Saturday, July 31, 2010

How Useful Is the Concept of "Failure to Thrive" in Care of the Aged?

In an issue of American Family Physician, Robertson and Montagnini1 reviewed the challenges of caring for an aged patient with multiple problems whose health and vitality are rapidly declining. The term “failure to thrive,” which was borrowed from health care for children to describe this accelerated decline, began appearing in the geriatric literature more than 30 years ago to denote a range of circumstances including physical and mental deterioration, abuse and neglect, and rapidly progressing frailty.

In a study2 of physicians who used the term “geriatric failure to thrive,” the authors noted that it “is a term irregularly used and poorly defined.” They questioned whether the concept should be used in reference to geriatric patients, fearing that it “can reinforce the stereotype of elderly people as demented and decrepit” and “may actually hinder the urgent search for treatable, reversible causes of an elder’s deterioration.”2 Other authors3 concluded that “the label ‘failure to thrive’ promotes an intellectual laziness—accompanied by a certain resignation, passivity, or fatalism.” These authors3 responded with a recommendation for “the abandonment of the term ‘failure to thrive’ and the adoption of a more measurement-oriented approach” that explicitly assesses impaired physical function, malnutrition, depression, and dementia.

A review of MEDLINE citations and geriatric textbooks shows that, although “failure to thrive” is still a fairly common focus of authors in nutrition and nursing, it has become less prominent in the medical literature in the past six years as a central conceptualizing theme.

Contributing to concern about the use of the term “geriatric failure to thrive” are the generally vague or broad definitions, the huge clinical territory to which the term has been applied, and the difficulties of formulating a coherent research agenda. Family physicians should be wary of the application and implications of this label. First, geriatric failure to thrive should not be treated as a diagnosis or a specific disease.3 Second, it should not be equated with frailty.4 Decreased function, strength, and stamina are hallmarks of the frail aged person; however, frailty is primarily a state of increased risk and low reserve to stress, a state which all people who live into their ninth decade manifest at varying levels.4,5

Failure to thrive should be seen as an unexpected and significant falling away from the normal curve of declining vigor, weight, function, and reserve that affects even the healthiest aged persons.5 Finally, failure to thrive should not be a summary concept of a patient’s situation that prompts resignation and withdrawal of efforts to find underlying causes,2 and it should not be the final clinical thought.

If the term “geriatric failure to thrive” is of any use, it is as a brief reminder to the clinician that there is major work ahead in carefully reviewing potentially reversible underlying processes in aged patients who are manifesting unexpected and unexplained declines in nutritional intake and weight, self-care, cognitive function, and interest in life. It is true that a single major problem may not be identified or, if identified, may not be reversible. However, multiple contributors often can be found, and some of them can be ameliorated; some, when thoughtfully addressed, can serve to leverage improvement in other issues that had seemed refractory.6

Encountering the unexpected and unexplained acceleration of decline in a frail aged patient gives family physicians a wonderful opportunity to do what they do best: serve as human ecologists, as expert observers and investigators, and as healers of dysfunction in a complex hierarchy comprising a biological system and an individual with a mind, feelings, and personality, who is living within a family, community, and environment.

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Thursday, July 29, 2010

Woman awarded $7 million in court case

Jury holds Hillcrest Nursing Home responsible for former resident’s pain, suffering and medical expenses

LAUREL COUNTY, Ky. — A jury awarded a London woman $7 million last week for pain, suffering and medical expenses for injuries she incurred while recuperating from knee surgery at a southern Laurel County nursing home.

Grace Fugate filed a lawsuit against Hillcrest Nursing Home in 2004, claiming staff members at the facility were negligent in caring for her after her surgery.

After a three-day trial in Laurel Circuit Court, a jury awarded Fugate $383,097.95 for past medical expenses, the maximum amount allowed by Kentucky state law. She was also awarded $766,195.90 for future medical expenses and $1 million for past and future physical, mental and emotional pain and suffering.

Additionally, the jury awarded Fugate $5 million in punitive damages for the nursing home’s negligence during her stay.

Annette Morgan with Morgan & White Law firm in Manchester, Fugate’s attorney, said she is thrilled with the unanimous decision.

