Safeguarding nursing home residents against common risks

This is the Nursing Home Abuse Podcast. This show examines the latest legal topics and news facing families whose loved ones have been injured in a nursing home. It is hosted by lawyers Rob Schenk and Schenk Firm of Schenk Smith LLC, a personal injury law firm based in Atlanta, Georgia. Welcome to the show.

Schenk: Hi there and thanks for joining us at the Nursing Home Abuse Podcast. My name is Rob Schenk.

Smith: And I’m Schenk Firm.

Schenk: And we are trial lawyers and our practice focuses on Georgia nursing home abuse and nursing home neglect. We are coming to you from our offices in Atlanta, Georgia and in the library, a.k.a. The Dungeon. So thank you for joining us.

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Usually I bypass the pleasantries with my co-host will. I will go ahead and confirm to you that he is doing fine today and we will get right into the content. What’s on the agenda today, Will?

Smith: We’re going to be talking about safeguarding at-risk residents and we’re going to segway into some of the equipment and the methods that are used to do that. And the two main at-risks that we’re talking about are at risk for falling and at risk for developing bedsores.

Schenk: So nursing home residents who are at a potential for incurring an injury due to fall or an injury due to prolonged pressure on the skin.

Smith: Right. That’s right. And the first thing we’re going to talk about is falling, because falling, the older that you get and the weaker that your muscles become, the more brittle your bones become, gravity becomes one of your major enemies.

Just to give you some statistics, because we like doing that, from the CDC, there will be roughly 3 million nursing home patients by 2030, and between 16 and 20 percent of nursing home falls occur to environmental hazards. What that means is avoidable occurrences like slippery floors or objects on the floor, and these are all CDC facts.

Between 50 percent and 70 percent of elder patients suffer from a nursing home fall each year. That’s amazing. I want you to think about that – between 50 percent of the nursing home residents out there up to three-quarters…

Schenk: Sorry.

Smith: Speaking of gravity…

Schenk: Speaking of gravity.

Smith: Gravity is an enemy to all of us apparently.

Schenk: I’m not sure what happened there… Our studio…

Smith: …Is haunted.

Schenk: Our studio is haunted.

Smith: Between half and two-thirds of all the nursing home residents, and I’ve mentioned before in a previous podcast, there are about 2 million nursing home residents out of the 16,000 nursing homes that we have, between half and two-thirds of those are going to fall each year.

And some other facts – these are all from the CDC – the CDC is one of the best places to go for statistics and facts on nursing homes because they keep a tight leash around what goes on in those facilities. And one out of five falls causes serious injuries such as broken bones or head injury.

Elderly people in general, now I’m not talking about just nursing home residents, I’m talking about even people who live by themselves, even people who still work, out of all of the older people, 65+, 2.8 million o them are treated in emergency departments for falls and injuries every year. Over 800,000 patients a year, and these are elder patients, are hospitalized because of a fall injury, most often because of a head injury or hip fracture. And more than 95 percent of hip fractures of the elderly are caused by falling.

So falls are an enormous part… They’re an enormous risk for the elderly and they’re actually one of the leading causes of death, are fractures for the elderly.

Schenk: And according, again, to the CDC, it’s the most common cause of traumatic brain injuries.

Smith: Yeah, absolutely. And there are a couple reasons for this. Number one, you have a lower body weakness. As we get older, we all know this, our bodies begin to deteriorate, and so our muscular system is not quite what is used to be. Then there are vitamin deficiencies that lead to weakened bones. When an elderly individual falls and hits the ground, it’s not quite the same as when your 18-year-old kid or nephew falls and hurts themselves. Any of you with kids out there knows this because you’ve seen it before, but kids will fall on their heads…

Schenk: They’re pretty durable.

Smith: …And it looks like they should have shattered every bone in their body and they’ll stand right up and shake it off. The elderly, however, because of vitamin deficiencies, vitamin D deficiency being an enormous problem with the elderly, their systems are not quite the same. They’re not as study. They’re not as resilient. So they can break a hip. And when they break a hip, it’s very difficult for them to return from that and it’s very difficult for them to return from head injuries.

