One Third of Skilled Nursing Patients Harmed in Treatment

One-in-three patients in skilled nursing facilities suffered a medication error, infection or some other type of harm related to their treatment, according to a government report released today that underscores the widespread nature of the country’s patient harm problem.

Doctors who reviewed the patients’ records determined that  59 percent of the errors and injuries were preventable.   More than half of those harmed had to be readmitted to the hospital at an estimated cost of $208 million for the month studied — about 2 percent of Medicare’s total inpatient spending.

Patient safety experts told ProPublica they were alarmed because the frequency of people harmed under skilled nursing care exceeds that of hospitals, where medical errors receive the most attention.
“(The report) tells us what many of us have suspected ­­– there are vast areas of health care where the field of patient safety has not matured,” said Dr. Marty Makary, a physician at Johns Hopkins Medicine in Baltimore who researches health care quality.

The study by the inspector general of the U.S. Department of Health and Human Services (HHS) focused on skilled nursing care – treatment in nursing homes for up to 35 days after a patient was discharged from an acute care hospital. Doctors working with the inspector general’s office reviewed medical records of 653 randomly selected Medicare patients from more than 600 facilities.

The doctors found that 22 percent of patients suffered events that caused lasting harm, and another 11 percent were temporarily harmed. In 1.5 percent of cases the patient died because of poor care, the report said. Though many who died had multiple illnesses, they had been expected to survive.

The injuries and deaths were caused by substandard treatment, inadequate monitoring, delays or the failure to provide needed care, the study found. The deaths involved problems such as preventable blood clots, fluid imbalances, excessive bleeding from blood-thinning medications and kidney failure.

Full Article and Source:
One Third of Skilled Nursing Patients Harmed in Treatment

See Also:
Find Nursing Home Problems in Your State

Read the report from the Department of Human Health Services:  "Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries"

Introducing the Administration for Community Living

"For too long, too many Americans have faced the impossible choice between moving to an institution or living at home without the long-term services and supports they need. The goal of the new Administration for Community Living will be to help people with disabilities and older Americans live productive, satisfying lives."
- Secretary Kathleen Sebelius

All Americans - including people with disabilities and seniors - should be able to live at home with the supports they need, participating in communities that value their contributions. To help meet these needs, HHS is creating a new organization, the Administration for Community Living (ACL) with the goal of increasing access to community supports and full participation, while focusing attention and resources on the unique needs of older Americans and people with disabilities.

The ACL will include the efforts and achievements of the Administration on Aging, the Office on Disability and the Administration on Developmental Disabilities in a single agency, with enhanced policy and program support for both cross-cutting initiatives and efforts focused on the unique needs of individual groups such as children with developmental disabilities, adults with physical disabilities, or seniors, including seniors with Alzheimer's.

Source:
Introducing the Administration for Community Living

Senate Special Committee on Aging Holds Hearings on Assisted Living Facility Abuse

It was an early-morning awakening that Alfredo Navas said he'll never forget: His sister on the phone, telling him that their 85-year-old mother had drowned in a shallow drainage pond behind the facility that was caring for her.

But the safeguards his family had assumed were in place to monitor an elderly woman with dementia - cameras, door locks and vigilant caretakers - failed his mother in 2008, Navas told the Senate's Special Committee on Aging on Wednesday [11/2/11].

Those abuses and others were chronicled in a Miami Herald series "Neglected to Death," which focused this spring on critical breakdowns in Florida's enforcement system, including failures by the state's Agency on Health Care Administration to fully investigate deaths or to shut down some of the worst offenders among Florida's 2,850 assisted-living facilities.

"This is America in the year 2011, and these kind of things shouldn't be happening," said Sen. Bill Nelson, D-Fla., who read aloud of the worst examples of abuse.

They include a 75-year-old Alzheimer's patient in Clearwater torn apart by an alligator after he wandered away from his assisted-living facility for the fourth time; a 71-year-old mentally ill Hialeah man who died from burns after he was left in a bathtub filled with scalding water; and a 74-year-old Kendall woman who was restrained for six hours until the bindings cut into her skin and killed her.

