The Nursing Home Neglect Report

News and Updates on Elder Neglect and Elder Care Issues

‘For Profit’ Nursing Home: Choosing Profit Over People

By Justin P. Walsh on Posted in Adult Family Homes, Elder Abuse and Neglect, Elder Care, For Profit Nursing Homes, Independent Living Facilities, Nursing Homes, Pressure Ulcers

It’s been a while since my last post. I’ve made the decision to only post here when there is something new that I haven’t written about before or when some story just grabs me. Today, while going through my morning news, I can across a story that instantly made me mad and sad:

Last November a ministry inspector wrote, “Five different nursing staff members working the day shift from all home areas… indicated they are only provided with one (diaper) per (eight hour) shift for the resident and frequently have to go to another home area to try and borrow products.”

The report also described a resident with an open sore whose diaper was soaked in the morning. Since staff could not find a replacement, the resident was only given a paper insert to keep urine from the senior’s wound.

The Toronto Star reported on a slew of other problems within the health ministry, including wrapping residents in plastic bags to keep their beds dry, untreated bedsores, lack of food, dehydration, outdated care plans.

“Management says they are on a budget and have to cut back. So, we try to do whatever we can to keep them comfortable,” the worker said.

And therein lies the largest problem with “For Profit” care of our elderly. Corporations aren’t content with making the same profit year after year. They want to make more profit than they did last year. There are only two ways to do this: Charge more or provide less services (or both).

So in this case, the private chain decided to provide less services. They cut diapers to the point where the residents could only have one per shift. This puts residents at a risk of developing skin conditions, including pressure ulcers. It puts them at risk for developing urinary tract infections, which can lead to more serious conditions, such as urosepsis.

Staffing is one of the major ways that Nursing Homes try to maximize profit. Its one of the largest budget items. Trimming 1 person can put anywhere from 12,000 – 40,000 back into their pockets. When this happens, call lights go unanswered. People aren’t turned to prevent pressure ulcers. People suffer falls because they try to transfer themselves or go to the bathroom on their own. People aren’t fed timely. People go without water. People suffer, and often die.

So what’s the solution? Not-for-profit nursing homes are a start. They do not operate to save a dime, but to really care for their residents. This isn’t to say that not-for-profit homes are perfect, but they certainly have fewer problems as a general rule.

Another solution is to offer home care services, and not move the person to a home at all.

All I know is that as time goes on, it becomes increasingly evident that corporations are given all of the perks of being a person. They get free speech rights and due process rights. However, they’re not expected to behave like a person. Only under the most egregious circumstances will the officers be charged with a crime. The corporation itself goes on without that person, free and clear of the responsibility expected of all of us. And that makes me sad.

 

 

Elder Care Referral Services: Know What They Know!

By Justin P. Walsh on Posted in Adult Family Homes, Elder Abuse and Neglect, Elder Care, Elder Care Referral, Independent Living Facilities, Nursing Homes, Pressure Ulcers

Oftentimes, elder care referral services will advertise in hospital waiting rooms, online, television, and even on the side of vans.

So what is an elder care referral service? When someone is about to be discharged from a hospital, or when they are no longer able to live independently (or at the same level of care to which they were accustomed), these services are supposed to provide an informed choice to seniors.

Based on the information they receive from your loved one or your family, they make recommendations as to facilities that are able to care for your loved one. There are two problems. First, often the referral service hasn’t done their research on the facilities. Second, often they’re basing their recommendations based on incomplete information.

There are several types of facilities that may be able to accomodate your loved one. The facility type often varies based on the level of care your loved one requires.

For example, Nursing Homes are usually able to care for varying levels of dependent individuals. Some simply have some trouble getting around or need a little assitance with washing. Some are completely dependent on others for all of their activities of daily living (ADLs). Adult Family Homes provide a more close-knit care system, with fewer beds and more caregivers per person. However, they lack the large infrastructure and resources of a nursing home. Independent Living Facilities offer activities and meals, but largely let your loved one remain independent in a condominium or apartment style setting.

Most referral services are by no means charitable. They operate to garner a profit. The way they make their profit is generally by receiving the first month’s rent that you pay the facility. This means that the less they spend on research of the facility, the more money they are able to make. So its important to know which questions to ask.

