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For most families who have already experienced the traumatic effect of having to place their loved one in a nursing home, they are too often familiar with the dangers associated with falls. Between 30% and 40% of all people over the age of 65 in some form of a long-term care facility will fall within a given calendar year. This number increases to 50% for residents who are 80 years or older. This means that, on average, 50% of all long-term care facility residents will fall each year. These falls often result in injury to the resident and sometimes those injuries are catastrophic.

In fact, the injuries that result from falls are so severe that they account for 62% of all emergency room visits for those 65 years of age or older. A major issue associated with falls is the generalized belief among healthcare professionals in nursing homes that falls are unavoidable and an inevitable part of the aging process. This erroneous belief is alarming for two reasons: 1) complications from falls are the leading cause of death in those older than 65, and 2) falls are manageable and preventable.

Upon admission to a nursing home, an elderly resident should be assessed for his or her risk of falls. This assessment should take into account the resident’s history of falls, difficulties in gait and balance, medications, and any preexisting illnesses or diseases. Should a resident experience a fall after admission, the facility and its employees should treat this occurrence as a “Significant Change of Condition.” Significant changes of condition in residents require that a resident be reevaluated and an updated/modified plan of care be instituted for that patient. Interventions to be implemented upon evaluation of this significant change of condition can include: bed mats, bed alarms, wheelchair alarms, walking assistive devices such as a cane or walker, modification of medication dosages, and the requirement that residents have a staff member assist them when moving about. When nursing homes fail to update the resident care plan or acknowledge that a significant change of medical condition has occurred it can result in a deviation from the standard of care. Negligence in regard to resident falls are extremely common because of understaffing in the facilities and inadequate education of the staff on how to address falls.

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Malnutrition is a widespread problem in most long-term care facilities. A 2013 study using the Mini Nutritional Assessment found that 60.2% of nursing home residents studied were categorized as malnourished. Another study found that 71% of elderly adults who were hospitalized met the criteria for malnutrition or were malnourished. For the elderly, weight loss associated with malnutrition can have serious negative consequences to overall health and is often times predictive of mortality because it is more difficult for these elderly patients with other comorbidities to recover from the effects.

Nutritional needs of elderly residents and patients are determined by multiple factors. They include: the level of activity, energy expenditure, and the necessary caloric intake, as well as personal food preference, underlying diagnoses such as diabetes, and a resident’s ability to chew and digest food. A commonly accepted definition of clinically important weight loss is a loss of 4 to 5 percent of total body weight over a six to twelve month period.

Because malnutrition is such a common problem in nursing homes, it is vital that health care professionals in these facilities regularly monitor residents for symptoms of malnourishment and adjust their diets as required. An initial evaluation of a resident’s nutritional status should be conducted on any resident who is noted to have lost weight. The healthcare professionals should:

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Pressure sores, also known as decubitus ulcers or even more commonly as bedsores, develop when continuous pressure to certain areas of the body begins to breakdown the skin because of decreased mobility. Pressure sores develop most commonly over bony prominences of the body such as the sacrum, a triangular bone at the base of the spine and at the upper, back part of the pelvic cavity. They can sometimes develop underneath casts, splints, or cervical collars. Approximately sixty percent (60%) of pressure ulcers develop in the area of the pelvis.

Although decreased mobility resulting in continuous pressure to these areas is the most common cause of sores, other factors can also increase the risk of development in adults. These factors include: malnutrition, obesity, decreased sensory perception, decreased activity, friction and shear, increased moisture, increased age, smoking, emotional stress, and skin temperature.

So, how do pressure sores play into nursing home abuse? Decreased mobility in elderly residents and hospital patients combined with other factors can put these people at high risk for developing pressure sores. If left untreated or undiagnosed, pressure sores can be extremely harmful and even deadly. Deviations from the standard of care or negligence for these residents and/or hospitalized patients include failure to properly treat these pressure sores; failure to properly diagnose these pressure sores; failure to properly assess these pressure sores under certain measurement scales; and failure to modify or change the plan of care when a pressure ulcer develops.