Federal regulators and lawmakers both said that they are uninterested in the federal government being responsible for regulating living facilities. Although more states are using Medicaid money to pay for some portion of assisted living care for the poor, the federal government has a limited role in the facilities their oversight has been and will likely continue to be a state duty.

But federal regulators do want more of an ability to ensure states are doing their part to enforce laws and safety regulations already on the books, said Barbara Edwards, who directs the disabled and elderly health programs group at the Centers for Medicare and Medicaid Services at the Department of Health and Human Services.

Full Article and Source:
Abuses in Assisted Living Facilities Come Under Senate Panel's Spotlight

Tommy Thompson: Guilt-Ridden Children Are Spending Too Much On Grandma’s Health

Former Wisconsin governor and US health secretary Tommy Thompson offered up an intense psychoanalytic take on the thorny issue of end-of-life care this week, saying that “guilty” children who ignore their elders then overcompensate at their deathbed are responsible for spiraling costs.

“What happens? Mother or father or grandpa and grandma, you’ve been away, you haven’t done very much. Children come home, mother or father’s on their deathbed, they feel guilty because they haven’t being paying attention to mother or father,” Thompson said at a luncheon in Madison. He continued: “Let’s face it. So they say ‘let’s do everything we can for mother or father. Don’t spare the costs.’ I’m not talking about denying anybody anything. I’m just saying let’s let mother and father have their wishes. They may not want to be on a respirator the last six months of their life.”

According to Wisconsin Radio Network, Thompson, who is expected to run for Senate in Wisconsin, “said people need to have durable power of attorney to ensure their wishes are known, and he also said the nation’s medical schools need to start talking about death.”

Full Article and Source:
Tommy Thompson: Guilt-Ridden Children Are Spending Too Much On Grandma’s Health

More Than 90% of Nursing Facilities Employ Workers With Criminal Record

More than 90 percent of nursing homes employ one or more people who have been convicted of at least one crime, federal investigators said Wednesday in a new report. In addition, they said, 5 percent of all nursing home employees have at least one criminal conviction.

The report was issued by Daniel R. Levinson, inspector general of the Department of Health and Human Services, who obtained the names of more than 35,000 nursing home employees and then checked with the Federal Bureau of Investigation to see if they had criminal records.

“Our analysis of F.B.I. criminal history records revealed that 92 percent of nursing facilities employed at least one individual with at least one criminal conviction,” Mr. Levinson said. “Nearly half of nursing facilities employed five or more individuals with at least one conviction. For example, a nursing facility with a total of 164 employees had 34 employees with at least one conviction each.”

Full Article and Source:
Study Finds Criminal Pasts of Nursing Home Workers

Download Report (OEI-07-09-00110)

CPS and Legalized Kidnapping

The suffering endured by Africans who were kidnapped from their native land and brought to America as slaves is sometimes referred to as the Black holocaust, which some say ended years ago but, that is not the case according to parents who have had their children taken from them by the Denver Department of Human Service (DDHS) or the Adams County Social Service Department (ACSSD). Jo Nash-Conner’s son Quentin, 10, currently resides at Mount St. Vincents Children’s Home (MSVCH), a facility which proclaims to provide programs and services to “help children with a wide range of emotional and behavioral problems.”

Nash-Conner, however, has not found the center to be helpful and instead has been disallowed from visiting her son and has not seen him since February. The mother’s horror story began just over a year ago and is outlined in a typed statement entitled “A Declaration and A Desperate Mother’s Cry for Justice.”

She said: “My 10-year-old son was kidnapped by the Child Protective Services (CPS) Department of DDHS on March 20, 2008.”

Full Article and Source:
Child Protective Services & the Business of 'Legalized Kidnapping'

Online Adult Abuse Registry

Delaware residents who need a caregiver for their elderly loved ones now have an easier way to check up on a potential hire.

The state has activated an online Adult Abuse Registry that anyone can access to learn whether a caregiver has been investigated by the Department of Health and Social Services for a complaint of abuse, neglect or financial exploitation of the elderly.

