Articles Posted in Advances in Patient Safety

A recent study adds to the growing body of research regarding overuse of antipsychotic medications in nursing home patients and the associated risks of severe medical complications and death, with a specific focus on residents of nursing homes run by the U.S. Department of Veterans Affairs (VA). The American Public Health Association’s Medical Care Section published the report in the November issue of its official journal, Medical Care. The VA is reportedly making a variety of efforts to reduce antipsychotic use among patients who would be better served by other treatments. This is particularly true of dementia patients in nursing homes.

The researchers, led by Walid Gellad, M.D., M.P.H., reviewed data from the VA’s 133 Community Living Centers around the country from the period January 2004 through June 2005. The data covered 3,692 veterans 65 years of age and older who were admitted to one or more of these facilities for at least ninety days. They found that 948 patients, just over one-quarter of the total number, received an antipsychotic medication, but that only 59.3% of them had an “evidence-based indication for use.” Patients who displayed aggressive behavior, who were receiving nine or more different medications, who were also receiving antidepressants or dementia medications, and/or who were living in an Alzheimer’s or dementia care unit were more likely to receive antipsychotic drugs. The researchers found that patients with dementia but no recorded history of psychosis were just as likely to receive antipsychotic drugs as those with a documented need for such drugs.

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A federal program intended to help transition nursing home residents who receive Medicaid into community- and home-based care has had some success in Maryland, but people in many states have experienced difficulties with relocation. The Money Follows the Person (MFP) program, initiated in early 2008, is intended to help individuals who might benefit from home-based services to get out of long-term care institutions. It could potentially help ease the burden on overcrowded or understaffed long-term care facilities, thereby improving care for all residents.

The primary goal of MFP, according to the Center for Medicare and Medicaid Services, is to help state governments “rebalance their long-term care systems” to favor home- and community-based services (HCBS) over institutional services. HCBS may include small group homes, private homes, or apartments with some degree of living assistance. The program is also intended to expand the use of Medicaid funds to allow patients greater choice in long-term care services, and to provide oversight and quality control over HCBS that receive Medicaid funds. Forty-three states, including Maryland and Virginia, and the District of Columbia have signed on to the program. The Affordable Care Act of 2010 extended the program from its initial five-year period until 2016, appropriated additional funding, and expanded the eligibility criteria for patients.

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Healthcare-associated infections (HAIs), generally defined as bacterial, viral, or fungal infections contracted by patients while receiving medical treatment, are a potentially major hazard for residents of nursing homes and other long-term care facilities (LTCFs). As many as 2.8 million LTCF patients may contract HAIs, some of them fatal, every year. A group of epidemiologists recently revised the definitions used in the surveillance of HAIs, providing new tools to document and track infections. The Centers for Disease Control and Prevention (CDC) has also issued new guidelines to help LTCF’s monitor HAIs. These new tools will hopefully help reduce the development and spread of infections among nursing home residents.

HAI Surveillance Definitions

In the October 2012 issue of the Society for Healthcare Epidemiology of America’s (SHEA) journal, Infection Control and Hospital Epidemiology, a panel of experts present a new set of definitions for use in monitoring LTCF infections. The existing set of definitions, known as the McGeer criteria, date back to 1991.

A group of experts led by Allison McGeer published a set of definitions in the February 1991 issue of the American Journal of Infection Control. The purpose of the McGeer criteria was to establish a uniform set of guidelines to monitor infections in nursing homes, such as standards for identifying newly-contracted or worsened acute infections that require monitoring.

According to the paper containing the revised definitions, the McGeer criteria work well in nursing homes providing non-acute care to older residents, but they do not necessarily address concerns faced in LCTFs providing acute care and care to younger patients. New types of nonhospital treatment facilities have appeared since 1991, so newer criteria for identifying and tracking HAIs is necessary.

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A recent study found that elderly women residing in nursing homes may face greater rates of mortality if they are not getting enough vitamin D. The study will appear in the Journal of Clinical Endocrinology and Metabolism, a publication of The Endocrine Society. Researchers at the Medical University of Graz, Austria, looked at a sample group of 961 residents. Members of the sample group had an average age of 83.7 years. The study found that, not only does vitamin D deficiency carry a greater risk of death, but that vitamin D deficiency may be common in nursing homes. This could have important implications for the nutritional care that female residents receive in nursing homes.

The researchers examined the 961 residents and followed up twenty-seven months later. They found that 284 individuals, roughly thirty percent of the group, had died during that time. They noted low vitamin D levels in 92.8 percent of the group members. While vitamin D deficiencies have been common knowledge among researchers for some time, the study authors said, no one has developed good strategies for treatment yet. Given the increased risk of bone fractures and other such injuries in patients with low vitamin D, the researchers urge the medical community to work on ways to remedy these deficiencies.