  • Has anyone from the referral service visited the facility?
  • What staff are available to your loved one at the facility?
  • Is there an nurse or doctor onsite or readily available?
  • Are they able to meet the needs of your loved one?
  • What does the facility have in place to prevent pressure ulcers?
  • What training do the caregivers at the facility have?
  • What does the facility do about medications?
  • Has the facility been cited by DSHS?
  • Have their been any lawsuits against the facility?
  • Have their been any actions against licensed staff?
  • What forms of payment do they accept?
  • What are the refund policies?

A lot of these things may seem like they require a lot of time and effort. However, a quick visit and a couple of questions to the facility’s owner can turn up most of the information. Most DSHS websites offer quick and easy public disclosure requests (or even online checks) into licensing and actions against a provider’s license.

The facility should be collecting information from your or your loved one in order to make the right recommendation. A lot of facilities will claim to have “care advisors”, but are solely making their recommendation based on ability to pay and geographic location. However, that is only the tip of the iceberg. In order to properly care for your loved one, they need to know what activities they can and can’t do. Can they brush their teeth, are they incontinent, do they have the potential for skin breakdown and require a higher level of care to prevent pressure ulcers. If the facility cannot meet the care needs of your loved one, they should not recommend that facility.

The referral process does not end there. Once options are given, the family should go check out the facility. Talk to the caregivers, talk to other residents. When choosing the facility, try these tips (click on the link).

Finally, once you choose a facility, visit early and visit often. Stagger the times and days you visit, so you can get an idea of the care that is actually being offered at the facility. If you are not comfortable with the care, move.

It may seem like a lot of work, but taking the time to ensure a proper referral will help to make sure your loved one isn’t exposed to abuse or neglect.

Proper Care of Pressure Ulcers (Bedsores) – Counting

By Justin P. Walsh on Posted in Elder Abuse and Neglect, Medical Malpractice, Pressure Ulcers, Wound V.A.C.

Pressure ulcers are nasty nasty things. Unfortunately, when the pressure ulcer, commonly known as a bedsore, reaches a certain width and depth, they become much harder to heal. The circulation to the skin and tissue has been cut off, the tissue starts to die, leaving a hole.

In normal wounds, there are no circulation problems and the skin can heal itself as it normally would. In pressure ulcers, the skin and tissue need a little help to heal.

While I will save a full discussion on wound vacs, and how they help heal decubitis ulcers (the fancy medical term for pressure ulcers or bedsores), there is one little bit that is very helpful when dealing with wound care.

KNOW WHAT YOU PUT IN; KNOW WHAT YOU TAKE OUT!

I know it may seem a little silly to go stuffing material into a wound. Pressure ulcers are a little different in that they need to gradually heal from the inside out. You need to close the wound slowly. You need to keep the wound open with packing material and make the pressure ulcer inhospitable to infection. There’s a lot that goes into healing a pressure ulcer, and that means you can’t just stitch the skin and muscle up and call it good. Again, I’ll save that for another day.

When you’re stuffing the wound, you often use strips or pieces of wound care foam.

 

There are many forms of wound dressing, but two things is always a must. You count what you put into the pressure ulcer. You count what you take out of the pressure ulcer. Why is that? You may not always be able to see the dressing the next time you open up the pressure ulcer to take a look. As a wound heals, it may not heal uniformly. There may be tracts and ducts that are left, that aren’t visible to the naked eye.

I had one case involving an elderly gentleman who was receiving wound care. The hospital and wound care nurses were not documenting what went in and what came out, and there was no policy to that affect. A piece of dressing remained in a spot where the nurse couldn’t see it, and in the course of time, the wound completely closed up, leaving the foreign object inside the man. Because the wound dressing was designed to prevent bacterial infections, nothing happened for quite some time. Unfortunately, the bacterial fighting ability doesn’t last forever. The material caused a massive infection (sepsis), and the man passed away.

The need to count what goes in and what comes out is will documented. According to one of the leading providers of wound vacs:

Always count the total number of pieces of foam used in the wound. Document the foam quantity and dressing change date on the drape or Foam Quantity Label, if available, and in the patient’s chart.