The registry has existed for years, but not on the Internet. Previously, anyone making a request to check a name would have to do so in writing and wait for weeks to get the results. With the online registry, the results are instantaneous.

House Majority Whip Valerie J. Longhurst: "I hope this gives people the peace of mind that they can get information and access it quickly."

Longhurst sponsored House Bill 165, which created the online registry and requires health care providers, nursing homes and similar facilities to use it before making a hire. The bill -- championed by AARP of Delaware -- passed the House and Senate unanimously and was signed by Gov. Jack Markell on June 30.

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Registry offers instant access to elder care complaints

Lawsuit to Get Abuse Report

A legal advocacy group is expected to announce that it filed a lawsuit against the New Jersey Department of Human Services on behalf of a family denied information about an episode they say traumatized their 41-year-old severely disabled son living in a state institution.

Rosamund and Daniel Caliendo of Hampton said they arrived at the Hunterdon Developmental Center in Clinton for a holiday party on Dec. 1, 2007 to find their son, Damian, in his electronic wheelchair facing a wall with the chair's front wheels suspended in the air and the tray table jabbed into his stomach.

Their son, who cannot speak and is diagnosed with cerebral palsy, a seizure disorder and other medical conditions that required neck surgery a year earlier, "was scared to death he was going to fall." No one at the party came forward to explain what happened to Damien, who has lived at the institution for 30 years. The family believes an employee placed him in an unlawful restraint to punish him. They filed a complaint and demanded an investigation.

But when the Caliendos asked for the investigative report, the department gave them only a summary saying "staff did not act according to policy," and "additional training will be conducted." The summary did not include information about who was responsible or whether anyone had been punished.

Disability Rights New Jersey tried to obtain a copy of the report on the family's behalf but was told state law does not permit the department from sharing investigative reports without a court order.

Full Article and Source:
Disability Rights group sues N.J. to get report about disabled man's alleged abuse

Lawsuit Against State Facility

A lawsuit has been filed in U.S. Federal District Court alleging abuse at a state mental health treatment facility.

The suit alleges that the Minnesota Extended Treatment Options facility in Cambridge, Minnesota, routinely restrained patients using metal handcuffs and shackles without cause.

The suit also contends the facility secluded patients for extended periods and deprived them of family visits. The facility is run by the state Department of Human Services.

Full Article and Source:
Lawsuit alleges abuse at state-run mental health facility

More information:
Abuses Alleged at State-Run Mental Center

Improper Restraint Common At Minnesota Hospital, Suit Says

25-Year-Old Lawsuit Settlement

The stories were horrifying and heart-wrenching: a boy beaten bloody while in foster care; a 15-year-old girl tortured and starved to death by a mentally ill guardian; a 5-year-old fatally scalded by his mother after state officials removed him from a safe foster home.

It's no wonder such egregious cases of abuse and neglect have helped drive a 25-year-old lawsuit over how the Maryland Department of Human Resources and the Baltimore Department of Social Services care for the state's most vulnerable children and adolescents.

That's why the settlement announced this week between advocates for Baltimore's children and the city's foster care system represents a potentially tremendous step forward for the health and well-being of children in Maryland.

Some of the requirements:
1. The state must make sure children in its care have case plans and that they actually receive the health care, educational support and other services identified in those plans.

2. The agreement would allow the state to free itself from federal court supervision for the first time since 1988 if it meets dozens of specific goals and maintains that performance for an 18-month period.

3. Each caseworker will be responsible for no more than 15 children, and a single supervisor will be responsible for no more than six caseworkers.

4. The system has agreed to hire an outside expert with broad credibility in the field to monitor its progress and make periodic reports.

Full Article and Source:
A milestone for youths - Our view: Maryland now has a unique opportunity to fix its long-broken child welfare system; for the sake of future generations, it can't let that chance go to waste

Guardian Shot Grandson

Robert Clark Jr. could quickly move from playing with his 6-year-old grandson to yelling at him, said a neighbor.

Michael Levigne, 6, and his younger brother lived with their grandparents for about four years, since guardianship was switched by a probate court.

