Why are Hospital Errors so Rampant in the U.S.?

Excellent ARticle in the Washuington Monthly about the cause of so many medical errors in the U.S. The Article ponders this issue:

"Last year there wasn’t a single fatal airline accident in the developed world.

So why is the U.S. health care system still accidently killing hundreds of thousands?"

Their answer is a lack of transparency.



First Do No Harm - Marshall Allen

Winnipeg nursing home resident dies from neglect

WINNIPEG - Manitoba's Health Department says that negligent nursing home staff so thoroughly failed to treat an elderly woman who later died in hospital that their actions amounted to "physical abuse by neglect."

Officials are reviewing care at the Saul and Claribel Simkin Centre, where Lillian Peck, 93, suffered as her skin became infected by her own feces and later ruptured.
"Documentation on basic nursing care, assessment and treatment, and examination of the wound itself was absent," Bernadette Preun, assistant deputy minister of health, wrote in a letter dated July 20 that was made public Monday. "The evidence further showed staff were uncertain and lacked confidence in their knowledge of the wound and how to treat it." Negligent wound care may have caused the nursing home  wrongful death.

Peck was at the home last October and was generally alert and in good spirits, according to her daughter Marsha Palansky. Palansky said she visited frequently and ensured her mother had a companion that would walk her around several hours each week.

Neither realized Peck was suffering an infection in her pelvic area until her health deteriorated and she was transferred to a hospital. That's when Palansky was shown how the infection had affected her mother.

"The skin was black. At one point, one of the doctors thought she might have flesh-eating disease, that's how dark it was," Marsha Palansky said Monday. "I literally broke down. I could not believe anybody could be in that condition.
Peck had not been washed after bowel movements, Palansky said. She died from heart and renal failure two days after being moved to the hospital. The Winnipeg Regional Health Authority has apologized to Peck's family and said it is reviewing standards at all nursing homes in its jurisdiction.
Seven nurses have been disciplined, including one who no longer works at the home, and the facility has implemented an improvement plan. "It should not have happened," said Real Cloutier, the authority's chief operating officer. "A big part of this was ... just not following the protocols in place."
Manitoba Health is also conducting a thorough review of the 200-bed nursing home, which bills itself on its website as "one of the most respected personal care homes in Winnipeg."
Palansky said she hopes no one else will go through what she has. "I'm hoping that this home becomes a quality long-term care home," she said. "But I don't think a lot of education (of staff) has happened."

Winnipeg nursing home resident dies after being neglected: government review - Winnipeg Free Press

Black Nursing Home Residents have more Pressure Sores - JAMA

Nursing Home Neglect:
In a study published this month in the prestigeous Journal of American Medicine:
"... Nursing Home pressure ulcer rates in 2.1 million white and 346 808 black residents of 12 473 certified nursing homes in the United States that used the nursing home resident assessment; Nursing homes were categorized according to their proportions of black residents.

The study essentially measured the odds of pressure ulcers in stages 2 through 4 for black and white residents receiving care in different nursing home facilities.

Results ....... black residents of nursing homes showed persistently higher pressure ulcer rates than white residents.

In 2003, the pressure ulcer rate was 16.8% for black nursing home residents compared with 11.4% for white residents; in 2008, the rate was 14.6% compared with 9.6% , respectively. In nursing homes with the highest percentages of black residents (≥35%), both black residents unadjusted rate of 15.5%  in 2008; and white residents unadjusted rate of 12.1% had higher rates of pressure ulcers than nursing homes serving primarily white residents, in which white residents had an unadjusted rate of 8.8%.

Conclusions From 2003 through 2008, the prevalence of pressure ulcers among high-risk nursing home residents was higher among black residents than among white residents. This disparity was in part related to the site of nursing home care."

Association of Race and Sites of Care With Pressure Ulcers in High-Risk Nursing Home Residents, July 13, 2011, Li et al. 306 (2): 179 — JAMA

nursing home death ruled homicide

GLENVIEW, Ill.— The Nursing Home wrongful death of an 86-year-old nursing home resident from injuries sustained in an attack by another resident is being investigated as a homicide, suburban Chicago nursing home officials said.

