Why are bedrails in nursing homes so dangerous?

Episode 71
Categories: Neglect & Abuse

Schenk: Hello out there and welcome to episode 71 of the Nursing Home Abuse Podcast. My name is Rob Schenk.

Smith: And I’m Will Smith.

Schenk: And we are trial lawyers focusing in the areas of nursing home abuse and neglect in the state of Georgia and we are your co-hosts for this episode of the podcast. As this episode goes to air it is June 4th and let me tell you we are–Do you hear something?… Do you hear anything?

Smith: I can only imagine…

Schenk: Do you hear that?

Smith: What is that?

Schenk: That is middle age knocking.

Smith: Yeah.

Schenk: Middle age is knocking on the door to Will’s life because…

Smith: In eight days. In just a week…

Schenk: In just a short period of time…

Smith: I will turn forty years old.

Schenk: Forty years old. Middle aged man. On June 12th, 1978, bread cost a nickel a loaf.

Smith: I don’t think it did.

Schenk: The most watched TV show…

Smith: A house cost ten dollars.

Schenk: The most watched TV show was The Six Million Dollar Man.

Smith: That’s probably true and Reese’s Pieces came out.

Schenk: No.

Smith: Yes, in 1978.

Schenk: In 1984.

Smith: Nope, 1978.

Schenk: They came out with ET.

Smith: Do you want to put money on this?

Schenk: I almost think that I do want to put money–You’re talking about, not Reese’s Cup…

Smith: Reese’s Pieces.

Schenk: Reese’s Pieces? That was…

Smith: 1978.

Schenk: We’ll put lunch at…What’s?  it’s not El Azteca anymore…

Smith: El Ponce.

Schenk: El Ponce.

Smith: Okay.

Schenk: Lunch at El Ponce on the fact that…

Smith: And again, the main thing is who’s going to be right?

Schenk: Okay. Alright, so I think that I’m right, but we’ll look that up. Gene, during this episode…

Smith: …get that information

Schenk: Don’t tell us though and then when we go off camera, that’s when we’ll figure

this out.

Smith: Yeah.

Schenk: But anyway, it’s an actual–It’s an extra-special episode of Nursing Home Abuse Podcast because we have a guest and let me just say this, one of our listeners, Geri Wilson, she pointed out to me several months ago now that we are a male dominated podcast. We have yet to have a single female appear as a guest on this podcast.

Smith: Is that, right?

Schenk: Yeah.

Smith: Wow.

Schenk:  Can you believe that?

Smith: Okay.

Schenk: It’s just dudes.

Smith: I didn’t realize that. Okay.

Schenk:  It’s just dudes. Yeah. So, this episode, it breaks that spell. Who do we have on the podcast today, Will?

Smith: Well, today we have Robyn Grant, she is the Director of Public Policy and Advocacy at the National Consumer Voice for Quality of Long Term Care. It’s Consumer Voice is the organization. In this capacity, she is responsible for leading the development and implementation of the Consumer Voice’s public policy agenda and growing and mobilizing the grassroots network to support the organization’s policy work. Before joining Consumer Voice, she served as the Long-term Care Policy Director at United Senior Action an Indiana senior advocacy organization that consulted with the National Ombudsman Resource Center. She has a Masters in Social Work with a specialization in aging. Robyn was the Indiana State long-term care Ombudsman for eight years and President of the National Association of State Long-term Care Ombudsmen Programs for two terms.

Now, the way that I know her specifically is at the National Conference for Consumer Voice, back in November of 2017. She is the individual that gave the surprise tongue lashing to the two CMS workers who–employees who came to the conference. It wasn’t really directed at them. It was directed at CMS, but she had them on stage. They were about to talk about CMS and CMS’ new policies about not really implementing the new rules or fines and while she had them up there, she read them the riot act and it was a surprise to most people there. Certainly, a surprise to the CMS employees, but it was amazing. And so, we are very happy to have her. She is a staunch advocate for the elderly and for nursing home residents. We’re very happy to have her on the podcast.

Schenk: We are. She’s going to be talking about the dangers of bedsores– I’m sorry.

Smith: Bed rails.

Schenk: Bed Rails.

Smith: Another B word.

Schenk: Another B word. We’re going to have her talk about the dangers of bed rails.  Robyn, welcome to the show.

Robyn: Oh, Thank you so much. It’s a pleasure to be here.

