A September inspection of Emeritus revealed:

• An 82-year-old patient who died after staff failed to provide her heart medication for four days
• Inaccurate resident counts by facility managers
• Residents with infected bed sores (also called decubitus ulcers, pressure ulcers or pressure sores)
• Neglected patients-  some Alzheimer's patients had toe nails so long that they curved around their toes
• Falsified medical records
• Staff administering the wrong medications to patients that resulted in injury

The documented findings above, come on the heels of a suspected Norovirus outbreak in August at the facility.  The outbreak originated in the facilities cafeteria and sickened 19 residents and two staff members.

In response to the recent findings, management of Emeritus at Crossing Pointe recently held a meeting for residents and their families.  According to acting executive director, Pam Campbell, the identified conditions by inspectors are "not what Emeritus stands for" and calls findings "very sad for us."

Rest assured, once the state lifts the suspension on new admissions, Ms. Campbell says her facility is prepared.  "We're ready for them any day."  

Great.  

I find it difficult to believe the Ms. Campbell-- or any manager in her position-- is capable of turning around such a troubled facility so quickly.  The reason the state's inspection report listed such extensive violations is because Emeritus allowed a culture of poor patient care to exist.  My guess is that until management decides to delve deeply into these problems and evaluate each employees role in this neglect, it is only a matter of time before more problems surface.

Emeritus Corporation

Emeritus Senior Living is part of the Emeritus Corporations, a publicly traded company based in Seattle.  Emeritus Senior Living operates more than 300 assisted living, Alzheimer's care, and retirement communities across the country.

Resources:

Report: Patient at South Orange County assisted-living facility died after she wasn't given her medicine, Orlando Sentinel, November 15, 2009

We're fixing problems, assisted-living manager tells residents, Orlando Sentinel, November 17, 2009

The facility’s health inspections rated a mere one out of five stars, which is a much below average rating.  In the past year, the nursing home had 14 health deficiencies, which is 6 more than the average number of health deficiencies in Illinois and in the United States.  However, this is an improvement compared to the 30 health deficiencies that the facility received in the previous year. 

Nursing homes must meet strict regulatory standards in order to be certified by Medicare.  Certified nursing homes have an obligation to provide a safe and secure facility for its residents and to provide proper care and supervision to achieve and maintain the highest level of well-being for its residents.   

Pressure Sores

One resident who entered the facility with a pressure sore on his ankle did not receive adequate treatment and services in order to promote healing.  This same resident also did not receive adequate services to prevent the development of a new sore on his left heel. 

These failures by the nursing home staff pose immediate danger the resident’s health and well-being.  Pressure sores are a serious concern for nursing home residents, especially those with limited mobility due to weakness or illness.  Without proper treatment (cleaning, removal of damaged tissue, dressings, antibiotics), pressure sores can become infected, leading to bone and join infections and even sepsis, which can result in death. 

Many residents rely on nursing home staff to provide proper services to prevent pressure sores including turning the resident often enough and pressure reducing mattresses and cushions to help relieve pressure.    

Because of the serious nature of pressure sores, nursing home facilities must ensure that a resident who enters the facility without does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable, and a resident having pressure sores must receive necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.  Pershing Convalescent clearly failed to meet this requirement. 

Failure to Treat Wounds

According to survey reports, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of its residents by failing to ensure that one resident received proper medical treatment and services to treat wound areas on his right arm.  This resident was completely dependent on staff for bathing and other activities of daily living. 

Despite being bathed by staff, staff members failed to notice and therefore failed to treat two open wounds on his arm.  Proper wound treatment is important in elderly nursing home residents because of the risk of infection and further complications.  As such, it is important that staff members be observant to catch injuries and wounds early in order to provide proper treatment. 

Restraints

Nursing home residents have the right to be kept free of physical restraints use for disciplinary purposes or convenience and not required to treat medical symptoms.  However, two residents who did not have physician orders or care plans in place for the use of restraints, were kept in reclining chairs with a lap trays to keep them from getting up.  In order to protect the rights of nursing home residents and prevent abuse, staff members should obtain physician orders for restraints. 

Unsanitary Conditions

Nursing home facilities must maintain a sanitary, orderly, and comfortable environment for nursing home residents.  However, recent survey reports verify that Pershing Convalescent failed to meet this requirement because of pungent and pervasive urine and fecal odors that were noted on all three days of the survey. 

