An incident such as this is both tragic, and a reminder that elder care is something that must be monitored by those close to the elderly nursing home resident. Whether the abuse comes from an actual assault, as happened here, or through neglect, it is our duty to remain diligent in protecting the rights of our elderly loved ones in these facilities.

CBS News New York has the full story of this incident.

This will come as welcome news to the many families suffering from this disease (the Alzheimer's Association estimates approximately 5.4 million cases of Alzheimer's nationwide in 2011). Regardless of the ability to prevent and treat the disease, at the very least an increased awareness of Alzheimer's and its effects will potentially lead to a greater level of understanding among those tasked with caring for our nation's elderly. Secretary Sebelius' dedication to funding this disease is certainly a step in the right direction for treating those afflicted.

Resource: Medpage Today, Emily P. Walker, April 25, 2012

Nursing home facilities must ensure that a resident maintains acceptable levels of nutrition, such as weight and protein levels, unless his or her physical condition renders this impossible. The failure to do so can result in the avoidable development of pressure ulcers (decubitus ulcers, bedsores). Elderly residents of nursing homes do struggle to maintain weight and protein levels. The facility has a duty to take necessary interventions to attempt to overcome these natural struggles. In the instance cited in the Andrus report, an 85 year old woman was admitted with several diagnoses that would exacerbate a struggle to maintain nutritional levels. The facility, on admission, ordered a protein supplement which, according to the DOH, was not provided. Upon readmission, no such supplements were ordered. The resident's weight and protein levels both diminished during her stay. Certainly these health risks are dangerous when viewed alone. Low weight and low protein also make the elderly more susceptible to developing pressure ulcers and/or contracting infections.

A facility must develop and maintain an infection control program to provide a safe environment for its residents, as well as to prevent the spread and transmission of infections. In the case of Andrus, an LPN was observed placing, after use, soiled medication containers on her medication cart adjacent to clean containers for use with future residents.The same was done with supplements consumed by residents prior to administering the full content of the medication tray. Maintaining separation between new and used medications and/or supplements is a way to ensure that residents do not mistakenly consume those of another resident. This separation also avoids contact between differing medications of residents. The DOH noted this as an isolated incident, with the potential for more than minimal harm.

To read the full findings of the Department of Health, click here.

A facility must develop a comprehensive care of plan for each individual under its supervision. The care plan must be unique to the individual, including measurable objectives to meet the resident's needs. One resident, although diagnosed with a history of urinary tract infections, was not given a care plan to address potentially recurring UTI's. Due to the patient's history, this should have been included in the care plan. The resident had shown a propensity for developing these infections. The facility did not provide an explanation for why this was not addressed in the care plan.

The services provided by the facility must be administered by qualified persons in accordance with each resident's care plan. The DOH report illustrates how West Ledge failed in this regard. One resident, diagnosed with cellulitis and osteoarthritis, had a physician's order that required a chair alarm be in place when the resident was out of bed. This may have been to prevent a potentially dangerous fall. She was observed out of bed without a chair alarm, however. The Nurse Manager revealed that the chair alarm had been discontinued by a staff member, but not a physician (a physician initially put the order in place). The physician reportedly felt that this was a necessary intervention, yet it appears from the DOH report that someone else independently changed the order. This, according to federal regulations, is unacceptable.

Care plans are created to provide nursing home residents with a path toward rehabilitation and recovery. They include safety measures to ensure that a resident is monitored and unable to inadvertently harm him or herself. When a care plan is inaccurate, or is not followed, the possibility of harm is increased.

For a full report of the DOH findings, click here.

Sprain Brook Manor failed to notify a resident's legal representative (her daughter) prior to instituting a prescription for a new form of psychoactive medication. When the daughter learned of this new medication, she refused to continue her mother on the treatment. The DOH notes that no documentation exists indicating that the daughter was advised of the potential benefits and risks of this treatment. Despite the daughter's refusal of the medication, the facility administered two doses of this psychoactive medication prior to discontinuing its use three days after the initial prescription.

Providing correct and timely medication to residents is an integral aspect of a nursing home facility. Just as integral is informing the resident and his or her family of the purpose and possible side effects of such medication. In certain cases, because of the risk of adverse side effects, particularly with respect to psychoactive medications, the resident or his or her guardian may refuse medication.

The full details of the Department of Health report can be found here.