The manufacturer is very clear as to why this is a huge issue:

V.A.C. Foam Dressings are not bioabsorbable. Always count the total number of pieces of foam removed from the wound and ensure the same number of foam pieces are removed as were placed. Foam left in the wound for greater than the recommended time period may foster ingrowth or tissue into the foam, create difficulty in removing foam from teh wound, or lead to infection or other adverse events.

The good news is, its easy to tell if there may be a problem. Check the flap on the wound, it should have the number of pieces and the date of the change. At the end of a home nurse visit, ask you if can see the chart. Did they document the number of pieces? Usually this isn’t a problem, but it is an avoidable one.

Pressure Ulcers: How to Assess Risk, Prevent, and Recognize Bedsores

By Justin P. Walsh on Posted in Elder Abuse and Neglect, Nursing Homes, Pressure Ulcers

One of the more common neglect problems within Nursing Homes, Hospitals, and even Adult Family Homes is the development of pressure ulcers in residents. Pressure ulcers, which may be noted as bedsores or decubitis ulcers, are essentially a breaking down of the skin and tissue in areas cut off from circulation. They often happen in patients with limited mobility, especially patients and residents who are bed-bound or wheelchair bound

A pressure ulcer develops when an area of the body remains in one position for a prolonged period of time. The weight of the body presses downward, cutting off circulation to the skin and tissue. Common areas for developing pressure ulcers include the coccyx (the area just above wat we commonly know as the butt-crack, where the spine ends), the scapula (shoulder blades), and the heal. Though any bony prominence or area of prolonged pressure creates a risk of pressure ulcers.

If left untreated, this reduction in circulation causes your outer layer of skin to produce cells slower than it usually would, and to lose layers. This leads to a pressure ulcer.

Pressure ulcers are referred to in stages. Stage I pressure ulcers look to be an irritated area of the skin. Whereas normal redness and irritation will blanche, or turn white, when pressed, a Stage I pressure ulcer will remain red when pressed. (It’s important to note that if the skin is dark, you may not be able to tell blanching anyhow, but the skin will still look different than the surrounding area).

Stage II pressure ulcers involve actual breakdown of the thickness of the dermis, or the outer layer of skin. This loss of thickness usually results in a small break in the skin, or ulceration. It may also appear simply as a serum filled blister.

Stage III pressure ulcers cut through the entire dermis, or outer layer of the skin. Its referred to as a full thickness loss. At this stage, you may be able to view the layer of fat beneath the skin. There may also be slough, or discolored dying tissue, in the wound.

Stage IV pressure ulcers are by far the most serious, and involve the loss of tissue all the way to muscle or bone.

 

It is usually in Stage III or Stage IV of a pressure ulcer that a resident runs the risk of a serious infection. Left untreated, large areas of the wound can become necrotic, a fancy word for dying tissue. An infection can also put the resident at risk for Osteomyelitis (an infection of the bone), or Sepsis (an infection in the blood). Once a pressure ulcer is infected, the risk to the resident increases dramatically, and it may result in death.

So how do you prevent pressure ulcers? It begins at the admission of the patient. A risk-assessment should be done at admission in order to properly evaluate the patient’s risk for pressure ulcers. Patients who have limited mobility, fragile skin, nutritional issues, or other risk factors usually necessitate a pressure ulcer prevention program. The most common measure for risk is known as the Braden Scale. The lower the number, the greater the risk. Any score lower than 16 warrants pressure ulcer prevention measures (15-16 = low risk, 13-14 = moderate risk, 12 or less = high risk):

So what preventative measures should be taken. Those will vary from patient to patient. However, the most common preventative measure include:

  • Repositioning by staff (every hour for wheelchair-bound individuals, every two hours for bed-bound individuals)
  • The use of cushions to relieve pressure
  • Special mattresses that alternate areas of pressure on the body, relieving pressure in other areas
  • Floating body parts (a special boot to keep pressure off the heel) or positioning of bony prominences to relieve pressure
  • Cleaning of skin with mild soap and water, patting dry
  • Talcum powder in areas of excess moisture
  • Daily skin inspections
  • Management of incontinence (assistance, cleaning, changing, moisturizing if needed)
  • Dietary help, including increased calories and protein, and monitoring of hydration

If you think your loved one is at risk of developing pressure ulcers, talk to the caregivers. Watch to see if they are being rotated, if bony protrusions are being taken care of. Take a look at your loved one’s skin. If, after talking to the people at the facility, you see they are not paying attention to the risk, you should consider moving your loved one. Pressure ulcers are a serious matter, and issues such as understaffing can affect their ability to care for your loved one, whether it be repositioning, toileting assistance, or even simply making sure your loved one has access to water nearby. All of these failures can lead to pressure ulcers and its important that you remain “plugged in” to the care being received.