Police say Clark shot and killed the boy in an incident that may have been triggered by the boy dropping a watermelon or cutting into it before his grandfather wanted him to. Clark also shot and wounded his wife before police shot him, according to Commerce Police Chief John Gaissert.

State Child Advocate Thomas Rawlings said Tuesday that his office is looking into the child’s death. He wants to know whether DFCS performed any assessment of the grandparents as adequate care providers.

Chief John Gaissert said there were “no flags” that suggested that Robert Lewis “Bobby” Clark was set to explode.

Full Article and Source:
Neighbor: Slain boy was yelled at often

Penny Slots Guardian

A woman accused of stealing about $34,000 from an elderly woman she was appointed guardian of in order to play penny slots made her initial appearance last week in Douglas County Circuit Court.

Carol Jean Tolliver faces one felony theft charge. She was appointed the other woman’s guardian in August 2006 and was to receive $250 a month for managing her finances. From April 2008 to February 2009, the woman’s bank account shrunk from $99,693 to $800, according to the criminal complaint.

Kathy Izzard, an economic support worker with the Douglas County Department of Health and Human Services who was investigating the case, noted that Tolliver had produced checks that had been written out to a Superior bar and to the bar’s owner from the account.

Tolliver told Superior Police Detective Mike Jaszczak that she wrote the checks out for cash and felt she could do so because her name was on the checks.

The complaint stated that she told the detective that because she has watched over the woman, who resides in a nursing home, “she was entitled to the money.”

Full Article and Source:
Penny slots spur thefts

Seniors and Taxpayers Obligation Protection Act

Catching criminals, stopping Medicare or Medicaid fraud, and recapturing an estimated yearly fraud loss of $60 billion are the aim of two proposed laws introduced in the U.S. Senate earlier this month.

The Seniors and Taxpayers Obligation Protection Act (STOP) is designed to reduce or eliminate massive financial losses each year by creating fraud prevention and detection systems.

The Medicaid Accountability through Transparency Act (MAT) will require transparency in billing for services and medical equipment.

If passed, the legislation will give the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services (HHS) and the Social Security Administration the tools and authority to prevent fraud before it starts and detect waste and abuse much earlier.

Full Article and Source:
New Legislation Proposed to Prevent Medicare Fraud

Lawmakers Push For EJA

With state officials predicting more than 100,000 cases of elder abuse next year, Kildee and other federal lawmakers are pushing for new legislation that would use $100 million to help local agencies find and address such incidences.

The Elder Justice Act would create offices of elder justice at the federal departments of Justice and Health and Human Services. Those offices, said Kildee, would raise the profile of the issue and make it easier to get federal money into communities such as Genesee County. "They're on the front lines," he said.

Any federal money would be welcome, said Genesee County Prosecutor David Leyton. The Genesee County Elder Abuse and Financial Exploitation program currently relies on about $750,000 in funding from the county's $8-million senior citizen millage.

Full Article and Source:
Lawmakers push for federal Elder Justice Act

Meeting on Medicare/Medicaid Fraud

The U.S Senate Special Committee on Aging met to discuss prevention of Medicare and Medicaid fraud, which costs taxpayers more than $60 billion a year, according to Sen. Mel Martinez, ranking member of the committee.

Martinez said in a statement following the hearing: "Entitlement fraud is out of control and we have 60 billion reasons why it needs to be addressed."

Martinez chaired the meeting, which brought together Daniel R. Levinson, inspector general at the Department of Health and Human Services, along with U.S. attorneys and businessmen from the healthcare field. Some of the conversations focused on Florida, which, according to witnesses, has a significant amount of fraud. R. Alexander Acosta, U.S. attorney for the Southern District of Florida at the U.S. Department of Justice, told the committee that his district prosecuted 245 individuals in 2008 for defrauding Medicare and Medicaid of nearly $800 million.

Full Article and Source:
Senate Special Committee on Aging addresses Medicare, Medicaid fraud in special hearing

Judge Dismissed Suit

A federal judge has dismissed a sweeping lawsuit that alleged widespread abuse of the children in Department of Children, Youth and Families care, saying the state’s child advocate, who brought the suit on behalf of 10 children, had no standing in the case.