Tipton & Tipton Law Offices in Corbin represented Hillcrest Nursing Home and its owner Terry E. Forcht in the lawsuit. Messages seeking comment were not returned by press time Tuesday.

Fugate, who was 67 at the time of the incident, had undergone knee replacement and was placed in rehabilitation at Hillcrest in July 2004.

According to the lawsuit, on Aug. 3, 2004, Fugate needed help getting up from bed and rang for a nurse assistant.

“An employee of Defendant Hillcrest Nursing Home rudely told her to ‘Do it yourself,’ adding the insult, ‘Get over yourself.’ Said employee placed the call button and/or beeper so that the plaintiff could not request the assistance of another aid and/or nurse and left the room after refusing to give assistance to the plaintiff,” the lawsuit reads.

Fugate then attempted to get out of bed on her own to use the bathroom, and fell in the floor beside her bed. The impact of the fall caused the surgical incision to rupture and damaged the ligaments around her knee.

“The nurse who came in and found her said that it was a horrific sight,” Morgan said. “Grace was taken to Baptist Regional Medical Center and had to be resuscitated due to the blood loss.”

Fugate, who now lives in Laurel Heights Home for the Elderly, remained at the Corbin hospital for two months. Morgan said Fugate’s son tried to care for her in his home, but she continued to have ongoing infections around the knee and eventually had to have the leg amputated.

Fugate has a long history of health problems prior to her fall at Hillcrest Nursing Home. She was diagnosed with rheumatoid arthritis when she was about 30 years old, Morgan said, and also suffered severe osteoporosis and multiple joint replacement at the time of the accident.

It took nearly seven years for a jury to hear Fugate’s case in part because the nursing assistant who allegedly denied helping Fugate that day in 2004, Ginda Rogers, was unable to be located.

“We spent several years trying to locate the employee,” Morgan said. “Seven years is a long time. But we did have to put off the trial three times due to Grace’s (Fugate) health. She’s had ongoing infections since the day she fell. And Grace wanted her day in court. She always told me that they knew what they did to her and that no one should ever be treated that way.”

Fugate’s health, however, prevented her from attending the trial last week, Morgan said.

The attorneys representing Hillcrest Nursing Home have 30 days to file an appeal.

“After those 30 days are up, I have the job of trying to collect this money for Grace,” Morgan said. “I want Grace to have some of this money while she is still living.”

Morgan said Fugate wishes to “go home.” Morgan wants to secure the award money for her so Fugate can pay a qualified person to care for her in her home.

“She wants to spend her last days at home,” Morgan said. “Now it’s my job to see that she gets some of this money so that she can.”

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Large damages set in Phila. bedsores case

In an highly unusual step for such a case, a Philadelphia jury yesterday leveled $5 million in punitive damages against Jeanes Hospital and a Wyncote nursing home in the death of a man who developed ultimately fatal bedsores while at both facilities.

The damages -- $1.5 million against Jeanes and $3.5 million against the Hillcrest Convalescent Home -- came two weeks after the same Common Pleas Court jury awarded $1 million in compensatory damages in the case. The damages were awarded to the widow of Joe N. Blango, who died of bedsores in 2008, two years after being discharged from Jeanes Hospital in the city's Fox Chase section.

While compensatory damages are not unexpected in such cases, punitive damages are, according lawyer Robert L. Sachs, who handles nursing-home cases and serves as liaison to the Philadelphia court for other nursing-home litigators.

"To my knowledge, this is the first nursing-home case to go to the jury on punitive damages in Philadelphia," said Sachs, who was not involved in the Blango case.

Rebecca Harmon, a spokeswoman for Temple University Health System, which owns Jeanes, said Temple would appeal the verdict.

"There is not one shred of evidence to support any liability in this case as it relates to Jeanes Hospital, and the contemplation of punitive damages is simply inexplicable," she said in an e-mail. "We're very proud of the high-quality care provided to patients each and every day at Jeanes Hospital."

Attempts to reach a representative for Genesis HealthCare Corp., which owns Hillcrest, were unsuccessful.

Steven R. Maher, who represented Blango's widow, said that in his 25 years of handling such cases, this was only the second time a jury had awarded punitive damages.