Schenk: And that’s the damage after the fall. Again, the elderly are more likely to be… The elderly are more likely to fall for other reasons aside from the fact that as we get older, our coordination is more impaired, but you have many times in the elderly population cognitive impairment, you have visual impairment of some sort. I know that if I don’t have my contacts in, I’m falling over everything. You have a lot of times with elderly residents in nursing homes, they’re on different types of medications that could affect their ability to walk and ambulate.

There are a host of reasons why the elderly actually fall on top of the fact that they’re more likely to be injured from a fall than a younger person based on what Will said in terms of bone density, vitamin deficiencies and the more likelihood that there will be a broken bone for that reason.

Smith: And just to give you another fact here, the price tag of all of these falls by the elderly is 40 billion, and it is slowly approaching 60 billion by 2020. So this is not just a minor issue within one area, that being elder law – it is a national issue. It is costing us billions, tens of billions of dollars a year.

Now as far as nursing home falls, the reason the vast majority of falls occur in the nursing home more so than other places is because a lot of these residents are on medicine, like Rob said. A lot of them have medical conditions. And where we come into play as nursing home abuse and negligence attorneys is looking at the negligence of the nursing home in failing to prevent a fall.

And I put it that way because this is not the kind of case where they are causing the fall. It is not that often that they are causing the fall. What they’re doing more often than not is failing to properly assess these nursing home residents for falls. And there are a couple methods they use when they’re doing these minimum data sheets, these MDS reports that they send to Medicaid and Medicare that are the initial assessment of the residents. And when it comes to falls, it’s the Morse Fall Scale.

Schenk: That’s right, and the Morse Fall Scale, again to be clear, the nursing home upon admission of the resident, the nursing home is going to be required to do a top to bottom assessment of each and every resident at the time of admission, and that does include evaluating the risk of falls for that individual resident. And that is required and is obligated by the law. And once the assessment has been done, it is required by the law for the nursing home to take adequate measures to reduce the risk based on the assessment.

So as Will was saying, in terms of the first part, which is doing the risk assessment, that is to say, “What is the likelihood of this resident to fall and injure themselves?” How is that done? It is done through different methods, but one of the most common assessments is called the Morse Fall Scale.

Smith: And there are a couple of subjects that it looks at. One – and I think this one is a no-brainer – is a history of falling, immediate or within three months. And that to me goes without saying. Have they fallen in the past? Have they fallen recently? And this is important because when you are admitting your loved one, when you’re admitting your mother or your father into the nursing home, make sure you tell them if they have fallen. This is incumbent upon you as their family member, as their representative. They need to know, “Hey, listen. Mom fell two weeks ago. She fell a month ago.” This is the very first thing they look at. This is the Morse Fall Scale…

Schenk: One of the first considerations.

Smith: Yeah, one of the very first considerations.

Schenk: And the reason why that’s important is you’ve got to think about falls almost like recidivism with prisoners. I mean the recidivism rate is very high. It’s kind of the same concept with falls. If they’ve fallen before, they’re probably going to fall again.

Smith: And this is… There are many different risk assessment tools. There’s one from Johns Hopkins and one of the very first issues it looks at, again, is fall history. This one’s only different because it expands it up to six months, but it gives it the maximum, a high point value, which is five points. Both of these are extremely important. So number one – fall risk.

Number two is secondary diagnosis. And what this means – is there another medical diagnosis that they have that is going to increase their likelihood of falling?

Schenk: So for example – glaucoma.

Smith: Glaucoma, mental issues, Alzheimer’s, dementia…

Schenk: Certainly any type of knee issue…

Smith: Knee issue.

Schenk: Knee replacement surgery – anything that would affect the gait, affect the ability to stand up and support oneself on one’s feet and legs.

