Thursday, August 12, 2010

CA nursing home fined $100,000 after man suffers fatal head injury

A Northern California nursing home was fined $100,000 after its staff allegedly failed to prevent a patient from falling twice and suffering a fatal head injury for which he was not treated, state public health officials announced this week.

The 85-year-old patient, who had a heart condition and diabetes, was supposed use a walker and be supervised when walking, according to a state investigator’s report released Tuesday on Pilgrim Haven Health Facility in Los Altos.

But a state investigator found Pilgrim Haven staff failed to install an electronic fall monitor as ordered by the patient’s doctor and also failed to ensure that the patient’s walker was within reach. On Oct. 3, staff members discovered the man sitting on the floor of his room, having fallen and scratched his head, according to a fax sent to his doctor.

Los Altos nursing home fined $100,000 after man suffers fatal head injury

CA nursing home fined $100,000 after man suffers fatal head injury

A Northern California nursing home was fined $100,000 after its staff allegedly failed to prevent a patient from falling twice and suffering a fatal head injury for which he was not treated, state public health officials announced this week.

The 85-year-old patient, who had a heart condition and diabetes, was supposed use a walker and be supervised when walking, according to a state investigator’s report released Tuesday on Pilgrim Haven Health Facility in Los Altos.

But a state investigator found Pilgrim Haven staff failed to install an electronic fall monitor as ordered by the patient’s doctor and also failed to ensure that the patient’s walker was within reach. On Oct. 3, staff members discovered the man sitting on the floor of his room, having fallen and scratched his head, according to a fax sent to his doctor.

Los Altos nursing home fined $100,000 after man suffers fatal head injury

Legislators fail to help Iowa elderly in Nursing homes

Legislators fail to help elderly in Iowa Nursing Homes homes

Kentucky Nursing Home in Trouble

Attorney General Jack Conway announced, Hazard Nursing Home Incorporated and its owner, Sheila Noe, 61, are charged with failure to report suspected abuse.

The state alleges, Noe was told about a case of sexual abuse last year but did not report it to authorities.

Noe has been summoned to appear in Perry District Court September 13th.

The news comes on the same day the Bluegrass Care and Rehabilitation Center in Lexington was placed on the federal government's list of nationally troubled facilities.

The government found 22 deficiencies at the home in fiscal year 2010 more than three times the national average.

Two homes in Kentucky, Arbor Place of Clinton in Hickman County, and James S. Taylor Memorial Home in Louisville, have been on that list for at least six months.

Both are categorized as showing no signs of improvement.
Several Nursing Homes in Trouble

Falls in Nursing Homes Facts

How big is the problem?

* In 2003, 1.5 million people 65 and older lived in nursing homes.3 If current rates continue, by 2030 this number will rise to about 3 million.4
* About 5% of adults 65 and older live in nursing homes, but nursing home residents account for about 20% of deaths from falls in this age group.
* Each year, a typical nursing home with 100 beds reports 100 to 200 falls. Many falls go unreported.
* As many as 3 out of 4 nursing home residents fall each year.2 That’s twice the rate of falls for older adults living in the community.
* Patients often fall more than once. The average is 2.6 falls per person per year.
* About 35% of fall injuries occur among residents who cannot walk

How serious are these falls?

* About 1,800 people living in nursing homes die each year from falls.
* About 10% to 20% of nursing home falls cause serious injuries; 2% to 6% cause fractures.
* Falls result in disability, functional decline and reduced quality of life. Fear of falling can cause further loss of function, depression, feelings of helplessness, and social isolation.

Falls in Nursing Homes, Facts - NCIPC: "- Sent using Google Toolbar"

Monday, August 09, 2010

Medical Error List of Never Events includes Pressure Ulcers

The National Quality Forum calls these 28 medical errors "never events," meaning, of course, that they should never happen.

Most of these mistakes are likely to happen while a patient is being cared for in a healthcare facility. Others can happen anywhere, including in a patient's home.
Surgical Events

* Surgery performed on the wrong body part
* Surgery performed on the wrong patient
* Wrong surgical procedure on a patient
* Retention of a foreign object in a patient after surgery or other procedure
* Intraoperative or immediately post-operative death in a normal healthy patient

Product or Device Events

* Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
* Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended
* Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility

Patient Protection Events


* Infant discharged to the wrong person
* Patient death or serious disability associated with patient disappearance for more than four hours
* Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility

Care Management Events

* Patient death or serious disability associated with a medication error
* Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products (transfusion of the wrong blood type)
* Maternal death or serious disability associated with labor or delivery on a low-risk pregnancy while being cared for in a healthcare facility
* Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
* Death or serious disability (kernicterus) associated with failure to identify and treat jaundice in newborns
* Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
* Patient death or serious disability due to spinal manipulative therapy

Environmental Events

* Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility
* Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
* Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
* Patient death associated with a fall while being cared for in a healthcare facility
* Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility

Criminal Events

* Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
* Abduction of a patient of any age
* Sexual assault on a patient within or on the grounds of a healthcare facility
* Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

Many patients are surprised to learn that hospital-acquired infections such as MRSA or C.Diff are not included on this list.

Patient safety is now being addressed by a number of groups across the country. The National Patient Safety Foundation sponsors a week in March each year to call attention to patient safety issues.

What Is a Medical Error -- A Master List of Never Events from the National Quality Forum