One reason, he said, was the high standards required to permit punitive damages to be considered. A jury must find that a facility had engaged in "outrageous and reckless conduct," he said.

Blango went to Jeanes on May 21, 2006, after suffering weakness and confusion. He was 74 at the time and was thought to have suffered a stroke.

According to Maher, doctors at Jeanes failed to properly diagnose that Blango was suffering from a urinary-tract infection that, as a result, worsened and left him susceptible to the bedsores that ultimately killed him.

After about a week at Jeanes, Blango was transferred to Hillcrest, where he stayed two weeks until his condition worsened and he was returned to Jeanes. He was released to go home after three days.

Maher contended that workers at Jeanes and Hillcrest allowed the bedsores to fester and Blango to go malnourished to the point that he lost 28 pounds.

After he returned home, Blango was cared for by his wife, Shirley, before dying from the bedsores two years later.

"This verdict sends a message," Maher said, "that this type of care is unacceptable and will not be tolerated."

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Jury awards $5 million punitive damages in nursing malpractice case

A Philadelphia jury has awarded $5 million in punitive damages in a nursing home medical malpractice case. Just a week and a half ago the jury found Hillcrest Convalescent Home, owned by Genesis Healthcare Corp. of Kennett Square, and Jeanes Hospital of Northeast Philadelphia liable for $1 million in damages in the 2008 death of Joe Blango.

The jury's punitive award was for $3.5 million against Hillcrest and $1.5 million against Jeanes, which is part of the Temple University Health System.

In May 2006 Blango, then 73, developed serious bed sores during admissions - first to Jeanes Hospital, and then to Hillcrest, according to court filings. Over the next five weeks Blando contracted infections, became seriously malnourished and dehydrated during hospital and nursing home stays, according to the complaint filed by the lawyers for Blando's estate. The complaint also noted that the man's bed sores became progressively more serious and "led directly to his death" according to the plaintiffs' medical expert.

"Mr. Blango was treated at Jeanes Hospital for five days in May 2006 and again for 3 days in June 2006," said Temple University Health System spokeswoman Rebecca Harmon in a statement. "He was discharged in June 2006 in stable condition - with no complaints, no pain, and normal vital signs. Mr. Blango expired two years later - in April of 2008. There is not one shred of evidence to support any liability in this case as it relates to Jeanes Hospital, and the contemplation of punitive damages is simply inexplicable."

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Nursing home owners can be liable in neglect cases

A three-judge Superior Court panel has overturned an Allegheny County Common Pleas judge and declared that a local nursing home and its owner may be held liable in a patient neglect death.

The court's ruling means that nursing home owners now may be sued for neglect in any of their homes. It also expands the legal interpretation of liability, which once restricted corporate negligence liabilities, to include not only hospitals and health maintenance organizations but also nursing homes.

"This is the first case in Pennsylvania to have such a holding," said Peter Giglione, a Pittsburgh lawyer who represented Richard Scampone in his suit on behalf of the estate of his mother, Madeline Scampone. She died Feb. 9, 2004, at Highland Park Care Center.

The suit filed in Common Pleas Court charged that Mrs. Scampone died of dehydration and presented witnesses who said the facility was understaffed, medical records were falsified and water was not provided to residents because the employees were overworked.

The Scampone estate won a judgment of $193,000 but sought and won a new trial after arguing that Judge Robert J. Colville erred in allowing the home's owner, Grane Healthcare, to be excluded from the suit.

The Superior Court panel was made up of Judges Mary Jane Bowes, Christine L. Donohue and senior Judge Zoran Popovich.

The judges concluded that Grane, the parent firm, played a substantial role in managing the Highland facility, including establishing quality assurance.

"We conclude that plaintiff's evidence established that both Highland and Grane acted with reckless disregard to the rights of others and created an unreasonable risk of physical harm to the residents of the nursing home," the court declared in its ruling. "The record was replete with evidence that the facility was chronically understaffed and complaints from staff continually went unheeded."

The court also declared that employees of the company "not only were aware of the understaffing that was leading to improper patient care, they deliberately altered records to hide that substandard care by altering [Activities of Daily Living records] that actually established certain care was not rendered."

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