According to federal regulations, a facility must ensure that it maintains a medication error rate of below five percent. In the case of Saint Catherine of Siena, a sampling of residents found medication error rates at 7.7%. On several occasions, medications were not administered in doses as ordered by physicians; in others, the wrong medication was provided. Although no actual harm resulted in these instances, the DOH noted that this type of behavior has the potential to result in more than minimal harm. Fortunately such harm was avoided here.

In the same vein as the deficiency noted above, the facility was also cited for failing to properly label drugs and biologicals. The facility failed to remove open and expired medications from residents' rooms. Not only does this violate federal regulatory standards, but it also violates the facility's own policies and procedures, which state: "All multi dose vials must be dated and initialed when opened and must be discarded after 28 days." Stricter adherence by the staff to both the facility's standards, and to those set forth in the CFR, could deter both the maintaining of expired medications and lower the medication error rates. Perhaps the DOH survey will aid in correcting these mistakes.

To read the entire DOH write up on Saint Catherine of Siena Nursing and Rehab Center, go here.

According to 42 CFR 483.25(a)(3), a facility must ensure that residents who are unable to carry out activities of daily living are given the necessary services the maintain adequate nutrition, grooming, and hygiene. With respect to one particular resident who needed assistance while eating, the DOH noted that the staff left an unopened tray of food on a table away from the resident during breakfast. The tray remained there for over one hour, with no staff member providing assistance with eating. Although the resident's regular CNA was off duty on the day in question, that does not relieve the facility, and any other CNA taking over the resident's care in her absence, of a duty to adhere to the resident's care plan and minimum data sets. The facility documented that the resident needed assistance at meal times, and this necessity went unheeded for the resident.

The second provision of the CFR relevant to this blog entry, 483.65, sets forth requirements for a facility to provide for infection control. The instance documented by the DOH relates to a bloody stylet needle found next to a resident's bed. The resident received regular IV fluid treatment, and the facility has policies in place regarding disposal of needles, so the process should have been familiar to the staff member administering the IV treatments. Instead of being placed in a sharps container, as is protocol, the needle was found on the floor of the resident's room. Fortunately there was no actual harm relating to this incident.

To read the full DOH report on Long Island State Veterans Home, click here.

At Daleview Care Center in Farmingdale, NY, Dieudonne Poulard, a Certified Nurse's Aide, reportedly gave a false statement regarding a fall sustained by a resident which led to a fractured hip. Ms. Poulard lied to administrators saying she had no knowledge of the fall, when in fact she had participated in giving care to the resident after the apparent fall.

Long-Term-Care Community Coalition, Enforcement Actions (9/16/11 - 12/15/11).

The four-count lawsuit filed in St. Clair County Circuit Court alleges that the home was aware that Giles had a pattern of trying to leave the facility (sometimes referred to as "elopement"), yet failed to monitor him and failed to have appropriate interventions in place to prevent him from exiting the premises. The family further alleges the nursing home violated various state regulations, failed to provide adequately supervise its staff, and failed to notify authorities in a timely fashion.

Daughters sue Belleville nursing home over death of man who walked away, Nicholas J.C. Pistor, Post-Dispatch, February 22, 2012.

Both Bain and Willaims were sentenced to a one-year Conditional Discharge with the conditions including the surrender of their respective licenses. They both must also refrain from working in the health care field for the duration of the Conditional Discharge.

Website Resource:

Long-Term-Care Community Coalition, Enforcement Actions.

In large part, the quality of a facility's nursing staff correlates with the quality of care that a resident receives. Nurses and nurse's aides interact with and care for residents constantly. For this reason, section 483.75(f) of the CFR states that nurse aides must demonstrate competency in skills necessary to care for the residents' needs. The DOH found that this level of care was not present in its review of The Hamptons Center. In one instance, a knee separator that had been ordered by a physician was not in place for a resident lying in bed. Separators such as this serve several important functions, among them a higher comfort level for the resident and the prevention of pressure ulcers. Failure to implement the knee separator, contrary to the physician's orders, posed a potential for more than minimal harm according to the DOH.

Elderly nursing home residents rely on their caregivers for the administration of necessary medications. As such, the CFR provides that it is the duty of the facility to ensure that residents remain free of any significant medication errors. The DOH report documents a resident who went three days without receiving a physician-ordered prescription because it had not been received from the pharmacy. For this particular resident, whose diagnoses included atrial fibrillation (irregular heart beat) and hypertension (high blood pressure), this failure to medicate could have had severe consequences. Heart conditions are serious matters for a patient of any age. In an elderly nursing home resident, this failure to medicate exacerbates the risk of harm to the resident.