Mercedes Iverson, a resident at Maryhaven Nursing and Rehabilitation Center in Glenview, died last week. The Cook County medical examiner ruled her death a homicide, saying she died from heart disease and brain injuries related to the assault.

"Within the past couple of weeks, an unfortunate incident occurred in a private room" in a part of the nursing home that handles patients with dementia, Brian Crawford, a spokesman for Resurrection Health Care, which runs Maryhaven, told the Chicago Sun-Times for a story posted online Sunday.

Crawford didn't offer further details on the alleged assault.

Glenview police, who are investigating the incident, have declined to comment until Monday.

Iverson was moved to hospice care at St. Francis Hospital in Evanston last week, the newspaper reported. She was pronounced dead Thursday.

Crawford said the incident was reported to the Illinois Department of Public Health as soon as nursing home officials were aware. He said state health officials launched investigations.

Police probe nursing home death ruled homicide - chicagotribune.com

State Operations Manual T/C

The State Operations Manual contains sections outlining the Federal Code of Regulations governing Nursing Home Care. The so called "F-Tags" are derived from these sections. The Table of Contents is listed below. All sections are contained in 42 CFR §483

§483.5: Definitions

§483.10 Resident Rights

§483.10(a) Exercise of Rights

§483.10(b) Notice of Rights and Services §483.10(c) Protection of Resident Funds §483.10(d) Free Choice

§483.10(e) Privacy and Confidentiality §483.10(f) Grievances

§483.10(g) Examination of Survey Results §483.10(h) Work

§483.10(i) Mail

§483.10(j) Access and Visitation Rights §483.10(k) Telephone

§483.10(l) Personal Property

§483.10(m) Married Couples

§483.10(n) Self-Administration of Drugs §483.10(o) Refusal of Certain Transfers §483.12 Admission, Transfer, and Discharge Rights

§483.12(a) Transfer, and Discharge

§483.12(b) Notice of Bed-Hold Policy and Readmission

§483.12(c) Equal Access to Quality Care §483.12(d) Admissions Policy

§483.13 Resident Behavior and Facility Practices

§483.13(a) Restraints

§483.13(b) Abuse

§483.13(c) Staff Treatment of Residents (F224* and F226**)

§483.15 Quality of Life

§483.15(a) Dignity

§483.15(b) Self-Determination and Participation

§483.15(c) Participation in Resident and Family Groups

§483.15(d) Participation in Other Activities

§483.15(e) Accommodation of Needs

§483.15(f) Activities

§483.15(g) Social Services §483.15(h) Environment

§483.20 Resident Assessment §483.20(a) Admission Orders §483.20(b) Comprehensive Assessments

§483.20(c) Quality Review Assessment

§483.20(d) Use

§483.20(e) Coordination

§483.20(f) Automated Data Processing Requirement

§483.20(g) Accuracy of Assessment §483.20(h) Coordination

§483.20(i) Certification

§483.20(j) Penalty for Falsification §483.20(k) Comprehensive Care Plans

§483.20(l) Discharge Summary

§483.20(m) Preadmission Screening for Mentally Ill Individuals and Individuals With

Mental Retardation.

§483.25 Quality of Care

§483.25(a) Activities of Daily Living §483.25(b) Vision and hearing

§483.25(c) Pressure Sores
§483.25(d) Urinary Incontinence §483.25(e) Range of motion.

§483.25(f) Mental and Psychosocial Functioning §483.25(g) Naso-Gastric Tubes

§483.25(h) Accidents

§483.25(i) Nutrition

§483.25(j) Hydration

§483.25(k) Special Needs

§483.25(l) Unnecessary Drugs

§483.25(m) Medication Errors

§483.25(n) Influenza and Pneumococcal Immunizations §483.30 Nursing Services

§483.30(a) Sufficient Staff §483.30(b) Registered Nurse §483.30(c) Nursing facilities

§483.30(d) SNFs

§483.30(e) Nurse Staffing Information §483.35 Dietary Services

§483.35(a) Staffing

§483.35 (b) Standard Sufficient Staff

§483.35(c) Standard Menus and Nutritional Adequacy §483.35(d) Food

§483.35(e) Therapeutic Diets §483.35(f) Frequency of Meals §483.35(g) Assistive Devices