As I know diagrams are sometimes not as helpful as you’d like, I’ve also included a real world example of pressure ulcers at various stages, after the jump. Continue Reading

Care Transition Teams Reduce Need for Nursing Home Admissions

By Justin P. Walsh on Posted in Elder Abuse and Neglect, Elder Care, Nursing Homes

One of the best ways to avoid neglect at a nursing home is simply to avoid going into one. Often times, the best approach is to go into a not-for profit nursing home. Unfortunately, sometimes beds are not available or the need for family to be near outweighs the closest facility not being the best to handle the job.

So why not avoid a nursing home altogether. Avoid the nursing home; avoid the abuse and neglect that can happen.

Care Transition Teams are a fairly new concept. It involves getting together a team of people to help your loved one transition either into the nursing home or back into home. What they’re finding is these teams are especially effective at preventing short term stays in a nursing home after discharge from the hospital.

[T]he Care Transitions Intervention was designed in response to the need for a patient-centered, interdisciplinary intervention that addresses continuity of care across multiple settings and practitioners. The overriding goal of the intervention is to improve care transitions by providing patients with tools and support that promote knowledge and self-management of their condition as they move from hospital to home.

So how does the process work? First, the discharge facility provides a PHR, or personal health record. This allows the people in the team to readily collaborate. Obviously, in a facility that has already moved to an electronic records system, creating these PHRs should be a snap. In a facility without, this may mean keeping a whole separate record that the team has access to.

Next, the team develops a pre-discharge checklist, “of critical activities designed to empower patients before discharge from the hospital or nursing facility.” These include mainly things informing the patient about what they need to do once they leave the hospital, including how to watch their own symptoms for signs of worsening.

The hospital then employs a coach, usually a geriatric nurse practitioner, to help the patient (and the caregiver) understand the first two elements of this.

Finally, and this is key, follow up visits to see how the first three are working out.

Intervention Staging for Care Transition Activities

The biggest part of this is educating the patient and the caregiver about red flags, so they can act and escalate appropriately.

The exciting part transitional care plans lies in reducing the need for patient admissions to nursing homes. Family and home health caregivers often do not feel they have the resources or knowledge to care for a loved one outside of a skilled nursing facility. If the resources are there, the transition team will identify them, make sure the caregiver knows how to manage them, and will allow for more attentive care without a profit motive. Profit motives mean people will skirt the care in order to make an extra buck. People who are motivated by care and a desire to help will generally do everything in their power to provide good care, and escalate when they don’t.

Thank the John A. Hartford Foundation and the Robert Woods Johnson Foundation for helping to fund this innovative program!

Preventing Isolation is Key to Preventing Elder Financial Abuse

By Justin P. Walsh on Posted in Elder Abuse and Neglect, Elder Financial Abuse

Mary Pillow at her 100th Birthday

This morning I came across an article in The Mountain Enterprise detailing yet another case of Elder Financial Abuse.

The woman, Mary Pillow, was 99 at the time this happened. One of her caregivers started isolating Mary from her friends. Mary, who was loved by everyone and had an active social life, was suddenly cut off from the outside world. Her friends were told that they could not see Mary anymore. The caregiver then tried to have Mary declared mentally incompetent in order to gain a foothold over her finances.