To read the full report of deficiencies for Hamptons Center for Rehabilitation and Nursing, see the DOH website.

Section 483.35(f) of the CFR dictates that the facility provide three daily meals to residents, with no more than fourteen hours between dinner and breakfast the next day, unless a snack is provided at bedtime, in which case the interval may increase to sixteen hours. One logical reason for this rule is that the facility provides these meals, so the residents eating habits are subject to the staff providing them. Also, as it is the duty of the home to prevent the development of bedsores and infections, a consistent nutritional allowance is a necessity. Hunger can lead to distraction and accidents, which the facility is bound by law to make provisions to avoid. In this instance, residents reported that snacks were not provided on a regular basis by the staff, although these residents claimed feelings of hunger and that they would have readily accepted offered snacks.

For an elderly person, a fracture can have serious, and potentially life threatening, consequences. When a fall with a possible fracture occurs, it is essential to diagnose the results as quickly as possible to ensure that the correct treatment is given and the resident can begin to recover. For this reason, CFR 483.75(k)(1) provides that the facility must obtain radiology and diagnostics for its residents, and that the facility is responsible for the timeliness of obtaining these. In one instance noted in the report, a resident suffered a fall and complained of hip pain. Although an x-ray was ordered immediately, the results of this x-ray were not reported until almost sixteen hours later. As such, the injury, which was an acute right hip fracture, went undiagnosed during this interval. As evidenced by the DOH deficiency report, this lag is unacceptable.

A full list of deficiencies noted by the DOH with reference to Smithtown Center for Rehabilitation and Nursing can be located here.

According to CFR 483.70(h)(3), a facility must ensure that corridors have firmly secured handrails on each side. In a facility in which numerous residents are fall risks, and the consequences of such falls are extremely serious, secured handrails are a necessity. The study found that three areas of Woodhaven's first floor were not equipped with handrails. Fortunately this did not result in actual harm for any of the residents. However, the study does note that the potential for more than minimal harm was present.

Section 483.15(a) of the Code specifies that the facility must promote the care of patients in such a manner that maintains or enhances his or her individuality. In three instances of Woodhaven failing to meet this standard, specific instructions for infection control were posted outside a residents' rooms, on some occasions left visible after the patient required such care. The information contained in the signs was plainly visible for other residents or visitors to see. When infections occur in nursing homes, as they sometimes do, it is the duty of the facility not only to treat the infection, but also to treat the resident suffering from the infection with dignity in the process. The DOH felt that Woodhaven failed to do this in these circumstances.

The full transcription of the Department of Health report can be found here.

According to the facility's own policies, residents are not allowed to smoke unless supervised. This supervision must be maintained during the entire period that the resident is smoking, which is permitted in the "quiet room." At no time are the residents allowed to have their own smoking materials, i.e. matches and cigarettes, but rather these are dispensed by the staff as needed.

On this occasion, the resident is seen on video in his wheelchair moving to and from the quiet room with no supervision. He lights a cigarette on his own with matches that he produces from the side of his wheelchair. At some point thereafter, although not seen on the video, the resident lit himself on fire while unsupervised in the smoking room.

In addition to violating CFR 483.25(h), Mosholu Parkway Nursing Home violated its own policies and procedures in this instance. The staff, however, failed to meet these internal standards. This failure affects not only the resident in question, but also all other residents who are exposed to a fire hazard. A situation such as this can prove to be deadly both for the smoker and for other residents in the event they become trapped in a burning building.

The complete DOH report, including violations for failure to prevent abuse and neglect, and failure to train employees in emergency procedures, can be accessed here.

In order to receive payment from Medicare, hospitals are required to report incidents of harm to patients, and make efforts to improve care and eliminate similar events in the future. Even with this stipulation, failure to report errors has been rampant, according to the study's findings. Additionally, Levinson found that even when incidents of harm are reported, such as bedsores, infections or medication errors, hospitals rarely make changes to policies or practices.

The Obama Administration, although it has strongly advocated the reduction of medical errors, has left the power to change this with the states. Additional federal reporting requirements are not being planned at this time.

Website Resource: Report Finds Most Errors at Hospitals Go Unreported, New York TImes, Robert Pear, January 6, 2012