§483.35(h) Paid Feeding Assistants §483.35(i) Sanitary Conditions §483.40 Physician Services

§483.40(a) Physician Supervision

§483.40(b) Physician Visits

§483.40(c) Frequency of Physician Visits

§483.40(d) Availability of Physicians for Emergency Care §483.40(e) Physician Delegation of Tasks in SNFs

§483.40(f) Performance of Physician Tasks in NFs

§483.45 Specialized Rehabilitative Services

§483.45(a) Provision of Services §483.45(b) Qualifications

§483.55 Dental Services

§483.55(a) Skilled Nursing Facilities §483.55(b) Nursing Facilities §483.60 Pharmacy Services §483.60(a) Procedures

§483.60(b) Service Consultation §483.60(c) Drug Regimen Review

§483.60(d) Labeling of Drugs and Biologicals

§483.60(e) Storage of Drugs and Biologicals

§483.65 Infection Control

§483.65(a) Infection Control Program §483.65(b) Preventing Spread of Infection

§483.65(c) Linens

§483.70 Physical Environment §483.70(a) Life Safety From Fire §483.70(b) Emergency Power §483.70(c) Space and equipment §483.70(d) Resident Rooms §483.70(e) Toilet Facilities

§483.70(f) Resident Call System §483.70(g) Dining and Resident Activities

§483.70(h) Other Environmental Conditions

§483.75 Administration

§483.75(a) Licensure

§483.75(b) Compliance With Federal, State, and Local Laws and Professional Standards §483.75(c) Relationship to Other HHS Regulations

§483.75(d) Governing Body

§483.75(e) Required Training of Nursing Aides

§483.75(f) Proficiency of Nurse Aides §483.75(g) Staff Qualifications §483.75(h) Use of Outside Resources §483.75(i) Medical Director §483.75(j) Laboratory Services

§483.75(k) Radiology and Other Diagnostic Services

§483.75(l) Clinical Records

§483.75(m) Disaster and Emergency Preparedness

§483.75(n) Transfer Agreement

§483.75(o) Quality Assessment and Assurance

§483.75(p) Disclosure of Ownership

Standards of Care

Nursing Home Standards of Care :
Are there federal and state standards of care?

The Federal Nursing Home Reform acts and regulations set daily care requirements for nursing facilities. Federal law only applies to Medicare and Medicaid-approved nursing facilities. Almost all nursing facilities are Medicare or Medicaid-approved.

Federal law contains four key standards of care for nursing facilities:

1. The nursing facility must provide services to help each resident attain or maintain the highest practicable physical, mental, and psycho-social well-being.

2. A resident’s ability to bathe, dress, groom, transfer, walk, toilet, eat, and communicate must not decline unless it is medically unavoidable.

3. If a resident is unable to carry out activities of daily living, he or she must receive help to maintain good nutrition, grooming, and personal and oral hygiene.

4. Each resident has the right to make choices about his or her care.
Besides these general principles, federal laws set minimum requirements for daily care. Some of these requirements are described below:

General Hygiene

Assistance should be provided for any resident that needs help with general personal hygiene including: skin, oral, and hair care. Residents should also have the opportunity to shave daily with assistance if needed. Residents should receive help to take a full bath or shower as often as needed.

Pressure Sores

Residents who lie or sit in one position for long periods of time often develop pressure sores, also known as bed sores. Pressure on the skin prevents blood vessels from carrying nutrients to the affected area. This causes skin breakdown which can lead to large sores, infections, and severe pain if not treated. Poor nutrition and certain conditions may also lead to development of pressure ulcers.

Residents confined to a bed or a chair should be checked and their position changed (turned) every two hours or more often if the resident is uncomfortable. If needed, supportive devices, special mattresses, pads, and pillows should be used to maintain normal body posture and to relieve pressure. Residents should receive daily help with walking and exercise to help maintain or improve their circulation, strength, and use of the body.

Dressing

Residents should be dressed in their own clean, comfortable clothing each day. Residents who walk should wear appropriate footwear, and non-ambulatory residents should have suitable foot coverings when out of bed.

