Nursing home residents with dementia improperly given antipsychotics

From April 29th Boston Globe: an article about excessive medication of our nursing home elders who should not be on anti-pyschotic med:
"Ledgewood Nursing home is one of many nursing homes that have commonly used antipsychotic drugs to control agitation and combative behavior in residents who should not be receiving the powerful sedatives. Nineteen percent of such Ledgewood residents - those without a diagnosis for which the drugs are recommended - received the medications, anyway, exposing them to the risk of dangerous side effects.
“There is a lot of guilt about putting your mom in a nursing home, and I felt I made a competent choice,’’ Weingartner said. “I wish that what I know now, I would have known then.’’
The situation she encountered at Ledgewood is alarmingly common in Massachusetts and across the nation, a Globe investigation has found. Federal data show that roughly 185,000 nursing home residents in the United States received antipsychotics in 2010 contrary to federal nursing home regulators’ recommendations - often elderly people like Murphy who have Alzheimer’s or other dementias.
The drugs, which are intended to treat severe mental illness such as schizophrenia, can leave people in a stupor. The US Food and Drug Administration has issued black-box warnings - the agency’s most serious medication alert - about potentially fatal side effects when antipsychotics are taken by patients with dementia.
Nursing home regulators have for years collected data about individual homes’ use of antipsychotics but have not publicly released facility-specific information, citing patient privacy concerns. The government finally provided the data to the Globe, 19 months after the newspaper submitted a Freedom of Information Act request.
The data show that in more than one in five nursing homes in the United States, antipsychotics are administered to a significant percentage of residents despite the fact that they do not have a psychosis or related condition that nursing home regulators say warrants their use. The proportion of homes using antipsychotic drugs in this fashion is even higher in Massachusetts


Nursing home residents with dementia often given antipsychotics despite health warnings - The Boston Globe

Nursing home violence

Two years into the state's fight to close a troubled South Side nursing home, the facility remains open and even has successfully booted out two state-appointed monitors who were installed to ensure patient safety.
Police reports and state health department inspections allege a pattern of patient-on-patient violence at the Rainbow Beach Care Center, a 200-bed facility that houses and treats indigent adults with mental illness.
In the most serious episode in July, two male residents were accused of pinning down a 45-year-old female patient and raping her. When police arrived at Rainbow Beach to investigate that allegation, they learned that the two men had allegedly attempted to sexually assault a second seriously disabled female resident just weeks before.
The state, which had moved to revoke the facility's license in April 2010, placed monitors at Rainbow Beach in the wake of those attacks. But earlier this year, an attorney for the facility persuaded a Cook County judge to issue a temporary restraining order barring them from the premises.
State authorities say the push-back from Rainbow Beach underscores how vigorously some nursing home operators are using the courts to contest enforcement efforts, even as the industry presses for legislation that patient advocates say could water down nascent state reforms.
Nursing home violence: Troubled Chicago facility expelled two state monitors - chicagotribune.com

Consumer Group Bashes SNF Industry for Inferior Care Despite “Astonishing” Profits

Nursing homes remained “highly profitable” despite Medicare reimbursement cuts, but they’re still providing inferior elder care, says citizen advocacy organization Families for Better Care—a claim that the American Health Care Association (AHCA) was quick to counter.
Despite “astonishing” recent nursing home earnings reports for publicly traded nursing homes, resident care remains “mediocre at best” with too many residents troubled by untreated pressure sores, falls, abuse, or other negligent medical practices, contends Brian Lee, executive director of Families for Better Care.
“The industry’s analysts framed the Medicare adjustment as an eventual doomsday for the nation’s nursing home market. But the industry’s own reports show quite the opposite, revealing surging revenues, strong profits, and expansion through acquisitions,” said Lee in a statement. “The industry is wallowing in strong profits while failing to consistently provide quality care.”
Even after the average 11.1% Medicare cuts to skilled nursing facility payments that went into effect last October, the industry remained a “thriving enterprise” with many companies reporting better than expected operating results, according to Lee. The resident advocacy organization cited one company’s annual revenues spiking nearly 200%, while another called 2011 an “exceptional year.”
“The reason care declines in nursing homes is that executives unnecessarily target labor costs to offset any reimbursement adjustments,” Lee said. “While this obviously maintains a robust bottom line for investors and cushy CEO salaries, the decline in frontline staff puts residents in jeopardy for harm while simultaneously creating dangerous working conditions for employees.”
A study released last November shows a steady decline in nursing hours for Medicare-licensed facilities and what Families for Better Care calls an unacceptably high level of deficiencies.
Consumer Group Bashes SNF Industry for Inferior Care Despite “Astonishing” Profits : Senior Housing News

“If you didn’t chart it you didn’t do it.” Part 1 | Pat Iyer.com

Incomplete documentation can dramatically affect a malpractice case. In the ideal world all pertinent observations and interventions are recorded. But is “If you didn’t chart it you didn’t do it” true? For a variety of reasons, medical records may be incomplete. Emergency situations, such as cardiac arrests, often result in gaps in documentation as patient needs take priority. Ideally the nurse tries to record detailed notes after the emergency is over, but this does not always happen because the nurse must direct attention to the other patients who took a back seat to the crisis. Sketchy documentation complicates the defense of a case and provides the plaintiff’s attorney with an opportunity to advance theories of liability.
Plaintiff’s attorneys may use the phrase, “If you didn’t chart it, you didn’t do it” to convince the jury that essential care was not given. Defense attorneys sometimes attempt to preempt the anticipated attack on the nurse’s credibility or documentation. This is brought up on direct examination of the nurse during trial by having the nurse testify about the impossibility of recording every detail or observation of the patient. Another defense technique is to have the nurse testify about the nurse’s usual practice which may or may not be recorded in the medical record.
Missing documentation coupled with a poor outcome complicates the defense of cases no matter what strategy is employed, and it provides the plaintiff with an opportunity to successfully argue that care was not rendered. In the case below, the nurses could not prove they contacted the physician, if they did.
The plaintiff, age sixty-three, suffered a back injury and could not to return to work as a nurse. She decided to have an anterior approach lumbar fusion of the spine. This was to include surgery to the spine from the front of the body and then a day or two later, surgery from the back. For the anterior approach the plaintiff’s abdomen was opened and her internal organs were moved in order to get to the spine. After surgery the plaintiff had fluctuating blood pressure and no pulse in the left leg. The nurses noted the lack of pulse in the leg but did nothing about it.
The next morning, when Dr. Brown arrived to perform the second part of the surgery, he discovered her problems and had her rushed for a CT scan which showed internal bleeding in her abdomen and a blockage of the artery which supplies blood to the left leg. The plaintiff was transferred to another hospital by helicopter, but the surgeons there were unsuccessful in salvaging the leg and an above-knee amputation was performed. The plaintiff had been unaware of the problem with the leg overnight due to being heavily medicated. The plaintiff’s abdomen took four years to heal because the surgical incision wouldn’t fully close due to the swelling of her organs and the internal bleeding. The plaintiff also had infections and required repeated surgeries to repair the damage to her abdomen. The matter settled for $5.25 million. (1)
Good documentation is consistent, concise, chronological, continuing, and reasonably complete. (2)
“If you didn’t chart it you didn’t do it.” Part 1 | Pat Iyer.com