What to Do in Nursing Home Cases
Immediately get a copy of the entire medical chart. There have been instances when records have been falsified, so you want to get the chart as soon as possible.2. Names of Staff
Get the names of the persons who you feel may be responsible. This would include any CNAs (certified nursing assistants), RNs or LPNs, the Supervisor of Nursing, the Director of Nursing, the Assistant Director of Nursing, the attending doctor and anybody else who you feel shared in the responsibility for the abuse or neglect.3. Complaint
In addition to filing a complaint in court, you can call the Illinois Department of Public Health's toll-free hotline at 1-800-252-4343. This state agency polices and investigates nursing home abuse and neglect.4. Bed Sores
Bed sores can occur when a person is bedridden. A bed sore develops when blood supply to the skin is cut off for more than two to three hours. A bed sore starts as a red, painful area, which eventually turns purple. Left untreated, the skin can break open and become infected. A bed sore can become deep, extending into the muscle (usually a stage IV bed sore). Bed sores often occur in the buttocks or lower back area (on the sacrum or iliac crest), or on the heels of the feet.
Bed sores can and should be prevented by inspecting the skin for areas of redness (the first sign of skin breakdown). Other methods of preventing bed sores and preventing progression of existing bed sores include the following:
- Frequent turning and repositioning
- Providing soft padding in wheelchairs and beds to reduce pressure
- Providing good skin care by keeping the skin clean and dry
Specific treatment of a bed sore is determined by your physician and based on the severity of the condition. Treatment may be more difficult once the skin is broken, and may include the following:
- Removing pressure on the affected area
- Protecting the wound with medicated gauze or other special dressings
- Keeping the wound clean
- Transplanting healthy skin to the wound area
- Medication (i.e., antibiotics to treat infections)
- Untreated or poorly treated pressure sores can result in many serious complications
If bed sores cause injury to a loved one, you should contact Ed Fox & Associates, Ltd.5. Sexual Abuse
If you are a victim or suspect that a family member is a victim of sexual abuse, immediately take all steps to remove the person from the nursing home.
Identifying and treating elder sexual abuse is difficult because elders are less likely to report it and the symptoms could be the same as other conditions the elderly may be experiencing. Cognitive impairments may make it difficult for the older victim to explain or remember the abuse. It is helpful and important that family members are able to recognize signs of sexual abuse to aid in detection and treatment of a loved one. The physical signs include:
- Bruising on inner thighs
- Genital or anal bleeding
- Sexually transmitted diseases
- Difficulty walking or standing
- Pain and/or itching in the genital area
- Exacerbation of existing illness
Emotional signs include:
- Scared or timid behavior
- Depressed, withdrawn behavior
- Sudden changes in personality
- Odd, misplaced comments about sex or sexual behavior
- Fear of certain people or of physical characteristics
For a victim of sexual abuse, you should ensure that he or she is seen at a hospital and given the appropriate treatment there. You should also contact Ed Fox & Associates, Ltd.6. Falls
Falls are especially dangerous for the elderly. Elderly persons who survive a fall experience significant morbidity. Hospital stays are almost twice as long in elderly patients who are hospitalized after a fall than in elderly patients who are admitted for another reason. Compared with elderly persons who do not fall, those who fall experience greater functional decline in activities of daily living and in physical and social activities, and they are at greater risk for extended otherwise unnecessary institutionalization.
