By AMANDA SCHAFFER
Published in the New York Times on February 19, 2008

To understand why some doctors and nurses take bedsores so seriously, it helps to call them by their clinical name: pressure ulcers.

An area of skin breakdown that occurs when sustained pressure cuts off blood circulation — usually in patients confined to their beds in hospitals and nursing homes — a bedsore can result in a wound so deep and painful that some patients require narcotics. If a bedsore becomes infected, the complications can be fatal.

“They are not just little sores,” said Susan D. Horn, senior scientist at the Institute for Clinical Outcomes Research in Salt Lake City. “If you’ve ever seen a very bad one, frankly, it would make you sick. You see a very reddened outer area, then you see, depending on how deep it is, just this hole in the skin, and it goes right down to the bone.”

Experts estimate that two million Americans suffer from pressure ulcers each year, usually through some combination of immobility, poor nutrition, dehydration and incontinence. The Centers for Disease Control and Prevention does not keep statistics on fatalities, but one prominent victim was the actor Christopher Reeve, who died of a bedsore infection in 2004 in the middle of a heroic battle against paralysis.

New research is suggesting that the battle against bedsores requires a team approach, enlisting everyone from nurses and nursing assistants to laundry workers, nutritionists, maintenance workers and even in-house beauticians.

In a study of a collaborative program involving 52 nursing homes around the country, The Journal of the American Geriatrics Society reported last August that team efforts had reduced the number of severe pressure ulcers acquired in-house by 69 percent.

“Preventing pressure ulcers is a 24/7/365 kind of job,” said Jeff West, a clinical reviewer at Qualis Health in Seattle, who helped to set up the collaborative in 2003. “It’s not as if one person can get it all done. And if it fails just a little bit, just during the weekends, for instance, you’re not going to get the results. It takes tremendous consistency.”

At the Lutheran Home in Fort Wayne, Ind., for instance, “the laundry workers helped us see that some clothes weren’t fitting the residents properly and were restricting their skin,” said Jeanie Langschied, a registered nurse there.

The kitchen staff began putting protein powders in cookies to boost nutrition. They added buffet dining, so residents would not remain in one position for so long, compressing fragile skin.

Even the beauty shop “realized that wait times needed to decrease,” Ms. Langschied said, and residents should be repositioned while getting their hair done. “It was all departments looking at everything, and it was just amazing the information that flowed through.”

Lutheran Home was one of the 52 facilities that took part in the collaborative, sponsored by the Centers for Medicare and Medicaid Services. Dr. Joanne Lynn, who helped begin the project when she was a senior natural scientist with the RAND Corporation (she has since joined the Medicare centers), said the goal was to educate nursing home workers in bedsore prevention and to encourage them to come up with creative, low-tech solutions of their own. “It was a combination of education, cheerleading and something like systems engineering,” Dr. Lynn recalled.

The number of superficial bedsores did not decrease to a statistically significant degree, for reasons that are unclear.

At David Place, a nursing home in David City, Neb., staff members say they focused on assessing each resident’s risk for bedsores, and noted this risk on the assignment sheets used by nursing assistants.

“The residents at highest risk,” said Dan Smith, director of nursing, “would be the last up for meals and the first down after meals so they would not be in their wheelchairs for long periods of time putting pressure on their bottoms.” Residents at risk from weight loss were given yellow plates, so that staff members would remember to encourage them to eat more.

David Place also bought new mattresses made of high-density foam to reduce pressure in key areas. Staff members say they redoubled efforts to keep feet elevated with pillows so that bedsores would not develop on the heels. And they began to use new moisture barrier creams with residents who were incontinent, since lingering moisture can speed the development of sores.

Staff members at Palatka Health Care Center in Palatka, Fla., initiated a similar blend of measures. They created a “skin-watch action team,” or SWAT, to identify vulnerable residents and to make sure that their heels were floated, that they were given pressure-reducing cushions and that they were repositioned frequently, said Carol Jones, a risk manager at the center.

“We got the grass-roots level, the certified nursing assistants, much more involved, and they were held accountable,” Ms. Jones said. If a bedsore began to develop, she said, “we’d ask them, how did this happen?”

Initially, as the collaborative collected data from participating facilities, the incidence of pressure ulcers did not appear to change, Dr. Lynn said. It was only when researchers focused on data for the most severe bedsores that they saw an improvement.

Clinicians document four stages of pressure ulcers, in which Stages 1 and 2 are superficial sores and Stages 3 and 4 are deep wounds that result from death of the skin and underlying tissues.

“In good care, almost all new stage 3 or 4 pressure ulcers show up fully formed,” Dr. Lynn said, meaning that they do not begin as superficial bruises that then go deeper. The injury, she said, “appears to be in the deep tissues from the start, though it can take a few days for the extent of dead tissue to become apparent.”

The deeper sores may have different underlying causes than the superficial ones, she said. But it is unclear why the less severe ones did not respond as well to the practices instituted by the collaborative.

Dr. Horn, of the Institute for Clinical Outcomes Research, praised the collaborative as “the first major national effort driven by Medicare to reduce pressure ulcers.” But she said that better outcomes could be achieved if more nursing homes improved their documentation, so that all of the information on a given resident, including details on eating, urinary and bowel function, appeared on a single sheet, with key reminders to nursing assistants and other staff members about best practices.

