Nursing Home Neglect

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Causes of Injuries in a Nursing Home or Assisted Living Facility

I. BED SORES
II. URINARY TRACT INFECTIONS (UTI’S)
III. MEDICATION ERRORS (OVER-MEDICATION, WRONG MEDICATION)
IV. DEHYDRATION
V. MALNUTRITION
VI. INFECTIONS
VII. URINARY TRACT INFECTIONS
VIII. SEPSIS

I. BED SORES
The best treatment for decubitus ulcers, pressure sores (also known as bed sores) is prevention.

Prevention is a must and should be stressed by the health care provider.

Florida laws and federal laws define a bed sore as a “non-event”. By this the state means a bed sore or pressure sores should never be left untreated and should be addressed by a facility’s staff immediately when symptoms are detected in routine patient monitoring each day.

Most health insurance’s will cover any needed device, material, or equipment necessary to prevent and treat bed sores.

Medicare will not pay health care facilities and providers for the medical costs attributable to them. The facility or care provider must bear the costs to treat and cure the bed sore when it develops in a resident. Medicare and the federal government believe bed sores should never occur in such settings.

A. STAGE I BED SORE

1. This stage is characterized by a surface reddening of the skin. The skin is unbroken and the wound is superficial. This would be a light sunburn or a first degree burn as well as a beginning of a Decubitus ulcer.
2. The primary question with a Stage I bed sore is what caused bed sore and how can the pressure on the area that created the initial bed sore be alleviated to prevent worsening.
3. Treatment of a Stage I bed sore includes alleviating pressure on the site of the bed sore in some fashion to avoid causing increased injury. In addition, treatment should include medicating, covering, protecting, and cushioning the bed sore site. Increased nutrition is part of prevention.
4. The presence of a Stage I wound is an indication to more closely monitor the resident’s ski care and time in a bed or sitting on areas where the bed sore formed. Preventive actions are critical to avoid further development of the sore(s).

B. STAGE II BED SORE

1. Stage II Bed Sores are characterized by a blister either broken or unbroken. A partial layer of the skin is now injured.
2. The goal of care is to cover, protect, and clean the area. Coverings designed to insulate and absorb and protect the area should be used as prescribed by the attending physician.
3. Skin lotions and medications are used to treat, hydrate surrounding tissues, and prevent the wound from getting worse. Padding and protective substances to reduce pressure on the area where the bed sore is located is important. Facility staff must pay close attention to clearing up, protecting, and preventing spread of the bed sore. Proper nutrition and hydration are also important considerations.

C. STAGE III BED SORE

1. In a Stage III bed sore, the wound has progressed to a level where all of the layers of the skin are involved. The wound is deeper and prone to serious infection if not treated aggressively by a wound care specialist.
2. On-going aggressive wound care and medical staff oversight of the care plan is necessary to properly manage the treatment protocol, promote healing, and prevent further infection. Stage III bed sores traditionally are known to progress very rapidly if left untreated and result in sepsis and possibly death due to infection in the body.

D. STAGE IV BED SORE

1. A Stage IV bed sore has evolved through all layers of skins and now spread into underlying muscle tissue, tendons and possibly into the bone. A Stage IV bed sore is very serious and often times results in producing life threatening infections if not aggressively treated.
2. Anyone with a Stage IV wound requires medical care by someone skilled in wound care. Surgical removal of the decayed skin, muscle and tissue is often required in the proper treatment and prevention of further infection in the case of Stage IV bed sores. A skilled wound care physician, physical therapist or nurse can sometimes successfully treat a smaller diameter wound without the necessity of surgery. Surgery is the usual course of treatment. Amputation may be necessary is some situations. Gangrene could also set in. Residents who develop a Stage IV bed sore definitely should consider legal action against the facility for failure to provide proper access to appropriate care and neglect of a resident and violation of the resident’s rights.