Smith: Yeah. Another issue that they look at are ambulatory aids. So for example, does the person have a walker? A lot of nursing home residents use walkers, as you can imagine. And if you don’t know what a walker is, it’s a device that goes in front of them. It’s kind of like mobile crutches. The back of it has padding that will keep it stable on the ground…

Schenk: Two legs.

Smith: …Two legs, and the front of it has wheels. So they can lift it forwards and walk with it and use it to stabilize themselves, and when they’re ready to stop, they can stop and put it on the ground and it won’t keep rolling.

Schenk: Right, so even if there are wheels on it, it’s stable once all four of the legs are on the ground.

Smith: Right. So that’s another issue, and I think that one’s kind of a no-brainer. It goes without saying that if this person has a walker, then they’re probably a fairly high fall risk.

Another issue that they look at, and this one’s extremely important, is an IV heparin lock, and what that means is this individual is taking some sort of blood thinner. The reason why that’s important is because like we were saying earlier, one of the main injuries you can get when you fall is a brain injury. So if you get a subdermal hematoma because you fell down and you’re on anti-coagulants and you’re not clotting like a normal person does…

Schenk: You’re going to bleed out.

Smith: You can bleed out and die. And one of the number one causes of death in head injuries in nursing home residents from our experiences with our cases is not the initial impact. It’s the fact that the nursing home doesn’t do anything.

Schenk: And that timeframe of not doing anything is extremely shortened when the resident is on a blood thinner. That’s why this is on the scale itself because it’s such an important thing. Once there’s a fall, if the individual resident is not on a blood thinner, then you have theoretically, depending on the type of trauma or impact, a longer time period in which to get that resident to treatment than you would if the individual resident was on a blood thinner. In that case, you do not have as much time. Sometimes you have minutes or even an hour or so before death can occur due to internal bleeding.

Smith: Now the last two of the Morse Fall Scale are just the gait and the ability to transfer, which has to do with your weakened muscular state than your mental status.

One thing that the Johns Hopkins fall risk assessment tool has that I think is extremely important that the Morse Fall Scale does not have – the Johns Hopkins has elimination bowel and urine assessment. I think that’s extremely important and the reason is the more somebody has to get up and go to the restroom or if they have to get up and go to the restroom at all, the more likelihood they are, the greater the likelihood they are to fall. So even if the nursing home doesn’t take into consideration, that’s something you need to bring up to the staff, like, “Hey, Dad gets up to go to the bathroom frequently,” or the very fact that Dad has to get up and go to the bathroom because he doesn’t wear an adult diaper, that’s something that you need to bring up because that’s something I think is important. Go ahead.

Schenk: And so as you can imagine, when the resident is admitted and they have either the Morse Fall Scale or the Johns Hopkins scale or whatever assessment tool they use, it’s going to be a piece of paper most of the time, maybe you’re in a place where there’s an iPad or it’s digital, but they have that list that we went through. And for every item that is relevant, it gets check marked and it gets weighted.

So for example, a history of falls might add a certain number, and each one of the categories add a certain number and therefore once you get to a high number, based on summing all of those relevant attributes, there’s going to be a risk assessment percentage that’s prescribed to the resident. And based on that percentage, various preventative interventions will be done by the nursing home.

Smith: So how do they implement those preventions? Well when it comes to fall risks, every CNA, every floor nurse, the charge nurses and naturally the DON, but all of the staff, including housekeeping, including dietary, including the activities coordinator and the activities helper, everyone is given some sort of clue to indicate who is a fall risk.

And a lot of times, that is done, for example, I’ve worked in nursing homes who would use a red leaf they would put on the resident’s door. You have to remember that you have to abide by HIPA, so you can’t put on a door, “This resident is a fall risk.” I mean that’s not very dignified and it is a violation of HIPA. But you can do it through certain codes, and one of the ways that we would do that is by putting a red leaf on the residents’ doors so that everybody knows, “Hey listen, be extra caution when you enter this person’s room. Be extra careful that you don’t let anything remain, any debris remain on the floor. Just keep in mind that this person is a high fall risk, that falls can be very, very fatal to the elderly.”