You should be aware if your loved one has risk factors for a fall. Some risk factors include:
- Previous falls
- Acute illness
- Chronic conditions, especially neuromuscular disorders
- Medications, especially the use of four or more multiple prescription drugs
- Confusion or cognitive impairment
- Use of cane or walker
- Reduced vision, including age-related changes
- Difficulty rising from a chair
- Foot problems
- Neuralgic changes, including age-related changes (i.e., postural instability; slowed reaction time; diminished sensory awareness for light touch, vibration and temperature)
- Decreased hearing, including age-related changes
- Gait disturbance, balance disorders or weakness, pain related to arthritis
- Central nervous system disorder, syncope, drop attacks, epilepsy
Nursing homes should assess their residents for their fall risk. A resident with a fall risk should be care-planned so that the risk is avoided. According to the Center for Disease Control, the care plan should include:
- Assessing patients after a fall to identify and address risk factors and treat underlying medical conditions
- Making changes in the nursing home environment to make it easier for residents to move about safely. This should include grab bars, raised toilet seats, lowering bed heights, and installing handrails in the hallways
- Reviewing the prescribed medications to determine their risks and benefits and to minimize their use
- Providing residents with hip pads that can effectively prevent most hip fractures if a fall occurs
- Using devices such as alarms that go off when residents try to get out of bed or otherwise move about without help
- Provide the appropriate physical assistance to those residents who need it
- Exercise programs and therapy can help with balance, strength, walking ability, and physical functioning
- Pressure stockings
If a nursing home or long-term care facility resident has a fall, you should make sure that the nursing home investigates and identifies why the person fell and then takes steps to undertake whatever preventable measures are required. This is important because in our practice we have seen situations where residents have had numerous falls before preventable measures are taken. Also, when a fall occurs, the resident should be transported to a hospital to be examined. Sometimes bones are broken or other injuries occur, but the resident is not properly and timely diagnosed and treated, thus causing unnecessary pain and other complications. If a fall occurs, causing injury, then contact Ed Fox & Associates, Ltd.7. Bruises and Abuse
Bruises can be caused by bumping into something that ruptures the tiny capillaries under the skin, leaving the area darkened. A purplish, flat bruise that occurs when blood leaks out into the top layers of skin is referred to as an ecchymosis. Some people bruise more easily than others, and this is indicative of fragile capillaries, poor health or an inability to create collagen. Blood vessels become more fragile as we age, and bruising may even occur without prior injury in the elderly. For people who bruise easily, bruises seem to appear for no apparent reason. Research has shown that a leading cause of frequent bruising is a deficiency in one or more nutrients. The elderly, due to their generally poor diet, are quite susceptible to having bruises. The remedy is very simple: Add supplements to their diet.
Deficiency in certain nutrients, primarily vitamin C, vitamin E, vitamin K, bioflavonoids, and zinc is related to bruising. A vitamin C deficiency may be caused by several factors:
- Eating too few fruits and vegetables
- Taking drugs which destroys this vitamin
- Long-time stress from illness, frustration or depression
- Smoking (one cigarette can deplete the body of 25 mg of vitamin C)
- Frequent emotional outbursts such as anger
- Exposure to pollutants, allergens or heavy metals
A deficiency in hesperidin, one of the bioflavonoids (sometimes called vitamin P), naturally occurring nutrients usually found in association with vitamin C, has been linked with abnormal capillary weakness. These bioflavonoids, including hesperidin, Citrin, Rutin, Flavones, Flavonals, Calechin and Quercetin, were found to be essential in correcting the tendency toward bruising.
The injury required to produce a bruise varies with age. While it may take quite a bit of force to cause a bruise in a young child, even minor bumps and scrapes may cause extensive bruising or ecchymosis in an elderly person.
The amount of bruising may also be affected by medications that interfere with blood clotting (and thus cause more bleeding into the skin or tissues). These drugs include many prescription arthritis medications called non-steroidal anti-inflammatories (e.g., ibuprofen/Advil, Nuprin and naproxen/Aleve) as well as over-the-counter medications, such as aspirin. Warfarin (Coumadin) is often prescribed by doctors specifically to prevent clotting in patients who have had blood clots in their legs or heart. Warfarin can cause particularly severe bruising, especially if the level of the medication becomes too high. Cortisone medications promote bruising by increasing the fragility of the tiny blood vessels in the skin. In addition, patients with inherited clotting problems or acquired clotting problems (such as in patients with liver diseases like cirrhosis) can develop extensive bruising or even life-threatening bleeding.
As a result of the foregoing, if a caregiver indicates that an elderly man "fell off the toilet," but the elderly man has bruises all over his body, for example, a handprint visible on his side or a contusion on his shoulder, you should be suspicious. Normal bruising is generally not seen on an elderly person's neck, ears, buttocks, genitals and feet. Thus, if it is found there or is suddenly seen with greater frequency in other areas, then this should raise a red flag. If there is a problem here, then you should contact Ed Fox & Associates, Ltd.8. Dehydration
Malnutrition and dehydration can lead to a number of serious health problems. Examples include infection, confusion, and weight loss. Federal law requires nursing homes to assess the nutritional status of residents.