II. URINARY TRACT INFECTIONS (UTI’S)

Most individuals with indwelling catheters for more than 7 days have bacteriuria. Bacteriuria alone in a catheterized individual should not be treated with antibiotics. Researchers indicate a long-term indwelling catheter (In greater than 2 to 4 weeks) increases the chances of having a symptomatic UTI. The incidence of bacteriuria is 4 times greater in individuals with long term indwelling catheter than in those without one.

For suspected UTIs in a catheterized individual, the literature recommends removing the current catheter and inserting a new one obtaining a urine sample via the newly inserted catheter.
Clinically, an acute deterioration in stable chronic symptoms may indicate an acute infection. Multiple co-existing finding such as a fever with hematuria are more likely to be from a urinary source.
No one lab test alone proves that a UTI is present. For example, a positive urine sample culture will show bacteriuria but that alone is not enough to diagnose a symptomatic UTI. However, several test results in combination with clinical findings can help to identify UTIs in a microscopic urinalysis, or a positive urine dipstick test
It is common for nursing home residents to have chronic bacteriuria. Symptomatic UTIs are based on the following criteria. Residents without a catheter should have at least three of the following signs and symptoms.

• Fever(increase in temperature of >2 degrees F(1.1 degrees C) or rectal temperature > 99.5 degrees F( 37.5 degrees C) or single measurement of temperature > 100 degrees F(37.8 degrees C) or chills
• New or increased burning pain on urination, frequently or urgency;
• New flank or supra-pubic pain or tenderness;
• Change in character of urine(e.g., new bloody urine, foul smell, or amount of sediment) or as reported by the laboratory( new pyuria or microscopic hematuria); and/or
• Worsening or mental or functional status (e.g., confusion, decreased appetite, unexplained falls, inconsistence of recent onset, lethargy, decreased activity).

The goal of treating a UTI is to alleviate systemic or local symptoms, not to eradicate all bacteria. Recurrent UTIs ( 2 or more in 6 months) in a non-catheterized individual may warrant additional evaluation or a referral to a urologist) to rule out structural abnormalities.

III. MEDICATION ERRORS (OVER-MEDICATION, WRONG MEDICATION)

Medication errors in nursing homes and assisted living facilities can be deadly.
The risk of serious injury or death in nursing homes and assisted-living facilities is greater because the residents who make up the populations of nursing homes and assisted-living facilities are there because of advanced age or illness. They likely do not know what medications they take and why and cannot assist their health-care provider in a patient-provider partnership when it comes to making sure their medications are correct.
Residents are given pills by facility staff to take and the resident does not know what pills he/she is supposed to be taking. The resident relies on the facility staff to give them the right dose and medication.
The most common medication errors fall into the following broad categories:

• Medications given to the wrong resident
• Medications given to a resident who is allergic to the medication
• Medications given in the wrong dosage (either overdose or underdose)
• Lack of follow-up after medicating to monitor the effects of the medication

IV. DEHYDRATION

Dehydration occurs when the body does not have enough fluids. Causes include an excess loss of fluids, lack of drinking enough or taking in enough fluids, or both.

Dehydration has become huge problem in nursing homes, due to the high susceptibility and comorbidity of the elderly.

Physiologic changes related to aging make an elderly adult more prone to dehydration. This may result from eating less, loss of appetite altogether, use of too much salt, that raises the body’s need for fluids. As we age the human body’s response to a requirement for additional nutrients and fluids may diminish. For that reasons, as we age it is easier for us to become severely dehydrated before we actually feel thirsty or symptoms are recognized by others not monitoring the possibilities that dehydration may occur.

Symptoms of dehydration in the elderly is characterized in many cases as reduced or poor skin elasticity (i.e., When the skin is pinched, it holds its form rather than returning to its normal shape.)

Dehydration when serious may cause death or other very serious illnesses. It is very important that family and medical staff in facilities are closely monitoring and watching for symptoms of dehydration.