Smith: So, Robyn, we want to talk to you about an issue that we know is extremely important now and that has to do with bed rails. I think that this is a little counter-intuitive for a lot of people just because it seems like bed rails are a safety feature. But, they’re also something that’s causing injuries, can you talk a little bit about that dichotomy there?

Robyn: I’m happy too, and you’re absolutely right. I mean, I think most people, when they think about bed rails, they think that that, “wow, that’s a way to protect somebody from falling or rolling out of bed.” Or, if they’re– If it’s someone, perhaps, with dementia, it’s a way to prevent them from getting out of bed. Perhaps, an individual is having trouble walking and needs assistance and would just get out of bed and try walking on their own and so I think people tend to think, “Well, if we put the bedrails up, that will stop them from getting out. That will keep them safe.” But, the truth is that bedrails are incredibly dangerous. Instead of keeping people safe, I mean, they can result in serious injury and even death.

Here’s what happens, people can get caught between the rails. There’s a risk of entrapment. So, a resident who wants to get out of bed may come up against a bedrail, they may try to go through the bedrail because there are openings between the different parts of the rail, so they may try to go through. They may try to go under. They could be doing this at the rail or they may try to go over the foot board and they get caught and they strangle and suffocate, and if they’re not save in time they can, in fact, die. So, there’s entrapment between the rails, but there’s also people that get caught between the rail and the mattress. The individual can roll into this gap if the bed mattress doesn’t fit right. Often, an individual may be too frail, too weak or whatever to change position and then the mattress presses against the person’s chest and prevents them from breathing and then they suffocate. Entrapment is a serious issue, falls are another one.

Folks who are confused or have dementia are particularly at risk of falls. If your trying to get out of bed and the bed rails are blocking your way, people frequently try to climb over the rails and what happens then is that can lead to a fall. They’re climbing up over the bedrails and the fall that they take then is higher than the fall if they’d fallen out of bed. So, it’s actually more dangerous. Falls from over the bed rail are actually more dangerous than just even a regular fall. So, while one part of our brain wants to say, “Oh, they keep us safe.” It’s really important to realize that that is not in fact.

Schenk: Robyn, what are the factors that a health care provider should consider when deciding to weigh the safety of preventing wandering or elopement with bed rails versus the dangers that bed rails actually–when the dangers from the bedrail is actually less great than the individual getting up and walking away. How is that decision made? What’s the analysis?

Robyn: Well, the first approach is to try other alternatives first. In fact, we have revised schedule regulations that went into effect in October of 2016 which require alternatives to be tried first. The facility would be responsible for doing a really good assessment of the resident and then looking at how that care could be individualized. So, finding other ways to keep somebody safe other than a bed rail and often that comes about by really knowing that individual. When I say individualized care, that’s–you’re knowing the person’s needs, their habits, their daily routines and trying to meet those. For example, if you know that Mrs. Thomas always gets up at 2 AM and she has dementia, to go to the bathroom, then part of what you do to provide care for her is to make sure you have staff there at that time to anticipate her needs. Part of the process is to go through and try these things first, and then if they don’t work it’s really trying to decide, so if Mrs. Thomas falls out of bed, how serious is that? What’s the risk of the compared to if she has this fall over the bed rail? Or if she gets trapped in between the rails? It’s doing a risk benefit analysis and sharing that with the resident if possible, and certainly with the resident’s representative, and making sure they give informed consent.

Smith: One of the things I’ve seen done, and I don’t remember if you and I have discussed this, I used to be a CNA and worked in nursing homes before I became an attorney…

Robyn: Oh, I did not know that.

Smith: Yeah, back in the early 2000’s, so like 2000-2008. It was in a lot of rural areas so they didn’t have a lot of technology. I think right when I was leaving we started getting more bed alarms and I have noticed that with bed alarms, the staff tends to get bed alarm deafness from those because they hear them go off so much that it doesn’t really become something that you immediately pay attention too. Which, is unfortunate, because that could be a good alternative. But, I also noticed a couple of times, and I always thought I liked this if it works out, they would try to put the bed almost all the way to the ground have a mattress–or not a mattress, but a pad on either side so that if they rolled out they wouldn’t really get hurt. I don’t think that works for every room or every resident, but it certainly seemed like it was something that worked for that resident.

Robyn: I’d like to speak to that, if I can.