Low levels of vitamin D can have multiple health effects. Scientists have known about an increased rate of mortality due to vitamin D deficiency for some time, but the Graz study has helped tie it to specific populations. Vitamin D is also very important for bone health. Deficiency can cause bone damage, sometimes known as rickets, and it can contribute to an overall loss of bone density that makes fractures and breaks more likely. Some research suggests that vitamin D supplements can help with cardiovascular disease, some cancers, asthma, multiple sclerosis, immune strength, and certain neurodegenerative diseases like Parkinson’s. These claims are all controversial, and no scientific consensus exists on any of them. The U.S. Food and Drug Administration only allows the food industry to claim on its labels that vitamin D “may reduce the risk of osteoporosis.”
Vitamin D may be obtained through certain types of fish, fruits and vegetables, or foods specifically fortified with vitamin D. According to the National Institutes of Health, many people meet much of their vitamin D requirements through exposure to sunlight. Ultraviolet radiation in sunlight interacts with chemicals already present in the skin to produce vitamin D. People who spend most of their time indoors, which could include many nursing homes residents, may face vitamin D deficiencies.

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The use of surveillance cameras to monitor treatment of elderly patients by nursing home staff, sometimes known as “granny cams,” is becoming more and more common in Maryland and around the country. While granny cams raise some concerns about the privacy rights of the patients, they have proven to be effective at exposing abuse that might have otherwise gone undiscovered, and state legislatures and agencies are taking notice.

This Maryland Nursing Home Lawyer Blog has previously reported on incidents when granny cams provided evidence of abuse, including a New Jersey case in which the family of a nursing home patient have sued for wrongful death after finding footage of an employee removing the patient’s oxygen mask and hitting her, which they claim led to her death. An Ohio man captured evidence of nursing home staff slapping his Alzheimer’s-stricken mother, shoving her into bed and into her wheelchair, and slamming her against walls. Three nursing home workers in Pennsylvania were arrested when hidden camera footage showed them mocking a patient while forcing her to stand topless.

The nursing home industry has vigorously fought legislative efforts to compel nursing homes to allow placement of cameras in patients’ rooms. Privacy advocates, as well as doctors, have also opposed such legislation at times, arguing that placement of cameras could be used to violate patients’ privacy, considering that nursing home patients requiring assistance in performing daily routines may often appear undressed on camera. Nursing homes further argue that the use of cameras may erode the trust between patients and staff and act as an invitation to lawsuits without good cause. Nursing home reform advocates, however, increasingly favor legal requirements that nursing homes allow cameras.

Some states have passed legislation preventing nursing homes from blocking the use of cameras, although Maryland is not yet one of them. Former Maryland Delegate Sue Hecht introduced such legislation several times beginning in 2001, after she witnessed her mother, Vera, suffering abuse at the hands of nursing home staff. Several bills titled “Vera’s Law” did not make it out of their committees, but a bill passed in 2003, also titled “Vera’s Law,” that required the Maryland Department of Health and Mental Hygiene to develop guidelines that do opt to allow use of electronic monitoring devices with the consent of the patient or the patient’s guardian. The Department issued its guidelines on December 1, 2003, and those guidelines remain in effect today.

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In a recent Hartford County nursing home lawyer injury blog, our attorneys discussed the problem of falls in nursing homes, with over 300,000 individuals over the age of 65 experiencing a hip fracture every year, often leading to injury or even death.

According to a recent University of Maryland School of Medicine study, hip fractures continue to be a major challenge among older individuals and will continue to grow rapidly as our population ages. The study discusses the opportunity available for the medical community to help prevent falls, by intervening and taking precautions with the elderly population.

The study recommends the following interventions:

• Screening for and treating osteoporosis in elderly patients, especially elder men who are rarely diagnosed for osteoporosis, even after an osteoporotic fracture.
• Nutritional interventions have proven to be effective in preventing hip fractures, including the appropriate levels of vitamin D and calcium, as the majority of elderly individuals who are at-risk for falls and fractures have a deficiency in key nutrients.
• Behavioral exercises that include physical activity encouraging walking, weight-beating activity and resistance training have been linked to the reduction of nursing home falls and fractures.

• Other prevention strategies to decrease falls include reducing the number of medications, especially sedatives, sleeping pills, antihistamines, or psychoactive drugs, as well as modifying an elderly person’s home to avoid fall hazards, especially with a person who has previously fallen or is at-risk for falling.

The study hopes that by implementing fall-related interventions, future generations of elderly individuals will be better able to handle the traumatic falls without injury because of better bone health and strength. Also, the study states that with continuing research, experts will be able to identify new approaches to the treatment and rehabilitation of individuals who have suffered from hip fractures in order to improve quality of life and reduce the problem of fall-related injuries on individuals, their families and on society as a whole.

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Our Baltimore nursing home injury attorneys have been following a recent University of Maryland School of Medicine study, published in the American Geriatrics Society’s Clinical Geriatrics Journal, stating that over 300,000 people over the age of sixty-five in the United States will experience a hip fracture every year, making it the second leading cause of hospitalizations for older persons.