V. MALNUTRITION

Good nutrition is critical to the elderly, however, due to adverse side effects of certain medications, loss in the sensation of taste, dislike of the food served in a facility setting, coupled with a failure of the body to recognize when it is dehydrated and needs fluids, and dental issues, many elderly are susceptible to malnutrition.

The symptoms of Malnutrition vary depending on what is causing the elderly to be malnourished. Common symptoms of Malnutrition are: fatigue, dizziness and weight loss.

Malnutrition can lead to many health problems in the elderly including: fatigue, depression, weak immune system, anemia, muscle weakness (leads to fall and fractures), digestive problems, lung and heart problems, and poor skin integrity.

A loss of around 5 to 10 percent of body weight in 1 to 12 months may indicate a problem in an elderly person. Drastic weight loss should not be considered a normal part of the aging process.

VI. INFECTIONS

Infections are very common in nursing homes, and assisted living facilities. They are a significant cause of disease and mortality among residents in these type of facility settings. There are many reasons why infections occur at a high rate in these facilities:

Residents are in a congregate or group setting and residents with infections are commingled into the facility community activities. In addition, some residents are cognitively impaired and unable to follow basic hygiene precautions, and the staff do not properly address hygiene of those residents and allow them to commingle with other residents which breeds infection.

The most prevalent infections in Nursing Home and Skilled Nursing Facilities are: pneumonia, urinary tract infections (UTI’s), scabies, staph, and sepsis amongst others. Pneumonia is a respiratory infection of the lungs. Germs called bacteria, viruses, and fungi are the primary cause of pneumonia. It is said that over 60% of all respiratory illnesses are Pneumonia.

VII. URINARY TRACT INFECTIONS

Are the most common infections occurring amongst nursing home residents. M any patients who have urinary tract infections are asymptomatic (not show signs of it).

Scabies, a skin disease is also very prevalent in nursing homes. Scabies is a contagious and infectious skin disease that is caused by the itch mite. Due to their weakened immune systems, Elderly people are more susceptible to scabies than the general population. Outbreaks of scabies are usually reported to happen in hostels, hospital, nursing homes and other places where elderly people reside. If not treated properly scabies can lead to more infections and death.

Sepsis is a severe infection where the bloodstream is overwhelmed by bacteria. This of course is more deadly in the elderly due to their weakened immune systems. As sepsis gets worse, it affects the body’s organ functions and eventually can lead to septic shock. Symptoms of sepsis included but are not limited to: a) Fever above 101.3° or below 95°, b) Heart rate higher than 90 beats a minute, c) Respiratory rate higher than 20 breaths a minute. Left untreated for too long will result in death.

VIII. SEPSIS

Sepsis is a very serious illness where the bloodstream is overwhelmed by bacteria. Symptoms of Sepsis are fever, chill and severe shaking, excessive breathing and heart rate amongst others.

Sometimes Sepsis can be caused by a urinary tract infection (UTI). This condition involves a buildup of bacteria or toxins in the blood of the urinary tract. This will lead to poisoning of the blood, and can bring on severe health problems like damage of organs, which can result in death.

Septic Shock is a serious condition that occurs when an infection leads to life-threatening low blood pressure. There are many patients/residents who are susceptible to septic shock including those with Diabetes, AIDS, Leukemia, and Lymphoma.

The primary treatment of a person with sepsis is the administration of antibiotics. Research studies have indicated persons often fail to get sufficient nutrition while they are in the hospital. This may lead to malnutrition, which stresses the immune system and can worsen the effects of sepsis.

Gregory G. Glenn, Esq. is a Certified Elder Law Attorney by the National Elder Law Foundation. He has practiced elder law since 1995. Prior to law school Mr. Glenn worked as a management consultant at the Big Eight accounting firm of Coopers & Lybrand, CPA’s and also at Dunn & Roth, CPA’s as a staff accountant. He has his law degree from MSU and completed his legal studies at the University of Miami School of law. His focus in elder law is on estate planning for the over 65, disability planning, probate, and Medicaid eligibility planning. His office is in Boynton Beach, Florida.