Toileting

Residents who have control of their bowel and bladder should receive help using the toilet as often as needed. However, some residents are incontinent, meaning they have lost control of their bowel or bladder. If this is the case, those who become wet or soiled should be cleaned and changed quickly. Incontinent residents should receive care to restore as much normal bowel and bladder functioning as possible.

Eating

Residents who need help eating should receive appropriate assistance during meal time. They may need packages opened or special eating utensils provided. In some cases, residents may require help feeding themselves. Food normally eaten hot should be served hot, and food normally eaten cold should be served cold.

Fluid Intake

The nursing facility must ensure that each resident receives sufficient fluids to maintain good health and prevent dehydration. Fresh water and drinking cups must be available on each bedside table.

Vital Signs

Upon admission residents must be weighed, have blood pressure, temperature, respiration rate, and pulse taken. These should be taken at least monthly or more often if ordered by a physician.

Family should always get a copy of the care plan. Monitor the care plan and talk with staff if questions arise.

See Standards of Care for Accidents: Accident Standard of Care

Lifecare MA Loses Wrongful Death Case: $376,000 Awarded for Negligence

Lifecare of Lynn, MA lost a Nursing Home wrongful death claim on July 6th, 2011 stemming from the wrongful death of one of its residents. She was awarded a total of of $376,000.
Geraldine McDonald fell off a curb outside lifecare on June 13th, 2008 fracturing both legs.  She died from pneumonia 3 weeks later.

Nursing home worker pleads guilty to attempted sex abuse

A nursing home employee accused of sexually abusing a female resident pleaded guilty to a lesser charge Friday morning and was sentenced to over 3 years in prison.
Eugene police arrested Robert Price just before the holidays after Valley West Health Care Center called them reporting an alleged case of sex abuse at their facility.
Price pleaded not guilty to first degree sex abuse on Dec. 30.
On Friday, Price pleaded builty to attempted sex abuse.
Judge Maurice Merten sentenced Price to 3 years and nine months in prison

Nursing home worker pleads guilty to attempted sex abuse

Elders not told of risks in hip study, US alleges

Federal health regulators have accused a research team led by a Harvard doctor of ethical violations after the scientists failed to inform elderly nursing home residents of serious health risks discovered during a study of hip fractures.

Tweet Be the first to Tweet this!.ShareThis .In a letter sent last week to a Harvard-affiliated institution and two other major research universities, the Department of Health and Human Services concluded that the scientists suppressed information about the dangers to elders participating in research on how to reduce often lethal hip injuries. The regulators said the scientists should have shared their findings about the use of protective padded underwear with patients and safety boards that routinely oversee medical studies.
As a result, the federal agency is now ordering the researchers to develop a plan to contact nursing home residents in Boston, St. Louis, and Baltimore who participated in the study and may unwittingly have been placed in peril.
The conclusions of the federal report were based, in large measure, on private e-mails exchanged among the researchers, including Harvard Medical School gerontologist Dr. Douglas P. Kiel.
“The investigators themselves, in candid e-mails to one another, recognized the significance of these findings,’’ the letter states. “Yet, in the face of these developments, efforts were made to either ‘slant,’ or completely fail to report . . . information to the groups . . . that might have found this information highly relevant in their deliberations.’’

The study included more than 2,000 patients, many of whom had significant cognitive impairments.

Nursing home patients often wear padded underwear to protect their frail hips. Typically, the underwear is padded on both hips. But in the study, researchers were assessing garments that were padded on just one side.

After they started to enroll patients in 2002, data from the study increasingly indicated that the one-sided padded underwear might be causing the very problems it was designed to prevent - seniors were more often having serious falls on the padded hip side than the one unprotected, according to the regulators.

Despite the fact that investigators learned risks existed, federal regulators said, they failed to disclose it to research participants; to the National Institutes of Health, which funded the study; and to other officials overseeing the research.

The regulators found that by October 2004, if not earlier, investigators had become “sufficiently aware of the risk of increased falling to the pocketed side and the associated risk of possible hip fractures, but failed to inform subjects who were enrolling during this time of these reasonably foreseeable risks.’’
The researchers continued to enroll patients in the study until summer 2006, according to the letter sent by federal health authorities June 23.