Senior U.S. District Judge Ronald R. Lagueux ruled that Child Advocate Jametta O. Alston and others who backed the suit had no authority to proceed because the children they claimed to represent are already in the jurisdiction of the state Family Court, where their guardians had been appointed.

Alston and the child-advocacy organization, Children’s Rights, pursued the suit in June 2007 on behalf of the 3,000 children now in state custody, with the aim to overhaul Rhode Island’s entire foster-care system. The suit alleged children in DCYF care were being molested, beaten and, in one high-profile case, killed. Her suit claimed staff faced excessive caseloads and that too many children were being placed in institutions and group homes, or being reunited with abusive parents.

The suit named Governor Carcieri, Jane Hayward, former secretary of the Office of Health and Human Services, and DCYF Director Patricia Martinez as defendants, and charged that the child-welfare system is underfunded, understaffed and mismanaged.

The state asked that the case be dismissed in January 2008. Lawyers questioned the remedy sought — namely that Alston wanted the court to take control of the DCYF. They argued the case belonged in family court, not federal court.

Full Article and Source:
Child advocate’s suit over DCYF care dismissed

Pitfalls of The Guardian System

Chuck Nagle says his father will want to write a check to donate to his church. But he won’t be allowed to write that check. “He has zero authority now to do anything. He can’t even subscribe to the newspaper.”

That’s because a non-profit corporate guardian has been appointed to represent William Nagle, whom Chuck said has early stages of Alzheimer’s. A guardian was appointed because of his medical condition.

The guardian system in Wisconsin is one where little information reaches the public, and sometimes even family members. "In Wisconsin, guardianship cases are considered to be closed. Even family cannot get information." It’s a system that he contends is broken.

Otis Woods is administrator for the Division of Quality Assurance of the Wisconsin Department of Health and Family Services, the agency that oversees the regulation of guardians. The state uses 13 criteria for those guardians, Woods said. If they violate any one of those 13, he said they can be removed as a guardian. But complaints are relatively rare. Woods: “We don’t receive very many. Maybe five a year.”

A second category, of for-profit guardians, are unregulated by the state. Woods said the state is in the early stages of reviewing that and possibly rewriting rules to include regulation.

Chuck Nagle says relatives can be shut out of receiving updated financial information on a regular basis. That decision is up to a corporate guardian and can be upheld by a judge. “The only information the guardians have to report is to the court, once a year.”

Rep. Scott Suder who represents the state’s 69th Assembly District: “Once a year, for any type of reporting, is clearly not enough.” He said perhaps the Legislative Audit Bureau could audit the state’s guardian program to see if changes need to be made.

State Rep. Kirsten Dexter who represents the 68th District where William Nagle lives, is also considering forcing guardians to report financial information more frequently.

About the case:
After William Nagle’s wife died in May 2007, family members couldn’t agree what should happen next. Chuck Nagle asked in June 2008 for a limited, temporary guardian be appointed for his father, which was done in October. The next month a permanent guardian from Chippewa Family Services, Inc. in Chippewa Falls was appointed.

Chuck Nagle now is restricted in his posing of questions of the guardian, according a March 6 letter from Chippewa Falls attorney Robert W. McKinley, who represents Chippewa Family Services and the guardian. "You are not to contact my client again absent a bona fide emergency concerning your father. If my client hears from you for any other reason, all contacts will be terminated,” the letter states.

Nagle said he is appealing decisions in his father’s case to the Wisconsin Third District Court of Appeals in Wausau.

And he’s warning others of the potential pitfalls of Wisconsin’s guardian system.

Full Article and Source:
Guardian system leaves questions

Robert McKinley is a certified guardian with The Center For Guardianship Certification, allied foundation of the National Guardianship Association (NGA)

Inspections in Limbo

Each time Rebecca Murphy visits her 90-year-old mother at a Chagrin Falls nursing home, she doesn't like what she sees. Murphy: "Every time I've gone there, my mother has had feces on her fingernails. They've taken her shoes away. Her feet are so full of fungus it is unbelievable. She wears the same shirt and pair of pants. I've talked to everyone and their brother the last couple years and I can't get any help. She shouldn't have to live her golden years like this. These practices are sickening. But every time I call the state, they say they found my mother to be completely fine. And the nursing home says, 'Your mother is so happy here!' But I can't sleep at night knowing what they're doing to her."

