the residents were no longer physically restrained, while the control group consisted of those who continued to use physical restraints. The study found that after three months without using physical restraints, the intervention group was more than two times likelier than the control group to permanently be free of restraints. Additionally, the intervention group also experienced a twice as likely chance of reducing their use of physical restraints by 25-75%.

Recent Study Confirms the Link Between Improper Documentation of Antidepressant Prescriptions in Nursing Homes and Serious Injuries and Death

November 15, 2011 | by Law Offices of Ben Yeroushalmi

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.

Evidence-Based Practices for the Prevention of Weight Loss in Nursing Home Residents

November 11, 2011 | by Law Offices of Ben Yeroushalmi

Weight loss is a very common issue among residents of nursing homes. Although it may seem to have a simple solution given the availability of food, malnutrition is actually a very serious, multifaceted problem because it is a direct cause of increased morbidity and mortality and poorer quality of life. A recent article, titled “Evidence-Based Practices for the Prevention of Weight Loss in Nursing Home Residents,” published in the 2011 volume of the Journal of Gerontological Nursing reports that 35-85% of elder adults living in nursing homes suffer from malnutrition.

Unintentional weight loss, which is a consequence of malnutrition, occurs in 27% of adults over the age of 65, and is defined as a loss of 10 pounds in 6 months, 5% per month, or 1% to 2% per week. The three main causes of weight loss are starvation or wasting, cachexia, and sarcopenia.

Starvation or wasting is the result of calorie deprivation. It is often seen in conjunction with a critical illness without adequate nutritional support, advanced AIDS, end-stage renal disease, end-stage liver disease, and marsmus. While starvation results in a loss of fat tissue, cachexia leads to a loss of muscle tissue. Cachexia is often a result of a critical illness with adequate nutritional support, congestive heart failure, liver disease, early renal failure, rheumatoid arthritis, HIV infection without opportunistic infection, and protein-calorie or protein-energy malnutrition.

Sarcophenia entails a decrease in muscle mass and strength that occurs during normal aging and results in physical frailty, increased risk of falling, and decreased ability to perform activities of daily living. Because it is possible to simultaneously have multiple types of weight loss or to progress from one to the next, it is essential to determine if your loved one suffers from unintentional weight loss, especially if he or she also suffers from any of the aforementioned illnesses.

Often, unintentional weight loss is a result of poor communication. Cognitive impairments prevent residents from feeding themselves. Consequently, nurses assist the residents in eating and often have difficulty interpreting the residents’ behavior and wishes. Even when residents are still able to feed themselves, they sometimes have trouble identifying their food and understanding the purpose of silverware.

Dental and oral health issues that are prevalent in elderly adults can also contribute to weight loss. Many residents of nursing homes need dentures but do not have them, while others who do have them are using defectives ones. These issues were discovered to be more common in adults who were dependent than those who were only semi-dependent, suggesting that many adults who are dependent are not receiving adequate care. A study has shown that a resident who received over three hours of care by a certified nursing assistant (CNA) per day had a 17% decreased probability of weight loss and those receiving over 4.1 hours got better feeding assistance. It is important to ensure that your loved one’s nursing home is not understaffed and that your loved one is receiving sufficient care from caregivers.

If you are unsure about your loved one’s health, nutritional assessments exist to determine whether or not he or she is suffering from unintentional weight loss. The most common indicator of weight loss is body mass index (BMI), which is weight divided by the square of height. Specialists say that a BMI between twenty-four and twenty-seven is acceptable. A lower mortality rate and best functional ability have been observed in women with a BMI between twenty-two and thirty and men with a BMI between twenty-three and thirty. If your loved one has a BMI between nineteen and twenty-three, he or she may be at risk of malnutrition. Additional assessments include the Mini Nutritional Assessment (MNA), the Council on Nutrition Appetite Questionnaire (CNAQ), the Simplified Nutritional Appetite Questionnaire (SNAQ), and the Minimum Data Set (MDS) administered by the U.S. Department of Health and Human Services.

There are many simple solutions to weight loss. Supplement intake may help prevent weight loss, as long as residents are continuing to consume the additional calories needed to gain or maintain weight. Food fortification allows residents to consume more nutrients without increasing the volume of food eaten. Feeding assistance from volunteers or family members can provide a positive social environment during mealtimes that also increase nutritional intake. Positive social engagement also helps wandering residents who tend to wander from the table during mealtimes.

Nursing Home Residents’ Assessments of Their Quality of Life with Dementia Should Be Considered Along With Effectiveness of Care

November 7, 2011 | by Law Offices of Ben Yeroushalmi

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.