Upon entering the nursing home facility, inspectors immediately noticed strong urine and fecal odors.  Inspectors continued to notice the odors throughout a tour of the first and second floors.  The pervasive and unpleasant odors do not create a comfortable environment for residents, most of whom are restricted to the interior of the nursing home. 

Verbal Abuse

Pershing Convalescent Home failed to report alleged verbal abuse to the Illinois Department of Public Health.  This incident involved a 74 year old female resident who suffered from spinal stenosis (narrowing of the spine that can cause pain), prolapsed bladder (bladder bulges into vagina) depression, and anxiety.  The resident told the administrator and the assistant administrator that one of the nurses was rude and verbally abusive. 

When the resident asked for her prescribed medication, the nurse responded, “Go away, get lost.  Get out of my face.  You only want the medication to get high.”  In response to the incident, the administrator suspended the nurse for three days during the investigation.  Although it is facility policy to report abuse to the state licensing agency, the facility never reported the incident to the state agency. 

Inadequate Staffing

Pershing Convalescent also failed to provide sufficient staffing for the number of patients at its facility.  Inadequate staffing places patients at risk of harm primarily due to a lack of supervision.   

Inadequate staffing is likely responsible for the elopement of a  62-year-old female from the facility.  In response to previously elopement attempts, the woman was placed on high-risk elopement monitoring.  Despite the implementation of high-risk elopement precautions such as: observation flowsheets that provided for visual checks every thirty minutes and a magnet alarm was put in place-- the patient still managed to wander from the facility.  

Although the resident was located unharmed by the police as she was walking along the side of the street.  The state's investigation revealed that a staffing deficiency was to blame for the patient's elopement as one of the CNA's was late for work.  

Making the decision to put a loved one in a nursing home is a difficult decision.  Families should not have the additional burden of worrying about their loved ones suffering from abuse and neglect.  Pershing Convalescent Home has many deficiencies, which calls into question the ability of the facility to provide residents with proper respect, care, and treatment. 

Resources:

Medicare website

IDPH website

Nursing Homes Abuse Blog: Quarterly Review Of Illinois Nursing Homes Reveals Major Problems 

It Matters Where You Live

By any standard, Columbus Park Nursing & Rehab Center fails to provide a safe environment for patients.  According to public records compiled in the Chicago Tribune's Illinois Nursing Home Safety Report website, Columbus Park cares for a particularly troubled population:

• Almost 1/3 of the patients at Columbus Park have been diagnosed with a mental illness
• 32 convicted felons
• Over 63% of the patients are under 65 
• 1 registered sex offender
• 17 cases of reported battery amongst patients in 2009

No excuse for nursing home violence

In the case of Andres Cardona, the staff at Columbus Park certainly appear to be guilty of failing to supervise Ardyce Hauden around other patients after he had acted violently in the past.  When facilities continue to allow patients with known violent propensities to remain at a facility, there is an implicit understanding that they will take the necessary steps to protect other patients.

Below is WGN news clip of this story regarding violence at a Chicago Nursing Home.

Putting it mildly, Dr. Reinstein has a very unique style of practicing medicine-- one that commonly entails use of the powerful psychotropic medicine, clozapine.  Among Reinstein's unusual practice 'accomplishments':

• In 2007, he prescribed medication to 4,141 Medicaid patients
• According to an audit report, Reinstein sees 60 patients per day, 365 days per year
• He is a the psychiatric medical director at 13 nursing homes in the Chicagoland-area
• Reinstein personally write more prescriptions for clozapine than all the physicians in the state of Texas combined write for their patients.

The dangers of clozapine

Clozapine (the generic medication for Clozaril) is an anti-psychotic medication approved for use in schizophrenia and for reducing the risk of suicidal behavior in patients with schizophrenia or schizoaffective disorder.

Clozaril carries five black box warnings-- the FDA's strongest warning.  Consequently, Clozaril is only approved for use in limited circumstances and the FDA requires ongoing monitoring of the patients to minimize the risk of complications.

1) Agranulocytosis-  An abnormally low white blood cell count. Since white blood cells are necessary to fight diseases, this is a potentially fatal side effect. Patients being treated with Clozapine must have a baseline white blood cell (WBC) count and absolute neutrophil count (ANC) before initiation of treatment as well as regular WBC counts and ANCs during treatment.