Smith: Yeah, go ahead.

Robyn: First of all, your point about bed alarms is a really good one. I think that, when they effort to reduce the use of side rails started, people thought bed alarms were the answer because you think there’s that sensor pads and so if the resident moves, the idea is obviously, that the alarm goes off and that someone comes into help. But, here’s what we’ve found. As, you’ve said there’s alarm fatigue.

Smith: Yes.

Robyn: There’s so many going off that they get ignored. But, there’s even more than that. Usually, by the time a staff person is really close by, by the time the get there, the resident usually has already fallen. Another issue is that we see that the sound really exacerbates the agitation of residents with dementia. In fact, you’ve probably noticed this yourself, it will drive you crazy.

Smith: Oh, absolutely.

Robyn: I mean hearing these alarms, that’s just no way to live. That’s impacting quality of life, but we’ve also seen residents become so afraid of making the slightest move because they’re afraid the alarm will go off and upset them and others. They just remain rigid and frozen in place and so they’re terrified and by not moving at all that actually ends up impairing their own mobility making them more at risk for falls. A lot of folks are recognizing that, you know, bed alarms aren’t really a good way to go necessarily. But, your point about lowering the bed is an excellent one. We’re seeing that being used a lot. You have a bed that can be raised and lowered and you keep it as low to the floor as you can. You’ve probably already also have seen mats.

Smith: Yeah. Absolutely.

Robyn: You can put mats on the side of the bed so that you cushion the side if the person does fall. There are body pillows that can be used to protect people from rolling out of bed or to aid in positioning. I’ve also seen trapezes, so if somebody needs a bar to help them reposition themselves, they can hang from the ceiling and the person can grab them and use them to help reposition. So, there are ways to keep folks safe without using the bed rail and a big key is individualized care.

Schenk: Right.

Robyn: And good staff training.

Schenk: So, Robyn, is it fair to say that there should be no reason at all to use bed rails in any circumstance? If at all possible.

Robyn: I think, if at all possible, yeah. The regulations don’t say you can’t use side rails. They do say that you have to have tried alternatives and they can only be used to treat a medical symptom and then you do try to use them for the least amount of time. The use of them should be infrequent, but they’re not completely prohibited.

Schenk: Gotcha. So, Robyn, let’s do this, a lot of our audience consist of persons who have loved ones in skilled nursing facilities and nursing homes. Place yourself into the shoes of one of those listeners. They walk into the nursing home to visit their loved one and they notice bed rails up. What’s the next thing that they should do?

Robyn: They should find a staff person, maybe the aid whose been caring for their loved one and just say, “I just came in and I’ve noticed there are side rails being used on my mother’s bed. Can you tell me what’s going on? Can you tell me why they’re being used?” Start by just getting information and asking, what’s going on? Because if you find out why they’re being used, then families often know their loved ones so well that they may be able to make some suggestions.

Smith: Yeah.

Robyn: Maybe the loved one was getting agitated, or getting out of bed a lot, a lot and they decided to put them up to keep their loved one in bed. The family member can say, “I am concerned about their use. I’m aware that side rails can be extremely dangerous and I know you wouldn’t want anything to happen to my mom. Can we talk about what we can do, other than using bed rails?”

Smith: Yeah, because I think–Go ahead. Go ahead.

Robyn: I was just going to say that this is a really good conversation to have at a care plan meeting.

Smith: I was going to say that the family should be involved in the care plan from the get go and a bed rail decision is definitely a care plan decision.

Robyn: Absolutely, and now it is a decision which, by regulation, has to be with informed consent. So, if your mother is cognitively impaired, has dementia, and you are the decision making, those bed rails should not have gone up without you knowing and giving consent and having all of the information presented to you about the risks and whatever benefits there may be. That should not happen.

Smith: Is that regulation one from 2016?

Robyn: Yes. Yes, it is.

Smith: Is it being implemented? Or is it being delayed?

Robyn: That’s an excellent question. This one is being implemented.

Smith: Oh, good.

Robyn: Yeah, I think it’s important for folks to know that the regulations related to bed

rails really have been strengthened and, I believe, are definitely an improvement. So, as I said, the alternatives have to be tried, there has to be informed consent. Facilities are required to make sure that they’re installed correctly, that the mattress fits the bed because that’s how many problems can arise when somebody gets caught between the mattress and the bed rail. So, they have to make sure that it’s the proper mattress. That creates lots of problems and they have to conduct regular inspections. So, the rates are vastly improved.

Smith: One of the things I remember seeing, because I worked in some pretty rural

counties in addition to some larger cities. But, in some of the really rural counties, in nursing homes that I am positive have been shut down by now, they clearly inherited hospital beds from a defunct hospital. So, hospital beds that were probably used in “One Flew Over the Cuckoo’s Nest”, they’re so old that these bed rails barely worked. They were just putting stuff together to get bodies in there to charge CMS and I think that can be a problem too, very bad beds, bad bed rails themselves.

Schenk: Well that’s–I actually have a question about that then. Robyn, I’m not saying

you’re an expert in manufacturing these things, but in your experience, are there

different types of bed rails and are there ones that are more inherently dangerous than others?

Robyn: Well, I am not an expert in the different types. The ones I have seen the most usually are with hospital beds. And so, the newer ones are certainly much better than the ones, Will, I think that you described having seen in these rural areas. Sometimes, rarely though, there may actually be rails–There are portable rails that sometimes are used, although rarely. Those, I find, are more problematic than the hospital bed rails.

Smith: I have definitely those because you’ve got that little metal push pen.  I think you know what I’m talking about Rob, where you connect something and that little metal push pin goes into the hole like this.

Schenk: Yep.

Smith: And you’ve got to push those out and take them out.

Schenk: And you lose skin.

Smith: Those were made for hospitals that had no intention of putting somebody with dementia or other issues like that in them. I mean, clearly it was like a 1970’s hospital where you’re a grown up, you know what’s going on, you’re there because you got your adenoids taken out or something and you’re staying overnight. Now, this nursing home has inherited it somehow. Those were absolutely horrible. I hope they–They need to ban the use of some of these different types of bed rails.

Robyn: Yeah, I think there, from our perspective, needs to be much more done. I know that this falls outside of the standards for Medicare and Medicaid services, but the FDA really needs to–They produce guidelines, safety guidelines, and they talk about zones of entrapment, but there really are not, as far as I know, really good manufacturing requirements, if any, that actually have to be followed. I think that’s an area where we need much better safety regulations.

Smith: Yeah, absolutely.  I mean I don’t think Rob and I ever had a case–No, we’ve never had a case with a bed rail suffocation.

Schenk: No, the cases that we’ve had are a lot of times were where the call button is wedged or tied to the bedrail.

Smith: But, we did have a case, and I’ll get to the point here, we did have a case where an individual got caught up in the window cord, the window blind cord.

Schenk: Yeah.

Smith: I really think that the FDA needs to get involved in these in the same way they would daycares or the production of cribs.

Schenk: Yeah.

Smith: Because you have the same kinds of issues where people are essentially, and I don’t mean any disrespect by this, but Mr. Johnson is 70 years old and he’s 6’ 3”, maybe he has dementia. In some way that’s no different than a 6’ 3” child walking around and you need to have the same precautions. You’re right, it can’t all fall on CMS. There needs to be more done about it.

Robyn: Yeah, in terms of the manufacture, absolutely, and safety warnings on the bed rails. I think there is a lot more that needs to be done in that arena. I mean, they’ve produced some materials for consumers, the FDA, so that’s good. But, I think, there’s more that needs to be done then education.

Schenk: Robyn, have you seen any trends in the statistics with bed rail injuries? Is, for example, is entrapment a greater risk than injuries from a fall from a great height because they’ve rolled over the bed rail? Tell us a little bit about the stats behind the injuries of bed rails if you can.

Robyn: Well, first thing to know about the stats is they’re pretty crummy. So, that’s an issue right there

Schenk: Sure. Yeah.

Robyn: I was doing sort of a little bit of research and they are–These incidences with bed rails are, for the most part, lumped together so it’s really hard to know exactly what happened. So, for example, they take incidents of people being caught, trapped, entangled, or strangled, and lump them all together. So, in one period of time from 1985, which is a long time ago, to 2009 they say there were 803 incidences of those.  The New York Time did an article and they looked at FDA data and law suits and nursing home surveys and they said that, since about 1995, there have been about 550 deaths. I think the tracking of this is woefully inadequate and we need better data to really know. But, that speaks to another point, which is that, unfortunately, I would say the majority of these are probably not even reported.

Smith: Yeah, I can see that too. The nursing home is not going to self-report on incidences like that.

Robyn: Yeah, they’re not going to report to the FDA or anything like that.

Smith: No. No, There not.

Robyn: Rarely. So, we have no idea, really, the number of injuries. Injuries, let alone deaths.

Smith: Yeah, and it’s really not until the New York Times or some private media gets involved, thank God for them, and they have the resources to do this kind of research, because it’s really difficult. You’ve got to get this information, and go through these all these documents to sort out who–Is there an f-tag for bed sores? Or, I mean, bed rails?

Schenk: For under a complaint investigation or any type of investigation where there’s bed sores and there’s an injury resulting from it, what’s the f-tag violation?

Smith: We keep saying bedsores, it’s bed rails.

Schenk: Well, a majority of our episodes and the majority of our cases involves bedsores. We have bed sores on the mind. Sorry about that, Robyn.

Smith: But, is there an f-tag for bed rails themselves?

Schenk: Yeah, let me…

Schenk: We’re putting you on the spot, this is like law school.

Robyn: Yes. The answer is yes.

Smith: It will be changing, right?

Robyn: So, I would be happy to follow up with you and give you the f-tag and it won’t be changing. It should remain the same.

Smith: Oh, really?

Schenk: And, Robyn, for our listeners, can you explain what an f-tag is?

Robyn: Absolutely. So, there are federal nursing home regulations that layout what facilities have to do and each of those regulations is give what’s called an f-tag. So, when the inspectors or the surveyors go in and look at the facility and try to determine if the facilities in compliance, they will write up f-tags and that indicates what regulation was violated. So, there’s an f-tag and then they all have numbers that go with them.

Smith: Yeah.

Robyn: So, F-395, something like that.

Smith: Right, so it’s like there’s a short cut for explaining what the violation was.

Robyn: I’m sorry?

Smith: Is it like a short cut to explain what the violation was?

Robyn: For those that know exactly what the f-tag is, it is.

Smith: Right.

Robyn: For most of us–You know after a while, if you work with them a lot, you get to know that so it becomes a shortcut. But, when they write up the report they will write the f-tag and they will actually write up the full regulation code.

Schenk: Right.

Smith: I’ve got you.

Schenk: It’s kind of like when you hear, “please dispatch we’ve got a thirteen one nine over at the high school”

Smith: Yeah.

Schenk: We’ve got a code 4-20 over here.

Smith: Okay. Okay.

Robyn: 10-4 good buddy. Yeah.

Schenk: There you go. Well, Robyn is there anything else that we haven’t talk about that you might want to talk to our listeners about the dangers of bed rails?

Robyn: I was just trying to think, I think the important point, as I think you mentioned in the beginning, is that it is counter-intuitive and that I think it’s important to keep in mind what we here from residents and the negative effects of what can happen, not just physically, but the type of social impact. That kind of haunts me, because I hear that residents feel caged in like animals when they have bed rails.

Smith: Yeah.

Robyn: There are residents that often feel isolated, alone, often see individuals withdraw, become depressed because they feel like prisoners. So, I think that it would have to be a really extraordinary situation for someone to really, I think, for bed rails to be used. And you certainly would want to be checking on the individual often and try to reduce them when at all possible. But, there are many many–There are alternatives to their use and above all individualized care and staffing is a major key.

Smith: Absolutely.

Schenk: Well fantastic, Robyn, you’ve brought a lot of insight for our listeners and we really appreciate you coming on and sharing that knowledge.

Robyn: The one last thing I’d just like to add, and you may have said this at the beginning, we have a lot of consumer information materials on our website which is: www.theconsumervoice.org and we have materials specifically for consumers, we have them for nursing home residents, we have them for family members. We do have materials that are related to physical restraints, which side rails are considered to be physical restraints if they’re being used to sort of prevent movement. And, we also have information from–We posted the FDA information about bed safety.

Smith: We’re going to put information up on the screen for all our viewers about Consumer Voice, but if you want to talk a little bit about Consumer Voice and what you guys do, I’d really appreciate that because you guys really are an amazing organization that is essential to the advocacy of long-term care residents because there’s not a lot of advocates for our long-term care residents. I mean, I hate to say it, but CMS is not always the greatest advocate and aside from, you know, we have some great Ombudsmen around the country, Melanie McNeil is the Ombudsman here in Georgia.

Robyn: Oh, yes wonderful.

Smith: She’s amazing and passionate. If you want to talk about what you guys do, please go ahead because we’d like to get more information out there about Consumer Voice.

Robyn: Well, thank you very much for the kind words first of all and then also for giving me an opportunity to then say a few words because we find that far too few people know about us. We are a national organization. Our primary focus is on advocating for quality of life, quality of care for nursing home residents, folks in assisted living, and folks receiving long-term services and supports at home. So, the whole continuum and we do public policy work. We’re on Capitol Hill talking to members of Congress to try to get good laws passed or oppose bad ones. We regularly engage with CMS about regulations and so trying to get the strongest regulations. Right now, we are trying to defend the regulations against being rolled back. And, we also work with agencies on policies and practices, so we are trying to get the best set of policies that we can that really are responsive to the needs of consumers in long-term care settings. So, there’s that part that’s fundamental to our work, but we also are very focused on trying to equip the individual, and family members as well, to know about long term care. To know about the options, to know how to select the best options for themselves whether that’s a nursing home. To know what good care looks like, to know what their rights are. You know, in a facility, so many people don’t know what the facility is–what it’s responsibilities are and what we have the right to expect and the level of care that they have the right to expect. We have materials and we try to educate about that and to also to help people know how to speak up to advocate for themselves.

You spoke about the Ombudsmen’s program, they are wonderful–wonderful advocates out there. But, all we hope that people, with information and some support, can speak up themselves and talk to, say, the nursing home administrator to get good care for a loved one or for themselves. One last thing that we do, is we do have the National Ombudsmen Resource Center, so we train and support the Ombudsmen that are throughout the country in our community. So, lots of information–Lots of written information on our website, and I certainly hope that people will take a look at that and use that information.

Smith: How are you guys funded?

Robyn: We are funded primarily through grants and private donations.

Smith: I’m sorry, people can donate if they go to the website, right?

Robyn: Oh, absolutely! And it’s always greatly appreciated.

Smith: Yeah. Because, you guys are essentially a special interest group that is for the long-term care residents and the more money that you guys have, the more you can lobby legislation that protects seniors and long-term care residents because your opponent in this matter is the nursing home and the health care industry that has billions of dollars to do this.

Robyn: You are so right.

Smith: It’s David and Goliath. It really is David and Goliath. Yeah, so anyone listening, you can go to Consumer Voice website and donate. That’s something that you absolutely must do.

Robyn: Thank you so much for that. It does very much feel like David and Goliath and understand the nursing home industry is extremely well funded. You’re absolutely right. So, all donations are always greatly appreciated.

Schenk: Fantastic. Well, Robyn, we really appreciate you coming on and we look forward to having you on again at some point in the future.

Robyn: I would love to do that and thank you so much for the opportunity, I really enjoyed it.

Schenk: You’re very welcome.

Smith: Alright, thank you. Robyn, we’ll talk to you soon.

Schenk:  Bye bye now.

Robyn: Sounds great, thank you. Bye bye.

Schenk: Wow. That’s a great organization. You could obviously tell that she’s extremely passionate.

Smith: She’s extremely passionate, just like everybody who works for this organization and all the Ombudsmen in the country because they don’t take this job for the money. It’s a non-profit organization, so they do it because they have a passion for it and it’s a passion for people, unlike the nursing home industry which has a passion for profit.

Schenk: Well… I was going to try to segue like we’re not profiting by staying on any longer.

Smith: Right.

Schenk: But, anyway we have reached the conclusion of this particular episode of the Nursing Home Abuse Podcast. As always, you can watch on our YouTube Channel or on nursinghomeabusepodcast.com or you can listen on Stitcher, iTunes, Spotify, Pod puppies, whatever you want, however you get your podcasts. And, with that, we will see you next time. Thanks for listening

Smith: See you next time?

Schenk: Oh, I’m sorry I just ruined that. I’m sorry.  And, with that, we’ll see you next time.

Smith: See you next time.

Thanks for tuning into the Nursing Home Abuse Podcast. Please be sure to subscribe to this podcast on iTunes or Stitcher and feel free to leave us some feedback. And for more information on the topics discussed on this episode, check out the show website – NursingHomeAbusePodcast.com. That’s NursingHomeAbusePodcast.com. See you next time.