$90 Million Verdict in Nursing Home Case Upheld

October 31, 2011 | by Law Offices of Ben Yeroushalmi

On October 25, 2011, Kanawha Circuit Judge Paul Zakaib Jr. affirmed an approximately $90 million award to the family of Dorothy Douglas who died after spending few weeks at a nursing home owned by HCR Manorcare in West Virginia.

When Dorothy Douglas was admitted to the nursing home, Heartland of Charleston, she had been suffering from Alzheimer’s and several ailments but was able to walk and speak well. After a three week stay at Heartland, she became seriously dehydrated and wheelchair-bound and subsequently died hours after her transfer to another nursing home.

The jury in this case awarded $11.5 million in compensatory damages and $80 million in punitive damages back in August 2011. The jury also found that only 20 percent of Heartland’s negligence was medical. Based on the jury’s finding, the Circuit judge recently held that approximately $90 million award was upheld because only 20 percent of the non-economic damages, which accounted for about $5 million of the award, applied to the state’s medical malpractice cap limiting non-economic damages to $500,000.

Dehydration, which Dorothy Douglas suffered in this case, can occur in nursing homes when their residents are not provided the necessary fluid content their bodies need. Serious dehydration can lead to other injuries, such as urinary tract infections, pneumonia, pressure ulcers, confusion and disorientation, and life-threatening electrolyte imbalances. Nursing homes thus have a responsibility to make sure that their residents do not become dehydrated by supplying adequate fluids according to an individualized daily plan, and to provide proper training so that their employees can recognize the symptoms of dehydration.

If your loved one is currently a nursing home resident, following up with the nursing staff regarding the risks of dehydration and ensuring that a specific care plan is designed and adequately implemented is one step towards ensuring that the staff is mindful of the needs of your loved one and is acting in your loved one’s best interests.

Malnutrition is a Common Health Concern Affecting Residents of Nursing Homes

October 26, 2011 | by Law Offices of Ben Yeroushalmi

If your loved one resides in a Skilled Nursing Facility (SNF) or nursing home in Southern California, you should be mindful of the risks of malnutrition and related health problems.

A study was conducted with nursing home residents in Germany, described in the article titled Prevalence of Malnutrition in Orally and Tube-Fed Elderly Nursing Home Residents in Germany and Its Relation to Health Complaints and Dietary Intake, published in the 2011 volume of Gastroenterology Research and Practice. According to this study, malnutrition is widespread among nursing home residents and is related to serious health problems, such as constipation, nausea, and vomiting. Among the residents in the study, 26.7% suffered from malnutrition and 52.9% were at risk of malnutrition. Health problems were more prevalent among malnourished residents. For example, approximately 40% of well-nourished residents and 40% of residents at risk of malnutrition suffered from constipation. However, 55% of malnourished residents had constipation.

MRSA Case Study: Challenges of Infection Control and Treatment in Nursing Homes

October 25, 2011 | by Law Offices of Ben Yeroushalmi

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.

Study Confirms Link Between Higher Staffing Ratios and Better Quality of Care in Nursing Homes

October 24, 2011 | by Law Offices of Ben Yeroushalmi

Nursing homes that get reimbursed from Medicare and Medicaid for residents’ services- approximately 96% of all U.S. nursing homes- must be certified and inspected annually. If a nursing home fails to meet federal requirements, inspectors cite the nursing home for violating specific standards (deficiency citations). Violations cited are first assessed by the scope of their effect on residents and the severity of harm to residents and then placed within categories, such as quality of care, quality of life, or resident rights. Under this methodology, both the scope and severity of deficiencies are evaluated and reported as a total point score, and such deficiency score is a reliable indicator of the nursing home’s quality of care.

Given that deficiencies have significant implications for the quality of care and the quality of life of nursing home residents, many studies have used nursing homes’ deficiency scores in measuring their quality of care. A recent study titled “The Influence of Nurse Staffing Levels on Quality of Care in Nursing Homes,” and published by The Gerontologist in May 2011, also used Florida nursing homes’ deficiency scores to find a strongly correlated relationship between the quality of nursing homes and nursing staff levels.

According to this study, higher nursing staff levels are “associated with lower scores on both total deficiencies and deficiencies related specifically to quality of resident care.” Specifically, the findings of this study demonstrate that “with every 6 minute increase (tenth of an hour) in [CNA hours per resident day], there is a 3% reduction in the quality of care deficiency score.” This means that if the nursing homes increase the average nursing hours per patient per day by hiring more CNAs or RNs, they would provide better quality of nursing services in compliance with federal requirements and thus receive lower deficiency scores. The study concludes that higher nursing staff levels would also benefit the nursing home providers because by increasing nurse staffing levels, providers subsequently will receive lower deficiency scores and “thereby improve their quality score and marketability to attract residents.”