As our attorneys discussed in a related Maryland nursing home blog post, traumatic injuries involving nursing home falls are a major concern for elderly individuals and seniors in nursing homes around the country. Hip fractures are frequently the result of a nursing home fall or minor trauma, or when the bone becomes fragile and deteriorated to the point that it cannot hold the weight of the person. By the year 2040, it is estimated there will be an increase of 500,000 annual hip fractures.

Hip fractures challenge the quality of life for older adults, as it can lead to mortality, restricted mobility, and decline in strength, lean body mass, and bone mineral density, as well as depression and constant pain.

According to the study, 18-33 percent of elderly patients with fractured hips will die within one year of their hip fracture, with 13.5 percent dying within the first 6 months. The study also found that those who survive the hip fracture will experience a reduction of mobility, and will have problems functioning on their own, with only 50-60 percent of hip fracture patients recovering their pre-injury walking capabilities in the first year following the fracture. Many of the patients who were completely independent in their daily activities were found to have developed new dependencies after the fracture of the hip.

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In yet another nursing home fall and wrongful death lawsuit that our Frederick County, Maryland nursing home attorneys have been following, a Texas nursing home is being sued by the daughter of a deceased resident for negligence.

According to the lawsuit, Miriam Davis is suing Friendswood nursing home for negligence, after her mother died from multiple falls while she was a resident in the nursing home. Davis claims that the nursing home admitted her mother, Virginia Melghem, in November 2009, even though they were aware that she was at-risk for falling, and that they could not properly care for, supervise, or monitor her mother’s needs for safe care and nursing home treatment.

Davis claims that she was told her mother would receive proper care that would be administered to her in a manner that was appropriate to her physical and mental condition. As a resident however, Davis claims that her mother went on to sustain injuries and trauma that included multiple nursing home falls, that last of which led to a broken hip. After her last fall, Melghem died one week later.

According to the CDC, 20 – 30% of elderly people who fall, experience moderate to severe fall-related injuries such as fractured hips, lacerations, or traumas to the head—which can increase the risk of early death. The CDC also claims that the death rates from falls with elderly men and women have spiked over the past decade.

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Our Washington D.C. nursing home injury attorneys recently discussed the prevalence of falls in nursing homes and hospitals in a blog, and how to reduce the number of falls that can result in nursing home resident injury and wrongful death throughout the nation.

The CDC reports that over 1,800 residents die each year from falls in nursing homes. Injuries sustained from nursing homes and hospital falls can be frequent, debilitating, and expensive health care issues for elderly adults to face. As the CDC reports, finding ways to prevent fall-related injuries with elderly residents in nursing homes and hospitals is extremely important in preventing future injuries.

Elderly residents who are weak, have difficulty caring for themselves or have difficulty walking, are often prone to nursing home or hospital falls, along with patients who have chronic health conditions, or memory problems like Alzheimer’s or dementia.

According to Dr. Ronald I. Shorr, MD, in hospitals, there are generally two types of patients who fall: patients who are frail, and patients who don’t want to interrupt or bother the hospital staff. Hospital providers have reportedly found success in preventing falls by installing alarms, scheduling the administration of medication to prevent falls, redesigning rooms to have bathrooms closer to beds, and updating fall-risk assessments that are shared with healthcare teams and patients, while they are hospitalized and after they leave to return home. Shorr is reportedly in the middle of a study funded by the National Institute of Health on how to prevent falls.

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As our Baltimore, Maryland nursing home injury attorneys discussed in a recent blog, under the federal Nursing Home Reform Act of 1987, (NHRA), all residents living in nursing homes are entitled to receive quality care and attention in an environment that improves and maintains their highest physical, mental health and psychosocial well being.

According to AARP, in 1986, Congress ordered a nursing home study to be performed by the Institute of Medicine, IOM. The study reportedly revealed widespread nursing home negligence, abuse, and substandard care. The IOM proposed massive reforms, a large majority of which became law in the passing of the NHRA, which is part of the Omnibus Budget Reconciliation act of 1987, (OBRA).

The NHRA secures quality care by requiring certain nursing home services to every resident and by establishing standards for these services. Required services include, periodic assessments of each resident, pharmaceutical, rehabilitation, and social services, a care plan for each resident that is comprehensive, and the services of a full-time social worker if there are more than 120 beds in a nursing home.

A Bill of Rights was also established under the NHRA to secure quality care for each resident. Under the Resident’s Bill of Rights, a resident has the right to freedom of nursing home neglect, abuse and mistreatment, and the right to treatment that is free from physical restraints. Under the act, residents and patients also have the right to privacy, the right to be treated with dignity, the right communicate freely, the right to have medical, social, physical and psychological needs accommodated, the right to exercise self determination, and the right to participate in reviewing their own plan, with full disclosure in advance about any changes in treatment, care, or status change within the nursing home. Nursing home residents are also entitled to communicate any problems without experiencing any discrimination or retaliation.

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