I’m sure Mary’s friends felt helpless. The article doesn’t detail how the elder financial abuse was uncovered, but there are things you can do to make sure it doesn’t happen to you or your loved ones:

1) Visit Early and Often

One of the ways these scam artists are able to gain a foothold over a vulnerable person is to isolate them from their loved ones. Its no different than an abusive relationship, where the abused is forced to put their care in the hands of the abuser. The more you visit, the more you take away that opportunity for the abuser to gain a foothold over the trust of your loved one. You also prevent the ability for the abuser to try things like having your loved one declared incompetent. If any such attempt is made, an elder law attorney can help you protect your loved one from the abuser, and help you set up a proper guardianship if one is needed.

2) Get to Know Others Involved in Care

This ties almost directly into the first point. Not only should you be around to prevent abuses by the caregiver or abuser, but knowing other friends and family and having a support system in place will allow you to present a unified front in the event things turn ugly.

3) Watch for Changes

Usually as an abuser starts to get a foothold, there will be changes you can notice. Is your loved one not talking with you near as much as they used to? Do they appear withdrawn or a little scared or nervous? Like any other con-artist, a financial abuser will use psychological trauma and suggestion in order to make them the trusted source for your loved one. Often, this can come in the form of subtle lies about friends and family which cause the loved one to lose the trust they had. Sometimes it can be more traumatic, with threats involved.

4) Act Early

Many times people will act only after its discovered that all the assets are missing. This can come in the form of care and services benig cut off for non-payment, loss of a house due to failure to pay taxes, or simply a collector starting to call about a long overdue $50,000 charge to a credit card that didn’t exist until the abuse hit full stride. Often-times, that’s too late. While it won’t stop a criminal prosecution, there may be no assets to recover from the abuser, leaving your loved one in a lurch.

If you suspect a loved one is the target of elder financial abuse, contact someone! An elder law attorney will be able to give you options and help you to intervene. They can help you navigate appointment or removal of a guardian, and obtaining an accounting of money spent. But the worst thing you can do if you suspect abuse is going on is to thing, “Maybe it will stop,” and do nothing. It won’t.

The part that bugs me most about Mary’s abuse is the way the system is handling the abuse. Despite over $12,000 in financial abuse, the prosecutor’s office has opted to charge only a misdemeanor theft ($400):

On May 13, 2011 charges were filed against Renee Gettler in California Superior Court alleging that Gettler (who has also used the name Renee Laudenberg) unlawfully took “money, labor or property belonging to Mary Pillow in an amount not exceeding $400” during 2010. Placing a $400 limit on the charge keeps it a misdemeanor, rather than a felony, according to authorities.

. . .

Charlie Hall reports that when he complained about the reduction of the charge to a misdemeanor, a deputy district attorney told him the state has little funding for jail facilities, suggesting that charges are frequently being lowered in the face of overcrowding at jails.

The decision to provide early release should fall on the sentencing judge and the jail, not the prosecutor. The prosecutor’s job is to seek and promote justice. By only charging a misdemeanor, the prosecutor is promoting abuse by letting financial abusers know there will be little consequence for their extreme actions.

 

Senator Blumenthal holds Hearing on Elder Abuse and Neglect

By Justin P. Walsh on Posted in Elder Abuse and Neglect

Unfortunately, I don’t get a whole lot of time anymore to read the news. This means that I largely get my news from about 5 minutes of CNN in the morning, the internet, my news reader, and twitter.

On August 23, 2011, Senator Richard Blumenthal (D-Conn.) took on the problem of Elder Abuse and Neglect in Senate hearings. Taking on the problem at the national level is something that needed to happen, and Senator Blumenthal made sure that many of the issues affecting Nursing Home Care and Elder Abuse were put into the record, including a 90-year-old WWII veteran who was the victim of financial elder abuse at the hands of his own son and Kathy Greenlee (Assistant Secretary for Aging in the Obama Administration) regarding reauthorization of the Older Americans Act, citing the fact that abuse creates a 300 percent higher chance of death (as compared to non-abused seniors).

“Our seniors have worked hard their entire lives, have given so much to our nation, and deserve our support. The fraud and abuse perpetrated on our seniors is absolutely unconscionable, and I am determined to combine my past experience as Attorney General with my new role in the Senate to end these outrageous acts and help bring security and peace of mind to our seniors. We need to give elder abuse the attention that it deserves, and I intend to attack it from every angle: building the infrastructure our states need to catch these perpetrators, and strengthening our federal justice system to allow for the maximum consequences for those who choose to undertake such acts.”