Physical and psychological causes of malnutrition and dehydration in nursing homes can include: illness, especially congestive heart failure, chronic lung diseases, and kidney diseases; adverse drug effects, such as nausea, vomiting, diarrhea, cognitive disturbances, or sleepiness; food and drug interactions, which decrease the ability of the body to absorb vitamins and minerals; depression and loneliness; swallowing disorders; mouth problems (including bad dentures, and mouth pain), tremors and dementia.
Other causes of malnutrition and dehydration in nursing homes can include staffing issues, including inadequate staff and inadequate attention and inadequate staff education in caring for the elderly.
The following are signs that your family member or loved one is suffering from dehydration or malnutrition:
- Losing weight
- Clothes fit more loosely than usual
- Dry, cracked lips or a pale-looking mouth
- Difficulty speaking due to a dry mouth
- Complaints about thirst
- Urinates infrequently and has dark yellow urine
- Skin feels dry and warm to the touch
- A dry, bright red, and furrowed tongue
- Complains about any problems relating to the mouth
- Thinning hair or hair that is growing sparser
- Wounds or bed sores that seem to take longer to heal or are developing more often
- Appears weak or disoriented
- Skin is breaking down or seems loose and looks or feels drier than usual
When you notice any of these symptoms, you should immediately request a care-planning conference in which these issues can be discussed with the staff at the nursing home. Demand that the staff develop a hydration and nutrition program with the help of a nutritionist. Figure out together what is causing the problem. It can be anything from staffing issues to depression to mouth issues to certain chronic illnesses.
Once a cause is determined and a plan is agreed upon, monitor your loved one to ensure that he or she is getting the appropriate nutrition and hydration. Ask the attending doctor to do the same. Attend a subsequent care-plan conference to follow up on the progress. If all of this does not work, get your family member into a different nursing home and contact Ed Fox & Associates, Ltd..9. Wrong Medication
Some of the most common types of medication errors include the wrong dose prescription, inappropriate medication, wrong time of administration, and the omission of administration. Underutilization of medication relative to national standards has also been documented for a number of common clinical conditions. Transitions between facilities is a high-risk time for medication errors.
The reasons for the medication errors include ordering errors, administration errors and failure to adequately monitor nursing home residents. Unfortunately, often it is difficult to prevent medication error problems before they occur. But, you should try to ensure that your family member is in a nursing home that has a system to provide medication checks. These checks can include monitoring of medications by the pharmacy and periodic review of the medical administration record ("MAR") by the supervisor of nursing and the attending doctor.
If you suspect that your family member is being given the wrong medication or that any type of medication neglect is occurring, call the attending physician and have him or her check the chart and the resident's condition immediately. If your loved one has been harmed by a medication error, call Ed Fox & Associates, Ltd.10. Wandering or Elopement
People with dementia or Alzheimer's wander or get lost for a variety of reasons. They may be searching for something, or trying to get away from a noisy or confusing environment. Some may even be trying to fulfill tasks from their former occupations. People who wander may be difficult to find, because they often behave in an unpredictable manner. For example, they rarely call for help or respond to searchers' calls. Once found, they often don't remember where they live. Some can't remember their own names.
Nursing home facilities should have a policy and procedure to assess whether a resident is an elopement risk. These facilities should also engage in care planning to support the safety of residents who wander, including guidelines for assessing risk, assessing resident need associated with behaviors, developing an individualized plan, reassessing and evaluating the care plan's effectiveness, and revising the plan as needed.
There are many ways to prevent wandering. In addition to keeping a resident in a sufficiently secure area, other ways of preventing wandering can include electronic tagging to track residents who wander; an alarm that sounds when a resident exits a door or enters a certain area; video camera surveillance; and bed alarms are also frequently used for the resident who leaves the bed at night to wander.
Notwithstanding this, a good nursing home will facilitate safe movement rather than prevent movement. When a resident does elope, time is of the essence as mortality rates and injuries for those who elope rise dramatically after 24 hours. The care provider is expected to notify the local police to facilitate a search and retrieval effort. An organized search by staff should include a periodic re-check of the area where the person was last seen. These missing persons are often found within a mile of where they were last seen.
Familiar places should be checked. If the person has not been located after a thorough search, or if the person has a life-threatening illness, or if weather conditions are severe, the media should be notified. The state regulatory agency should also be notified and provided a report on the incident as well as the provider's plan to prevent reoccurrence.