2) Seizures- Seizures have been associated with the use of Clozapine.  Studies have conclusively demonstrated that the the incidence of seizures increases as the dosage increases. Additionally, patients taking Clozapine, should be advised not to engage in any activity where sudden loss of consciousness could cause serious risk to themselves or others.

3) Myocarditis- Inflammation of heart muscle.  The incidence of myocarditis has been demonstrated to substantially particularly in the first month of use.

4) Orthostatic hypotension- A large, sudden decrease in blood pressure upon standing that can result in fall.

5) Increased Mortality in Elderly Patients With Dementia- Elderly patients with dementia-related psychosis treated with atypical anti-psychotic drugs, such as Clozapine, are at an increased risk of death compared to placebo. 

Not surprisingly-- especially when medicating such a large group, many with high clozapine dosages-- some of Dr. Reinstein's patients have suffered adverse effects and even death related to clozapine intoxication.  Who is responsible, the drug itself or the man responsible for prescribing it? Would his patients be better served with another type of treatment?

Related Nursing Homes Abuse Blog Entries

Medication Aides In Nursing Homes: A Push To Save Money Or Improve Patient Care?

Nursing Home Employees Plead 'Not Guilty' To Charges Related To The Intentional Chemical-Sedation Of 22 Elderly Residents

Pile On The Medication

Administrator Charged With Elder Abuse After Intentionally Over-Medicating Nursing Home Patients

1. Narcissistic Personality Disorder

Coumadin (generic name - Warfarin), is an anticoagulant (blood thinning medication) that is commonly used to help treat and prevent blood clots that could cause a heart attack, stroke, or pulmonary embolism.  This prescription medication works by blocking the creation of certain clotting mechanisms, which prevents blood clots from forming.  The goal of warfarin therapy is to decrease the clotting tendency of blood but not to prevent clotting altogether.

Complications related to diet

Certain foods and drinks can impair the effect of warfarin.  If you are taking warfarin, you should be consistent in your dietary intake of vitamin K because large amounts of vitamin K can counteract the benefits of warfarin.  The recommended daily allowance for men is 120 micrograms of vitamin K, and for adult women, it is 90 micrograms.  Drinks containing large amounts of vitamin K (green tea) should be avoided. 

Other beverages (cranberry juice, alcohol) can increase the effect of warfarin, causing bleeding problems.  Patients on warfarin should eat a relatively similar amount of foods with high levels of vitamin K on a regular basis (kale, broccoli, spinach, collard greens, Brussels sprouts, and cabbage).

Complications related to falls

A major complication associated with warfarin treatment is bleeding due to excessive anticoagulation.  Excessive bleeding can occur from any area of the body.  Studies suggest that elderly patients on warfarin, especially those over age 80, have an increased risk of bleeding compared to younger patients on warfarin (the rate of major hemorrhage on warfarin was higher than previously reported because the rates were derived from younger patients on warfarin). 

Another study also revealed that there is an increasing incidence of anticoagulant-associated intracerebral hemorrhage that is associated with increasing warfarin use.  Patients taking warfarin should report any falls or accidents and signs of bruising or bleeding.  Because of the associated risks, high dose or long-term treatment with Warfarin is only recommended for people who are at a high risk of developing blood clots that could cause a heart attack, stroke, or pulmonary embolism.    

Because elderly patients on warfarin may have a higher risk of bleeding, nursing home residents on warfarin should be closely monitored for signs of unusual bleeding including bleeding from the gums, blood in the urine, bloody or dark stool, a nosebleed, or vomiting blood. 

Consequently, nursing home staff must track of patients who take Coumadin and closely monitor them for any evidence of uncontrolled bleeding.  Staff must pay particular attention to patients after a fall to avoid complications related to both internal and external bleeding.  Additionally, staff should alert the patients physician for additional directives.

Thanks to Heather Kiel, J.D. for her assistance with this entry.

Resources:

Clot Care: Bleeding rates are higher in those over 80 years old when started on warfarin 

American Heart Association Journals: Circulation: Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation

Mayo Clinic: Warfarin side effects: Watch for dangerous interactions

Neurology: The increasing incidence of anticoagulant-associated intracerebral hemorrhage

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