Murphy's brother is her mother's legal guardian, and Murphy does not have enough money to file a lawsuit against the home.

The U.S. Department of Health and Human Services approved a rule in September that elderly advocates say has made it more difficult for people like Murphy to get key information about suspected abuse and neglect in the 16,000 U.S. long-term care facilities.

Under the new rule, nursing homes are no longer inspected by the state in which they are located, but by the federal government. State inspectors and Medicare and Medicaid contractors are now designated federal employees, a group usually shielded from providing evidence from either side in private litigation.

The rule was justified as necessary to accommodate the hiring of new contractors to make Medicare payments to providers and perform other work for the program. But the change is forcing litigants to go to greater lengths — including seeking court orders — to get inspection reports or depositions for cases they are pursuing or defending.

Advocates for the elderly also claim the change hurts nursing-home residents and their families by allowing bad practices to be kept secret by nursing homes and inspectors.

Lawyers on both sides of the issue are considering how to approach President Barack Obama's administration to get rid of the rule.

Full Article and Source:
Rule leaves nursing home inspections in limbo

See also:
New Rule Hurts Nursing-Home Residents

Mother of Guardian Lied

Diane Merrifield, the mother of a man convicted of sexually molesting and murdering his girlfriend's 2-year-old child, lied to a Child Protective Services investigator who was trying to locate Logan Goodall days before his 2005 death.

The revelation came during a pretrial hearing in the civil lawsuit filed by Jeremy Goodall, Logan's father, against the state Department of Health and Human Resources and Diane Merrifield. Dr. John Merrifield, Diane's husband and father of Michael Merrifield, was also named in the lawsuit, but he settled with Logan's estate for $775,000 in November 2007.

A Putnam County jury in January 2008 convicted Michael Merrifield of first-degree murder, child neglect resulting in death, and sexual abuse by a guardian. He is serving a life sentence without the chance of parole at Mount Olive.

Logan Goodall died on Sept. 6, 2005, of injuries that were consistent with repeated physical and sexual assaults, the state medical examiner's autopsy concluded.

In April 2008, John Merrifield pleaded no contest to gross neglect creating a substantial risk of serious bodily injury or death and was sentenced to five years on home confinement.

Full Article and Source:
Merrifield's mother lied to CPS just days before Logan's death

$6 Million Settlement

In a child-abuse case that shocked many people, the state and three other parties have agreed to pay $6 million to settle a lawsuit brought on behalf of a boy who was intentionally starved by his father and his girlfriend.

The state and three other parties have agreed to pay $6 million to settle a lawsuit brought on behalf of a boy who was intentionally starved by his father and the man's girlfriend.

The settlement, reached during mediation, stemmed from the case of Shayne Abegg, who weighed only 22 pounds at age 4 when authorities rescued him on March 7, 2007, from his Everett home. A year earlier, when Shayne came to live with his father, he had weighed 38 pounds.

Under the settlement, which requires approval by a judge, the state Department of Social and Health Services (DSHS) agreed to pay $5 million, with the remainder to be split between state-contracted therapist Brad Simkins and two social-service agencies that hired him.

The boy, through his guardian, originally sought $22 million in a tort claim filed with the state.

The lawsuit, filed in Snohomish County Superior Court, alleged DSHS, Simkins and the others failed to protect Shayne, who couldn't sit or walk when he was found. In addition, the boy's temperature had reached the dangerously low level of 87 degrees and his muscles were wasting.

The settlement comes at a time when state legislators are considering privatizing some social services to fix what critics call a broken child-welfare system. The Children's Administration, which is part of DSHS, has been plagued by problems for years, including dozens of child fatalities.

Full Article and Source:
$6M settlement for starved Everett boy