The full press release on the hearing can be found HERE. If I am able to obtain the full transcript of the hearings in the near future, I will post it here.

Please write Senator Blumenthal and thank him for the work he’s doing in this area. Awareness of Elder Abuse and Neglect helps curb it.

What to do if You’re Denied Access to Your Loved One

By Justin P. Walsh on Posted in Nursing Homes

Recently I was contacted through my other blog, The Amateur Law Professor, by a woman in Texas who was being denied access to her loved one, who was at a Nursing Home. Eventually, she was able to have her loved one moved to a different Nursing Home, but the problem continued. Come to find out, the two Nursing Homes were owned by the same company.

Selection of the Nursing Home aside, there are things you can do when this situation arises. The first step you have to take is to look at whether your loved one is in immediate danger. If the last time you saw your loved one, they were developing pressure sores, weren’t responding to you when they normally would, or looked severely dehydrated or underweight, there may be care issues that are an immediate threat to your loved one’s life. If that’s the case, you should immediately hire an attorney that specialized in Elder Abuse and Neglect, who can get the process started for immediate removal of your loved one for their own safety. If they are not in immediate harm, but you are still being denied access, your state’s Long Term Care Ombudsman may be able to help you solve the problem.

You can find your State’s Long Term Care Ombudsman HERE. Ombudsman address several issues related to resident care, including:

  • Violation of residents’ rights or dignity
  • Physical, verbal or mental abuse, deprivation of services necessary to maintain residents’ physical and mental health, or unreasonable confinement
  • Poor quality of care, including inadequate personal hygiene and slow response to requests for assistance
  • Improper transfer or discharge of patient
  • Inappropriate use of chemical or physical restraints
  • Any resident concern about quality of care or quality of life.

If your Ombudsman is unable to help you resolve the issue, you should contact an attorney specializing in Elder Law, who can help you deal with the process of court intervention. This is similar to dealing with life threatening issues, but on a non-emergency basis. The Ombudsman route is an informal process that often provide great outcomes for both the resident and their family without the costs of going to Court.

How to Choose the Right Nursing Home

By Justin P. Walsh on Posted in Nursing Homes

Probably the question that comes up most in my practice is “How do I choose a good nursing home for my dad/mom/loved one?”

Unfortunately, people almost never like my answer, because its not a simple one.

A few years ago, my  grandfather was having stomach pains. He went into the hospital, where they discovered that his colon was having issues. He went into surgery, and then had complications due to sepsis. He was in a coma.

After a few days, he came out of his coma and the doctor suggested we find a skilled nursing facility (nursing home) that he could stay at while he recovered.

My family did two things: (1) attempted to find a location closest to everyone; and (2) performed a tour of the facility. Within 24 hours of arriving at the facility, my grandfather passed away after not receiving his medication.

Finding a location that is close means that you are putting off many facilities that are very qualified to deal with the issue secure loved one is having. It also means you are limiting your options based on geographic location. It’s very possible that the only nursing homes close to you, our facilities that have severe issues in doing with patient care.

This is also why performing a tour of the facility does not work. The facility may have several citations for failing to live up to the care needs of the residents, but outwardly appear as a very competent facility.

So what can you do?

First, find out if the nursing home is a for profit or nonprofit. There’ve been many comparisons of patient care between the two, and nonprofits usually come out on top. Second, try to figure out how many staff are assigned per bed. The higher the number of staff, the better equipped a nursing home is to deal with issues around patient care. This means less time to respond to call lights, people available to assist your loved one to the restroom, and people available to assist with common issues such as pressure ulcers and providing food and water.

When you have it narrowed down to a few facilities based on those criteria, now is the time to look to the state and find out who has the least amount of complaints against them. If the facility has multiple complaints, or citations from the state, chances are it is not a place you want to place your loved one. Nursing homes with repeated violations are especially worrisome.

Now that you are narrowed down to a few facilities that have the qualifications, the people, and that can provide you with a safe environment, to where the facility and talk to the residence, to the staff, and to the director of nursing. Once you’re at that point, it is usually safe to go with your gut. But if you go with your gut without having the information to back it up, you’re doing your loved one a disservice.