Kiel, who is also a researcher at the Harvard-affiliated Institute for Aging Research at Hebrew SeniorLife in Boston, declined to comment yesterday when reached by phone at his office.

Elders not told of risks in hip study, US alleges - The Boston Globe

Duluth nursing home cited

Bayshore Health Center in Duluth has been cited by the Minnesota Department of Health for failing to report multiple patient altercations and problems — including a patient with frostbitten feet and another who used his power wheelchair to ram other patients.
The report, posted May 27, stems from a state inspection March 21 and 22 that found two serious violations of federal nursing home rules, including “a situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.
John Stieger, a spokesman for the Minnesota Department of Health, said a May 20 reinspection by the state found Bayshore “corrected most of the deficiencies,” including the most serious.

The state has recommended a $4,050 one-time fine, and a $200 daily fine that is still accumulating, to the federal Center for Medicare and Medicaid Services, which has not yet rendered a decision, Stieger said.
In one Bayshore case in the report, a wheelchair-bound quadriplegic patient who was allowed to smoke but who couldn’t light his or her own cigarette was allowed to go outside without proper footwear and suffered frostbite on both feet. The incident was not reported.
Duluth nursing home cited by state inspectors Duluth News Tribune Duluth, Minnesota

Nursing home abuse case caught on tape at the Quadrangle in Haverford, Pa.

Mary and Paul French of Havertown spoke for the first time Tuesday about a case of alleged nursing home abuse caught on videotape.
The victim was Mary's mother, 78-year-old Lois McCallister.
"We are furious," said Paul French, "at watching someone you love being beaten and being abused."
"She is not the type to fight back," said Mary French. "If you look at the tape she was just trying to get away."
Last month, three staffers from the Quadrangle in Haverford were arrested. Citing negligence and misconduct, state officials in Harrisburg revoked the facility's license on Friday. The upscale facility remains open during an appeal.
Mark Ordan, the CEO of Sunrise Senior Living, Inc., which operates the Quadrangle, said what occurred was an isolated incident.
"We had three rogue employees," he told Action News. "We were shocked. We were angry that people would do something like that. We have we have been 1000 percent cooperative with the authorities."
Cooperative? Not so, says the Frenches' attorney. He says Sunrise was required to report early abuse complaints to the Pennsylvania Department of Public Welfare (DPW).
"They were supposed to report to the government," said attorney Robert Mongeluzzi. "But they didn't."
Sunrise Senior Living has been in hot water before. On Tuesday, a spokesperson with the DPW said the company has had a long history of regulatory violation in Pennsylvania.
Last year, Sunrise promised the state it would take steps to improve its culture of care, to put residents first. It claims it does.
"We have 30 thousand people taking care of 40 thousand seniors," said Ordan. "And we put them first."
Lois McCallister is now living with Mary and Paul French. The family says Sunrise ignored their initial complaints of abuse, dismissing them as a manifestation of McCallister's Alzheimer's Disease. They hope a lawsuit they plan to file will change how Sunrise treats future complaints.
"They have to follow those rules and do something about it," said Mary French.
"Maybe the next family that comes forward, they will do something about it, rather than blame it on dementia," said Paul French.

Lawsuit planned in nursing home abuse case caught on tape at the Quadrangle in Haverford, Pa. 6abc.com