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The excessive use of psychotropic medications among the elderly has been an ongoing battle as nursing homes become more prevalent. With the passing of the Omnibus Budget Reconciliation Act (OBRA) of 1987, the federal government attempted to limit the use of these medications by citing facilities under 42 CFR 483.25(l) for failure to ensure that each resident’s drug regimen was free from unnecessary drugs. Specifically, this regulation sought to limit the use of excessive doses of medications for excessive durations without adequate monitoring. However, the government’s effectiveness in regulating their use has fallen short of success.

So, what makes the overuse of these medications so deadly? A main reason for limiting the use of these medications in elderly residents is to prevent the occurrence of side effects. Many residents in long-term care facilities are battling mental disorders and these medications are a way to treat various episodic events.

However, these psychotropic medications are often used as a chemical restraint on these elderly residents in situations that do not warrant their use. A chemical restraint is “the use of a drug to control an individual’s behavior and is legally appropriate only if used to ensure the physical safety of residents or other individuals.” 42 CFR 483.13(a) mandates freedom for every resident from medically unnecessary physical or chemical restraints imposed for purposes of discipline or convenience. OBRA mandates the restriction of these medications for chemical restraint purposes because the risk to elderly residents is a high one.

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Long-term care facilities are at a high risk of endangering the lives of their residents when they fail to properly control infectious diseases. Residents are confined to small spaces and often their daily living activities occur in groups. Furthermore, the elderly are particularly vulnerable in that many of their immune systems are already fighting other diseases. This vulnerability makes it difficult to diagnose infections in the elderly early on and in turn this delays prevention and treatment. It is estimated that infections contribute to sixty-three percent (63%) of deaths in long-term care facilities and are the primary reason for twenty-five to fifty percent of transfers of the elderly to hospitals. The Center for Disease Control estimates that one to three million serious infections occur every year at these facilities including: urinary tract infection, diarrheal diseases, antibiotic-resistant staph infections and many others. It is estimated that as many as 380,000 elderly residents who develop these serious infections will die.

Nursing Homes are required to have an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Under the infection control program, the nursing home is required to investigate, control, and prevent infection. 42 C.F.R. § 483.65.

Evan Jones has settled a case against a Georgia long-term care facility that failed to properly control and prevent the spread of multiple infectious diseases including: Group A Streptococcus, which later developed into necrotizing fasciitis. This is essentially a “flesh eating” bacteria. As a result of this infection spread within the facility, five residents developed the infection and three of the five residents passed away, including our client’s family member. By April, three healthcare works and thirteen other residents had developed the infection according to the infection control log. A review of the facility records revealed that the nursing staff of this long-term care facility were improperly trained and instructed in recognizing signs and symptoms of these types of infections. Furthermore, they were unable to effectively control the spread of these infections through specific isolation control techniques (standard precautions may include gloves, masks, gowns, etc.)

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Many nursing homes and assisted living/personal care homes are requiring family members and residents to sign Arbitration Agreements as a condition of residency. An arbitration agreement essentially is a contract between the family and the facility whereby any dispute including violations of federal, state law, and incidents of malpractice are decided by an arbitrator and/or an arbitration panel. The family and resident agree to waive their constitutional right to trial by jury. Often, the agreement also specifies that arbitration should also be conducted by a list of persons who defend or support nursing homes.

The arbitration agreement is inherently unfair, and “one-sided” so it should never be signed. If a nursing home attempts to require a resident, family member, or a person with a valid general power of attorney to sign, refuse to do so and immediately go to another facility. It cannot be made a condition of residency under Georgia Law.

Evan Jones has been very successful in having courts across Georgia declare that arbitration agreements are inherently unfair, unconscionable, and void as a matter of law. However, a recent trend has been that in Georgia and nationally, arbitration agreements have been upheld and a nursing home and/or assisted living, personal care home case has been removed from court and a trial by jury to arbitration panel.