Schenk: There’s also fall mats you can put down around a bed. Some of them with the high fall risk assessment can be placed closer to a nurse’s stations. There are various alerts, pressure pads, that alert the nurse whether or not the resident has gotten out of bed or even fallen out of bed.

Smith: And that’s something that’s interesting you bring that up because we’re actually going to talk about that a little bit later. And by and large though, the most common preventative measures are putting the bed closer to the floor, using floor mats and just extra vigilance, because at the end of the day, you can’t put this person in a wheelchair and put a restraint on them and say, “Look, Ms. Johnson,” and I realize that Mr. Johnson and Ms. Johnson are my constant go-to’s, but, “Look Ms. Johnson, we’re worried about you falling and hurting yourself, so we’re going to tie you to this chair so you don’t get up anymore.”

It’s the same thing with them drinking or smoking or having sex. These are still adults. They’re still humans. And even if they’re a fall risk, you can’t completely immobilize them to reduce that risk. It’s just not humane and it’s not legal, not to mention that.

So quickly moving onto the other at-risk resident would be those at risk for developing bedsores. We’ve talked about in the past some of the overlooked areas of neglect, and in doing so, we said two of the most prevalent areas of neglect were falls and bedsores. Bedsores are probably the most prevalent area of neglect in injury in a nursing home, and I’ve got an absolutely amazing statistic here about bedsores.

But to give you a little history on bedsores, a bedsore is a breakdown of the skin that is caused by pressure on the skin between the skin and either some kind of bone pushing against the mattress that causes a lack of circulation that results in inflammation and from the inside-out begins the process of skin deterioration.

And I thought this was interesting in an Indian journal of plastic surgery, pressure ulcers, which are bedsores, have been recognized as diseases for a long time, and we have found them in Egyptian mummies, some of which are 5,000 years old. So that’s pretty amazing.

Schenk: That’s impressive.

Smith: But they are one of the most common sources of injury in nursing homes, and they’re one of the most dangerous areas for the elderly period.

Schenk: It’s a very common injury and the reason why it is a common injury is because many nursing home residents fit the profile of a high-risk individual for bedsores. It’s almost like a circular or a self-fulfilling prophecy. Those who are at a higher risk for pressure ulcers, decubitis ulcers, bedsores, these types of injuries, are those individuals that are immobile, that need assistance ambulating or repositioning, that perhaps… What else?

Smith: Cognitive issues for sure – it may not seem like it, but an impaired mental ability can lead to that as well. There’s actually a scale that they use. There are a couple of scales – there’s one called the Braden, there’s one called the Norton. Like any risk assessment tool, you’re going to find multiple different rubrics that they use. I do like the Braden and it starts off with sensory perception, and the reason that that’s important is if the person has a declining cognitive ability and they can’t respond to the feeling of pressure, the feeling of pain, or they can’t express it, that’s a risk assessment.

Schenk: And again, when we say a risk assessment in the different categories of risk, we’re talking literally a checklist that the nursing home, individual, the CNA, the RN, whoever it is doing the assessment will check off each of these that are, these attributes, if they apply or are applicable to the resident. So some residents will have low risk based on these assessments. Some will have high risk because not each two residents have the same symptoms or the same risks.

Smith: And I found the statistic I was looking for. This was in the GeriPall blog – it’s a geriatrics and palliative care blog. And it says that nearly 60,000 – this is not just nursing home residents, this includes individuals at home, individuals in hospitals and individuals in other facilities, but total, total individuals who die because of pressure ulcers each year is at 60,000. And to put that into perspective, the statistics, okay, influenza results in 36,000 deaths per year. Guns result in about 32,000 deaths per year. Pressure ulcers, according to this blog, therefore cause nearly as many deaths per year as both influenza and guns combined.