Elders suffer from poor nursing-home staffing in Kentucky

"Dental neglect at nursing home; poor staffing a problem across state"
oral care in most nursing homes in Kentucky is atrocious, and this kind of abuse and neglect is still another example of how the nursing home industry refuses to hire enough caregivers to take care of their residents.
Why is this? What's going on here where the most vulnerable of our population, our poor elderly citizens, are being mistreated day in and day out?
The answer is one word: greed.
Many of these nursing homes are owned by big corporations, many run by fat cats on Wall Street or far away from the nursing facility, where the only important report to hit their desks is the profit-and-loss statement.
Advocates for nursing home reform have been telling government leaders this for years. In Kentucky, however, no one seems to listen, or lawmakers who could help are persuaded by generous donations to their re-election campaigns not to act.
It's also a shame that the sometimes total disrespect of the elderly in these facilities by the bosses and big corporate owners reflects on the many nursing home workers who go all out to try to help
Long hours and hard work are big problems for anyone brave enough to sign on to be a nursing home caregiver.
So something's got to be done. But how?
We know we need minimum staffing standards for nursing homes in Kentucky. They would help eliminate the abuse and neglect. They would, for example, ensure that there would be sufficient front-line staff to provide oral health care to all the residents of a facility.
What would these state staffing standards look like? They would force the nursing homes to hire the number of people necessary to provide for a ratio of one direct caregiver to every five residents on the day shift, one to 10 in the evening, and one to 15 at night.
Much research has gone into such ratios on whether they will work, and the conclusions are that they provide better nursing-home care.
 
Read more: http://www.kentucky.com/2011/05/09/1735008/citizens-suffer-consequences-of.html#ixzz1M2sCWs8DCitizens suffer consequences of poor nursing-home staffing Op-Ed Kentucky.com

Family claims wrongful death at Houston nursing home

HOUSTON (KTRK) --  an elderly woman who was allegedly attacked by a nursing home employee has died, not from the alleged attack, but from an infection. Now her family is suing the nursing home, saying their loved one was abused and neglected at the Nursing Home. Eyewitness News spoke with the family and tried to get a response from the nursing home. There's been no response from the nursing home, but this family is in a lot of pain, after they say the people they trusted failed to take care of their loved one.
Rosie Bartee said, "It feels like the value of a human life is devalued."
Bartee is grief stricken over the death of her 76-year-old mother, Sandra Campion. It's a death Bartee says was caused by gross negligence on the part of the Heritage Park nursing home in Katy.
She said, "You don't treat animals that way and that's the thing."
Campion died on April 3. According to her family lawsuit filed, doctors told them she contracted a massive blood infection, from a large bedsore on her back. Photos of the wound are too graphic to show on camera.
Jason Gibson, the family's attorney, explained, "They didn't turn her like they were supposed to and as a result she developed bed sores. Eventually, a wound that was 10 inches long and four inches deep became septic, and eventually caused her to lose her life."
But prosecutors say there's more. Just one month ago, Campion survived what prosecutors say was a brutal assault. They say a worker at the facility, Myrtle Lean Tillman, tried to strangle her.
Harris County Prosecutor Lisa Collins said, "He went in and saw the victim, who is a 76-year-old female, with a sweater around her neck being held there very tightly by the defendant in this case, Myrtle Tillman."
Tillman is charged with felony injury to an elderly person
The family is suing Heritage Park for wrongful death. But they say the case is not about money, it's about justice for Campion.
"This shouldn't happen to anybody, especially the elderly, somebody that's defenseless," Bartee said.
Victim's family sues nursing home after woman's death abc13.com

Three nursing home workers arrested in Delaware County

"Three employees at a well-known Delaware County nursing home are facing appalling charges. The District Attorney's Office is charging the Quadrangle nursing home workers with assaulting and neglecting an elderly patient - whose family recorded it all on a hidden camera. The 78-year-old woman told her family she was being abused and according to court documents the family found marks on her body. The family said it told nursing home officials who said the claims could not be substantiated, and pointed to the woman's dementia. Delaware County District Attorney Michael Green said the family hid the camera in the woman's room at the nursing home in Haverford. Three nursing home workers arrested in Delaware County — NewsWorks:

Nursing home worker pleads guilty

EUGENE, Ore. - A nursing home employee accused of sexually abusing a female resident pleaded guilty to a lesser charge Friday morning and was sentenced to over 3 years in prison. Eugene police arrested Robert Price just before the holidays after Valley West Health Care Center called them reporting an alleged case of sex abuse at their facility. Price pleaded not guilty to first degree sex abuse on Dec. 30. On Friday, Price pleaded builty to attempted sex abuse. Judge Maurice Merten sentenced Price to 3 years and nine months in prison. Nursing home worker pleads guilty to attempted sex abuse KVAL CBS 13 - News, Weather and Sports - Eugene, OR - Eugene, Oregon Local & Regional News: