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A new study published in the Journal of American Medical Directors Association, looks into the care of dementia in nursing homes. The researchers focused the diagnosis and treatment aspects of dementia, finding very low levels of each in nursing homes in the US and across Europe. Knowledge about dementia and how to properly care for those suffering is an important issue in nursing homes, as there is usually a high percentage of dementia patients. This means that nursing home staff must be trained and knowledgeable in how to identify, care for, and properly medicate dementia patients.

In America, patients suffering from diagnosed dementia generally make up from 26 to 48% of nursing home populations. This number is probably even higher as patients with general cognitive impairment are not included. Many residents also go undiagnosed, mainly due to a lack of knowledge about the condition on the part of nursing home staff. This recent study has identified that roughly 1/3 of all dementia go undiagnosed, resulting in them never receiving any treatment or specialized care. Official diagnosis with dementia is important as it shapes how the individual care plan is formed. Dementia patients are more susceptible to falls, so special precautions and observation need to be used to prevent such events. More direct care is needed to care for nursing home residents diagnosed with dementia.

Direct care staff are frequently untrained in the identification and care of common nursing home ailments, including dementia. There are two main medications recommended for dementia: cholinesterase inhibitors (ChEIs) and memantine, an N-methyl-D-aspartate receptor antagonist. These two treatments work especially for dementia due to Alzheimer’s and Parkinson’s. The drug can help lessen behavioral problems and aggressive outbursts, meaning that the patient does not have to be restrained and can maintain a more normal and freer lifestyle. This means that the intensity of direct care necessary is lessened, decreasing the possibility of staff burn-out, which is more common when caring for dementia patients. And yet 26 to 60% of patients remain untreated. And even when they are prescribed, it is not uncommon for their use to be discontinued, commonly due to lack of funding. These medications can be beneficial to the patient, and the nursing home facility, so it is important that staff are well informed about their use and in identifying which patients have dementia and are thus can be helped by their use.

Unfortunately due to understaffing and the lack of training in care facilities, there are not enough qualified nursing staff to adequately monitor and assist these patients and unnecessary physical restraints are used to subdue them. Antipsychotic drugs used excessively can act as chemical restraints and benefit from these medications is usually outweighed by the harmful side effects of the drugs. It is important that medication should be individually tailored to each patient’s health needs and not used recklessly and improperly, as happens when used as a chemical restraint. The use of uncalled for restraints, due to a dearth of trained nursing staff, is against the Patients’ Bill of Rights. Nursing homes are required to employ enough staff to individually care for all of their residents. Understaffing can also result in the preventable spread of common diseases and pressure ulcers.

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You go to a hospital to get better, or at least to receive what medical assistance as may be possible. What you do not expect is for the hospital to make you worse, to give you a new disease. This is exactly what has allegedly happened to patients at Exeter Hospital in New Hampshire. At least 20 people have been confirmed as testing positive for Hepatitis C. During their stay at Exeter they were possibly infected by contaminated needles and equipment. Many people who were hospital residents during the time when the infection was present are currently being tested with their results pending. The government has lent its assistance to the matter and designated two nearby healthcare facilities as alternative testing sites to expedite the process.

The source of the Hep C outbreak has likely been traced to a hospital employee. This person used intravenous drugs while on the job and possibly contaminated syringes that were later used on patients. A class action lawsuit has been filed against Exeter Hospital for their negligence in allegedly allowing this employee to cause the outbreak. It is a hospital’s responsibility to ensure that proper safety procedures are put in place to prevent events like this from occurring. As of now, there are 44 affected people as part of the lawsuit, but this number could easily grow as more than 1,000 were possibly at risk from exposure.

Healthcare facilities, such as Exeter Hospital, are responsible to their patients; they are required to provide a safe environment, free of threats and harm, to those under their care. There must be an adequate number of trained staff, who are properly supervised and monitored, to prevent the type of damage that allegedly occurred at Exeter. Unfortunately, it is very common, especially in skilled nursing facilities, for there not to be enough qualified care givers. Understaffing can be very dangerous and is a contravention of patients’ rights statutes. Studies have shown that understaffed facilities are more likely to have occurrences of harmful, and even fatal, mistakes by care personnel. Patient quality of life is also adversely affected.

Pressure sores are a common side effect of an understaffed and under-educated facility. Bedsores can be avoided by relieving stress on sensitive areas and maintaining skin health through diet and exercise. Unfortunately, many residents in skilled nursing homes are malnourished, which has a marked negative impact on their risk factor for contracting pressure ulcers and other diseases. Nursing home patients who are malnourished or dehydrated are much more susceptible to infections such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, and influenza. When healthcare facilities provide ample nursing staff to maintain and monitor each patient’s health and status, it is much easier to prevent the spread and outbreak of these harmful diseases. Care providers should be educated in the identification and care of common infections and pressure sores.

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The long awaited Supreme Court verdict on the Patient Protection and Affordable Care Act (dubbed Obamacare), has come back in mainly favor of the new law. In a close ruling, five Justices, including Chief Justice John Roberts, upheld Obamacare with the remaining four dissenting. Although the majority of the law was accepted, Chief Justice Roberts quashed certain aspects as unconstitutional, in violation of the balance of federal and state power. The ruling upheld the new law as an acceptable use of congressional power to “lay and collect taxes”. But the provision for the government to withhold Medicaid funds from non-compliant states was rejected. Under the ruling, Congress will only be able to withhold extra funds meant to ease the exchange to the new system, but not take away the existing state Medicaid budget in its entirety.

The effects of the Supreme Court ruling on the healthcare industry are being debated. Pundits are already acknowledging the important role this will play in the upcoming presidential election, but it is really too early to tell what the implementation of the law will mean for healthcare agencies, patients, and insurance companies in the long run. The full provisions of Obamacare do not come into play until January 1st, 2014, but some effects are already being felt. The court decision has affected the stock prices of the healthcare industry, with hospitals up but insurance and pharmaceutical company prices dropping. There are some new developments that the healthcare industry can be sure of. Medicaid will be expanded, with a larger percentage of the population now being financially eligible. It is expected that 50 million uninsured people will gain access to insurance under this act. Medicare is also greatly affected, as many expensive prescription medications will now be covered and available as well as an elimination of co-payments for many types of medical procedures. This is of benefit to many of those in nursing homes, who are commonly on Medicare benefits.

With the requirement for all Americans to be insured, insurance companies are now required to accept in people with pre-existing conditions, who would commonly have been rejected, and not charge a premium for the coverage. While this is certainly beneficial for individuals, the financial toll this could take on insurance companies could be great. Some analysts contend that the law will actually end up benefitting insurance companies, but most agree that the price of healthcare will continue going up and future reevaluations and budget changes will probably be necessary.

As with the implementation of any new system, it is likely that many institutions will have a difficult period during the transition. The effect of 50 million newly insured people on the healthcare system could be a strain. For nursing homes, having to house and care for the additional numbers of patients could lead to problems in overcrowding and understaffing. The next few years may be an unsteady time for the quality of nursing home care. Medicare and Medicaid are integral in funding skilled nursing facilities, so the new changes to those programs are bound to have reverberating impacts.

With the many changes to the healthcare industry coming up under Obamacare, it is vital that nursing homes be monitored to ensure they are providing the health and wellbeing of their residents and upholding the Patient’s Bill of Rights. No matter what happens, all those residing in skilled nursing facilities should be free of avoidable infections, pressure sores, and injury from falling.

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A recent study, published in the Journal of Clinical Nursing, looks at how the level of education about pressure sore prevention among nursing home staff affects the level of care provided to residents. The article, titled “Pressure ulcers: knowledge and attitude of nurses and nursing assistants in Belgian nursing homes”, relates the results of a survey of registered nurses and assistant. The survey team interviewed 145 nursing staff across 9 different nursing homes and observed the care of 615 residents.

The findings of the study show that knowledge about pressure sore prevention is very low, with registered nurses scoring on average 29.3%. The mean score for certified nursing assistants is even lower at 28.7%. RNs and nursing assistants are in charge of taking steps to prevent the development of pressure sores. And yet this study found that the full measures stipulated by nursing home guidelines were only carried out in 6.9% of residents designated as at risk for pressure sores.

Pressure sores, or Decubitus Ulcers, are areas of dead skin tissue, which can be very painful and lead to infection and the breakdown of skin and muscle. These sores arise from extended periods of unrelieved pressure on a person’s skin. They are commonly found on the joints, back, and head, where the skin contacts or rubs against a bed or chair. Pressure sores are classified in four stages of severity, with stage IV resulting in extreme skin breakdown to the extent that the bone may be exposed. Pressure sores of any stage are very painful and can lead to a lower quality of life.

The development of pressure ulcers is preventable. By moving and changing position periodically, pressure on the skin can be relieved and pressure sores prevented. Other factors such as a healthy diet and good hygiene also help. Nursing staff play a vital role in this process. They are responsible for turning and repositioning at risk residents as well as assisting in activities that help build muscle and maintain skin health. These nurses and nursing assistants should be informed of pressure ulcer prevention measures as well as the proper care procedures if for any reason a resident does develop an ulcer.

One of the main reasons that residents in nursing homes develop pressure sores is understaffing. Many nursing facilities do not have adequate numbers of staff to perform the duties necessary to prevent pressure ulcers in all of the residents. This does not excuse the facilities as the Patients Bill of Rights mandates that all those residing in care facilities have the right to be free from developing any bed sores. It is the responsibility of the nursing home to hire enough staff to properly care for all of the residents. The RNs and nursing assistants should also be fully educated, in subjects such as pressure sore prevention, so that they can provide the care and attention that each and every person in a nursing home deserves.

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Although it has always been required by law, many patients are unaware that health care facilities are required to provide them with access to their own medical records. The director of the Department of Health and Human Services Office of Civil Rights has recognized this problem and responded by releasing a right to access memorandum. This memorandum is a comprehensive one-page document that you can take to your doctor, hospital, or skilled nursing facility to retrieve your medical records.

Leon Rodriguez, director of the Office of Civil Rights, encourages patients to become more involved with their health care. His concern before issuing the memo was that too often, health care facilities used the Health Insurance Portability and Accountability Act (HIPAA) to prevent patients from having access to their own medical records. Some facilities act under false pretenses of protecting their patients’ privacy, while actually using HIPAA to their advantage to conceal and hold hostage their patients’ medical records.

You may wonder what incentives health care facilities have for concealing their patients’ medical records. Unfortunately, many California skilled nursing facilities today are guilty of nursing home neglect. When patients and their loved ones attempt to escape these abuses by taking legal action, nursing homes and their lawyers often use HIPAA to protect themselves by refusing to provide the patient with his or her medical records. Since the basis of a nursing home neglect case lies in the patients’ medical files, the inability of a patient to access his or her records can significantly hinder any lawsuit brought against the facility. For example, in certain class actions, attorneys will fight for years and are forced to take an excessive amount of steps and bring unnecessary motions just to send letters to other residents of the nursing home who may be potential class members.

In other instances, nursing homes have been found guilty of manipulating patient records or carelessly documenting certain conditions, while neglecting to document other important information. Inaccurate documentation can lead to improper assessments, withholding of treatments, and polypharmacy, all of which can lead to death. Because a nursing home staff may not be properly documenting your health condition, it is important that you use your right to access to obtain your own records and review them yourself.

Withholding of this information is especially egregious because patients have a legal right to access their own records. We hope that this article has been informative and will allow you to play a more interactive role in the care that you receive from any skilled nursing facility.

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Depression is a cognitive disorder that plagues one out of every ten Americans. Osteoporosis a bone disease, is also extremely widespread in the American population. Both are especially common in the elderly, and recently, researchers believe they may have found a link between the two. An article published in the June 2012 issue of the Journal of American Medical Directors explores the question “Do SSRIs Play a Role in Decreasing Bone Mineral Density?” The article reports that a certain type of antidepressant drugs may affect bone density. These drugs are classified as selective serotonin receptor inhibitors (SSRIs) and 62% of all antidepressant drugs fall within this category.

This recently discovered side effect of SSRIs highlights the need for extreme caution when administering antidepressant drugs. These types of drugs are very commonly abused in skilled nursing facilities and sometimes even used as chemical restraints. Before your loved one agrees to begin an antidepressant drug regime, make sure that he or she has exhausted all other alternatives. Leisure and social activities are just two examples of non-pharmacological therapies that improve depressive symptoms. The caregiver’s attitude toward his or her patients also has a profound effect on mental health. It is extremely important that your loved one’s caregiver is emotionally supportive and takes the time to personally interact with him or her on a daily basis. This will help prevent patients from feeling socially isolated and delay depressive symptoms.

The link between SSRIs and decreased bone mineral density, however, does not excuse the skilled nursing facility from any liability. In fact, a staff that is continually trained and educated should be aware of these risks and take them into consideration before administering an antidepressant drug regime to their patients. Each and every nursing home patient is entitled to access to an adequate staff. This legal right encompasses both quality and quantity of the staff available. If your loved one’s skilled nursing facility is lacking in either aspect, he or she may be a victim of nursing home neglect.

Furthermore, the nursing home staff is responsible for ensuring effective communication with any other team members that provide care for the patient. By operating under a team environment and maintaining accurate medical records, an efficient nursing home staff is able to prevent adverse drug reactions and polypharmacy, which can occur when a patient is taking an excessive amount of medications at once. By carefully documenting all treatments that the patient is receiving, physicians can be mindful of these other medications before prescribing additional drugs.

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Caring for the elderly is no easy task. While some elderly adults require acute care in skilled nursing facilities, others remain at home, often living with their children. Regardless of where they live, caregivers often experience burnout due to the high levels of stress encountered when caring for the elderly. A study recently published in the June 2012 issue of the Journal of American Medical Association compares job burnout in different healthcare settings. The article, titled “Professional Caregivers’ Mental Health Problems and Burnout in Small-Scale and Traditional Long Term Care Settings for Elderly People with Dementia in the Netherlands and Belgium” hypothesizes that caregivers in small-scale facilities experience less burnout than their counterparts in larger facilities.

These small-scale facilities refer to a relatively new type of care facility for dementia patients that treat dementia by allowing residents to maintain their own lifestyles and continue carrying out old habits, hobbies, and activities of daily living for as long as possible. Because these facilities are smaller, tasks are more integrated, meaning that a nurse is required not only to care for patients, but also to perform housekeeping and administrative tasks.

The benefits of a small-scale facility include a greater emphasis upon interaction with individual patients and more individualized care. For example, in larger facilities, all residents are forced to comply with daily routines and schedules, whereas in these small-scale facilities, daily schedules are based on each individual’s need. This highlights the inflexibility of care routines that is often a problem in larger facilities since previous studies have recommended that in order to effectively treat dementia, facilities should be open to modifying care routines to fit the needs of individual patients.

The study obtained its data by questioning workers in five different small-scale facilities and focused on those who care specifically for dementia patients, since the increased level of care required by dementia patients is often correlated with higher rates of job burnout, job dissatisfaction, stress, and mental health problems. “Burnout” was defined as feelings of exhaustion, depersonalization and disconnect from the individual’s job, and a reduced amount of personal accomplishments.

Interestingly enough, the results of the study disproved the hypothesis that caregivers in small-scale facilities experience less burnout than those in larger facilities. Despite the differences in care settings, workers in both types of facilities were observed to experience approximately equal amounts of burnout. However, the study determined that over time, caregivers in all types of care facilities, large or small, experience increased levels of burnout.

In conclusion, the researchers determined that the increased levels of job burnout in care facilities are a result of understaffing.

While these facilities are expected to provide the same quality of care with significantly fewer resources, government agencies are also increasing accountability in nursing homes by conducting inspections and issuing deficiency citations. Some government agencies even offer incentive programs to nursing homes that provide a high quality of care. Others base their funding on quantifiable factors such as number of incidents of preventable fall-related injuries and facility-acquired pressure ulcers. While Medicare’s ‘No-Pay’ rule has proven to effectively improve infection control measures, other programs, unfortunately, have often led nursing homes to withhold care and “downcode” certain injuries in order to avoid liability and continue receiving funds. For this reason, you must be extremely cautious when nursing homes report your loved ones health condition. Even if your loved one is being treated and assessed by nurses and physicians, it is still important for you to personally examine your loved one often since nursing homes often have incentives to conceal certain health conditions.

Many factors such as understaffing and consequently job burnout can prevent a nursing home from providing your loved one with the care that he or she requires. However, regardless of recent budget cuts and sometimes difficult working conditions, skilled nursing facilities continue to carry an obligation to provide your loved one with an adequately staffed facility and a high quality of care. They must learn to adapt and allocate their funding appropriately. For example, despite decreased levels of funding, many nursing homes continue to use their money wastefully by prescribing antipsychotic drugs in order to chemically restrain dementia patients, rather than using this money to increase staffing levels. Your loved one may be a victim of nursing home neglect and elder abuse if his or her nursing home is failing to provide him or her with proper care and an adequately staffed facility.

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Antipsychotic drugs, intended to treat mental illnesses such as schizophrenia, are the most commonly abused class of drugs in Los Angeles nursing homes. Despite warnings from the Food and Drug Administration (FDA) that using antipsychotic drugs to treat dementia patients can be fatal, one in four California nursing home residents receive these drugs before they are given safer and less expensive treatments.

Often, these drugs are used to chemically restrained patients, especially in understaffed facilities that lack the resources to provide proper dementia care to their patients. Rather than sedating dementia patients with antipsychotic drugs, nursing homes should be taking a non-pharmacological approach to the treatment of dementia. Numerous studies have been conducted to test the effectiveness of various dementia treatments and the results have consistently shown that dementia treatments should be behavioral in nature and involve social and leisure activities. In fact, other studies have shown that antipsychotic drugs actually aggravate certain symptoms of dementia, such as agitation, violent behavior, and delirium.

Because the abuse of antipsychotic drugs directly threatens the mental and physical well-being of patients, it has become a major issue of contention in nursing homes today. This week, U.S. Senators Kohl, Grassley, and Blumenthal took an initiative to end the abuse of antipsychotic drugs in skilled nursing facilities. They have proposed an amendment to the FDA’s Safety and Innovation Act S. 3187 that requires nursing homes to inform patients of the risks associated with using antipsychotic drugs and receive consent from the patients or their legal guardians before administering these drugs.

The California Advocates for Nursing Home Reform (CANHR) is working diligently to ensure the passage of this amendment. We encourage you to learn more about CANHR’s Campaign to end the Misuse of Psychotropic Drugs in California Nursing Homes. You can also contact California Senators Barbara Boxer and Dianne Feinstein to urge them to vote for this amendment to the Safety and Innovation Act S. 3187.

Even if you feel that the Safety and Innovation Act does not directly affect you or any of your loved ones, it is still important and beneficial for you to support this initiative because skilled nursing facilities are using Medicare funds to pay for these medications. In 2007, $116 million of taxpayers’ money were used to pay for the off-label use of antipsychotic drugs. This money could have been better spent in other areas desperately lacking in funding, or saved by using cheaper and safer non-pharmacological treatments for dementia.