The 2016 fiscal year budget for the CDC includes a request for 10 million for gun violence prevention research. There’s already 187 million allocated for influenza planning and response. There are no allocated funds to the CDC for prevention and research and treatment on pressure ulcers.

Schenk: That’s a huge discrepancy. That’s a huge slight to the elderly population.

Smith: Despite the fact that they cause more than twice, almost twice the amount as influenza and gun violence…

Schenk: And not discounting the injury and death resulting from gun violence in anyway or influenza in any way, but having a stage three, stage four, unstageable bedsore over any period of time can be excruciatingly painful. It is an open wound on the body. It is not something you want to ever have or want your loved one to experience.

Smith: Yeah. And so the way that they treat these at-risk residents is, number one, again, the MDS, the very first initial assessment they do of the resident’s need for care. They use some sort of rubric, whether it’s the Norton, whether it’s the Braden scale, mostly in America it’s the Braden scale, they determine what we need to do, and that should be promulgated out to the rest of the healthcare management team including the CNAs and the floor nurses on what needs to happen. This person needs to be turned every hour and a half or every half hour or ever two hours. They’re to be cleaned off twice daily. They’re supposed to have a wedge behind them.

So those are two at-risk classes – fall risks and bedsores that are very common and those are two of the ways, in summation, that they help prevent those. One is through proper assessment and then two is implementation of…

Schenk: Interventions.

Smith: …Of interventions. Okay, now to something a little more uplifting and humorous, and I think this is probably something that was keeping a little closer to a previous topic about can nursing homes kick us out. Well they did kick this guy out. A retired postman got evicted from a nursing home. This is in Tampa, Florida, and this is actually last summer, 2015 summer.

Paul Horner, which is a perfect name for this individual, Paul Horner who’s 92, he was a resident at the Three Palms Elderly Care Center and he hosted a party with two strippers. A neighbor of Horner heard loud music and sex sounds coming from his room.

Schenk: I want to read this next part.

Smith: Okay, go ahead.

Schenk: According to Nancy Adams, who’s the administrative director of Three Palms where this is going down, said, “We found Mr. Horner in his wheelchair having aggressive intercourse with one of the girls.”

Smith: And another girl was passed out in her own vomit on the air mattress, which would definitely prevent bedsores. There were bottles of vodka, adult toys and a beer bong.

Schenk: So what’s the moral of that story? Why did we just share that?

Smith: Well this relates back to another topic that we had about resident rights and the right to… It’s got both of them – the right to have sex, the right to drink alcohol. So you certainly have both of those rights, but this is a situation where Mr. Horner crossed the line, and he actually attacked staff, and it says here he repeatedly slammed his wheelchair into the legs of staff with the stripper still on top of him. So you can imagine a situation like this where he has probably crossed the line from resident rights to…

Schenk: …To Van Wilder movie.

Smith: …To a Van Wilder movie by a 92-year-old postal worker. But instead of them filing charges…

Schenk: Can you… So he’s 92 and he’s in a wheelchair having aggressive sex…

Smith: Aggressive intercourse.

Schenk: …With one of two strippers. What do you think he was doing when he was 18? Like I mean…

Smith: I can only imagine, but it’s also possible that he didn’t have his awakening until he was in his 90’s.

Schenk: So this is like making up for lost time.

Smith: Yeah.

Schenk: I get that.

Smith: He hit 90 years old and he was like, “You know what? I’m going to have aggressive sex with a stripper in my wheelchair before I die. I have nothing to lose at this point.”

Schenk: That’s right. Making up for lost time.

Smith: Yup.

Schenk: Speaking of lost time, we have unfortunately, for the listener or the watcher, come to the end of this particular episode of the Nursing Home Abuse Podcast. As always, you can download the audio version of this podcast on Stitcher or iTunes, or you can watch the podcast on our website, NursingHomeAbusePodcast.com, or check us out on YouTube. New episodes are available every Monday for your viewing and listening enjoyment and we will see you next time.

Smith: See you next time.

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