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As stated in our previous blog, Polypharmacy occurs often in cases that we have reviewed against nursing homes and assisted living facilities. According to medical literature, polypharmacy impacts the elderly in the following ways:

Older individuals are at greater risk for adverse drug events due to metabolic changes and decreased drug clearance associated with aging; this risk is compounded by increasing numbers of drugs used.

Polypharmacy increases the potential for drug-drug interactions and for prescription of potentially inappropriate medications. [Weng MC, Tsai CF, Sheu KL, et al. The impact of number of drugs prescribed on the risk of potentially inappropriate medication among outpatient older adults with chronic diseases. QJM 2013; 106:1009.].

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Medication errors occur frequently in nursing homes and personal care homes. We have handled cases where the elderly resident received the wrong medication or too much medication. Often, medication errors can lead to adverse reactions such as falls, impaired cognition, and even depressive disorders.

In nursing homes and/or assisted living facilities, it is important for family members to closely monitor their loved ones medication regimen. In nursing homes and assisted living, the care provider has a duty to notify the attending physician of any significant change in an elderly resident’s condition because of an adverse reaction to medication error. Additionally, each medication administered must be written in the Medication Administration Record (MAR). Unfortunately, miscommunication between care providers often occurs and leads to injury or even death. In other words, the care provider fails to communicate to the family and/or physician that a particular medication has caused a significant change in the resident’s condition.

In a case we settled recently, the nursing home mistakenly gave one of its residents a nitroglycerine paste which caused the resident to develop hypotension (low blood pressure) which resulted in a severe fall and his subsequent death. Furthermore, this particular nursing home had long-standing systemic issues regarding medication errors which caused the serious injury and/or deaths of several of its residents. It had a duty to ensure that its residents were free from any significant medication errors. 42 C.F. R. § 483.25 (M)(2). It violated this federal regulation and also failed to communicate this mistake to the family and attending physician. As a result, a beloved family member died prematurely.

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Elderly residents are prone to unattended and/or unsafe wandering known as elopement. Elopement frequently occurs in nursing homes and assisted living and/or person care homes. Residents can elope within the facility or even leave and wander several miles from the facility. It can be prevented.

Risk factors for elopement can include Dementia, Alzheimer’s, polypharmacy (too many medications), or a change in living environment.

An elopement can be very dangerous and can lead to serious injuries or even the death of an elderly resident. Residents have been known to wander throughout the facility and fall off of loading docks or even wander outside of the facility and wander into unknown areas where they are at further risk to dehydration, malnutrition, hypothermia, and heat exhaustion.

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The subject of this blog entry focuses on the standard of care of psychiatrists in the State of Georgia and the duty owed to their patients under the law.

Mental illness has a long history of stigmatization in the United States. Non-profit organizations, advocacy groups, and others too often overlook the mentally ill. The mentally ill have been shuffled from institution to institution, never being made to feel that they have a home or a support system. They too often receive the minimum care available and are not properly treated by their physicians. The general public misunderstands mental illnesses and the stigma surrounding these illnesses often forces those suffering from them to be outcast in their communities.

Mental illness is a common contributing factor to suicide, another stigmatization in our society, and the total suicide rates in the United States far exceed the death tolls from war, murder, and AIDS. 30,000 Americans die each year from suicide and nearly 765,000 Americans attempt it, which means every 17 minutes in America someone will take their own life. Unfortunately, the stigma surrounding mental illness and suicide means the issue is blatantly ignored. This in turn means that the public is extremely misinformed about the issues. The truth is; with suicide being the third leading cause of death among Americans aged 15 to 24, society as a whole can’t afford to ignore the effects of mental illness any longer. Suicide is one of the most preventable killers, but until we train more effective healthcare professionals and educate the general public on basic warnings, myths, and facts about suicide it will remain in the forefront of causes of death. C.C. Risenhoover, The Suicide Lawyers 111-14 (2004).

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