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Osteoporosis is an common bone disease, especially in women over the age of fifty. While many medications have proven to be effective in the treatment of osteoporosis, recent studies link a class of drugs called biphosphonates to thigh fractures. Two examples of biphosphonates that are used to treat osteoporosis are Fosamax and Actonel. The University Hospitals of Geneva conducted a study that was published by the American Medical Association to determine the risks of taking biphosphonates.

The Wall Street Journal reported that the study included 477 osteoporosis patients over the age of 50. Of these patients, 39 were inflicted with thigh fractures that are associated with biphosphonate drugs. These thigh fractures are particularly unusual because they occur upon minimal to no impact. For instance, some patients experienced these types of fractures from stepping off a curb. Of these 39 patients, 32 were taking a biphosphonate drug and 11 had fractures in both legs. The study concluded that although biphosphonate drugs are effective in treating osteoporosis, after three to five years, patients should consult their doctors about continuing on this drug regime. At this point, the risks of using biphosphonate drugs may outweigh the benefits.

This new information on medication for osteoporosis highlights the need for skilled nursing facilities to continually train and educate their staff. A nursing home with high quality care must take a broader approach to care of their patients. Although Registered Nurses (RNs) play an extremely important role in the care of nursing home residents, other types of staff are necessary as well. For instance, in this specific case, nursing homes need to employ bone specialists, dieticians, and physical therapists that have the most current information on osteoporosis treatments and can provide osteoporosis patients with the care that they require.

The involvement of multiple parties and disciplines in the care of an individual, however, also requires effective communication. Documentation of medical conditions becomes even more important because doctors, nurses, specialists, and therapists need to have accurate information about a patient’s health condition in order to provide the most effective care. When medications are involved, as is the case with these osteoporosis drugs, it is particularly important to accurately document a patient’s health condition. Often, when caregivers are not aware of other medications already being prescribed to the patient, polypharmacy occurs. Although polypharmacy may seem unrelated to this case with osteoporosis treatments, this new research on biphosphonate drugs definitely highlights the importance of communication and collaboration among the various fields of medicine.

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When it was first adopted, Medicare’s ‘no-pay’ rule was a controversial topic in the world of healthcare. Under the ‘no-pay’ rule, healthcare facilities are not eligible to receive Medicare funding for treatment of conditions acquired within the facility. However, this rule has actually proven to be beneficial to improving quality standards of healthcare facilities, as hospitals and nursing homes now have a greater incentive to prevent infections and other conditions from developing under their watch.

While many different conditions are can be facility-acquired, the three most common were various types of infections related to surgical procedures and the use of catheters. Some other examples of common infections include Methicillin-resistant Staphylococcus aureus (MRSA), scabies, Clostridium difficile (C. difficile), and sepsis. In a recent study by the American Journal of Infection Control, reported by American Medical News, it was found that 70% of professionals now claim that they are spending more time educating their staff on infection prevention techniques as a result of the ‘no-pay’ rule.

This is not the first incentive program that Medicare has implemented, however.
For example, another recently enacted Medicare program makes the amount of funding provided to a healthcare provider directly contingent upon its quality rating. Meanwhile, the Department of Health and Human Services will award healthcare agencies up to $216 million in funding for reducing preventable injuries.

While they have proven to be beneficial, the necessity of incentive programs highlights the many conditions that can develop as a result of nursing home neglect and understaffing. Some nursing homes will even “downcode” serious conditions in order to relieve themselves of liability and continue to receive funding from government healthcare agencies. This dangerous practice further decreases your loved one’s chances of receiving the care that he or she requires. Because nursing homes and other healthcare facilities have incentives to hide conditions from government health agencies, it is important for you to be extremely attentive of your loved one’s health. Rather than blindly accepting the nursing home’s assessment of your loved one’s health condition, you should often examine your loved one yourself. It is important for you to be aware of all these abuses before choosing a nursing home for your loved one.

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