Institutional change and work-flow redesign are critical, she added, given the high rates of turnover in nursing home staff across the country.

The changes need to become hard-wired in an organization, said Mr. West, of Qualis. “A lot of places do well when they have a lot of support,” he said. “But it’s hard to keep that momentum going. That’s the real challenge.”

Statewide efforts to reduce pressure ulcers are also under way in California, New Jersey, New York and elsewhere.

Bedsores are “a major quality-of-life issue, and a self-esteem issue,” said Joanie Jones, a nurse at David Place in Nebraska. “No one wants to have sores on their bottom. I don’t care how old you are. You still want your skin intact.”
 

WASHINGTON (AP) — After initially resisting their disclosure, the Bush administration on Tuesday published the names of 131 nursing homes with poor inspection records and said some were already showing signs of improvement.
The list released by the Centers for Medicare and Medicaid Services represents troubled facilities cited as a “special focus facility,” a designation used to identify those that merit more oversight. For these homes, states conduct inspections at six-month intervals rather than annually.

Last November, the government released a partial list of 54 nursing homes that ranked among the worst in their states, balking at releasing the full list of homes with the “special focus” designation. After a group of Democratic lawmakers began pushing for full disclosure, CMS said Tuesday it was publishing the names after cross-checking information to ensure the release of the most accurate data.

CMS will update its list of troubled nursing homes on a quarterly basis, with its next release scheduled for April.

“This is the latest in a series of steps we will be taking to improve quality and oversight in nursing homes,” said Kerry Weems, CMS acting administrator. “We are issuing more information on special focus facilities to better equip beneficiaries, their families, and caregivers to make informed decisions and stimulate robust improvements in nursing homes having not improved their quality of care.”

“This should just be one of the tools,” Weems added. “There is no substitute for visiting the nursing home in person.”

The list released Tuesday shows 52 nursing homes as not showing improvement after they were cited as a higher-risk nursing home, while another 52 did show some improvement. Twenty-seven nursing homes were added to the list in the last six months.

Out of the 54 nursing homes initially disclosed as poor performers last November, 21 have shown improvement, CMS said, adding that publicity about the problems might have played a factor.

There are about 16,400 nursing homes nationwide, and taxpayers spend about $72.5 billion annually to subsidize nursing home care.

While most nursing homes have some deficiencies, with the average being six to seven deficiencies per survey, the special focus facilities typically have about twice that number, and continue to have problems over a long period of time. However, the states determine which nursing homes should get the designation, and inspection standards vary among the states.

The offenses typically involve unnecessary use of medication for elderly residents, or inadequate safeguards to protect residents such as those with Alzheimer’s from day-to-day hazards in the nursing home.

Sen. Herb Kohl, D-Wis., who chairs the Senate Special Committee on Aging, applauded CMS’ move.

“We believe that Americans should have access to as much information about a nursing home as possible,” he said. “We also agree that giving consumers more information about our nation’s nursing homes is a good idea, but that doing so in a manner that causes a panic is not.”
 

Arbitration a growing trend in health care

By Stacey Burling, Philadelphia Inquirer Staff Writer

Within the space of two weeks late last year, Michael and Hedy Cohen, who happen to be experts on medical errors, each encountered what they saw as a disturbing development in the modern doctor-patient relationship.
They were asked by two groups of suburban doctors to sign away their right to a jury trial in the interest of reducing malpractice costs.

Legal experts say such attempts to channel potentially unhappy patients away from the court system and into arbitration are becoming increasingly common in health care. Agreements to settle future disputes with binding arbitration, in which an appointed individual or small panel decides the case instead of a judge or jury, are now pervasive in contracts involving many other things we buy, including credit cards, cell phones and cars.

Proponents say arbitration is faster, cheaper and fairer than trials, but critics say the secretive system can be weighted against consumers and makes it harder to track complaints or build legal precedents.

Eugene Rosov, who runs two malpractice-insurance companies that advise doctors to use arbitration agreements, said he thought they ultimately would reduce the cost of insurance and defensive medicine - tests ordered primarily to protect against lawsuits. “This agreement is better for doctors and for patients,” said Rosov, whose companies have 35 subscribers in New Jersey and Pennsylvania. “The only person it’s bad for is the plaintiffs attorneys.”

But Temple University law professor Bill Woodward thinks the growth of a private judicial system “is a pretty nasty legal development, I think, and it’s just crying out for correction from Congress.”

A bill introduced last year by Sen. Russ Feingold (D., Wis.) aims to do that. It would prohibit pre-dispute arbitration clauses involving employment, consumer, franchise and civil rights disputes.

Michael Cohen was handed an arbitration agreement when he visited his longtime primary-care doctor in Bucks County. Cohen said he was not the suing kind, but the thought of being asked to give up his right to sue “stopped me in my tracks.”

He said no, and his doctor saw him anyway.

Then Hedy Cohen, who has had a kidney transplant, was mailed a similar form by a group of kidney specialists she planned to see for the first time. The form from Hypertension-Nephrology Associates in Willow Grove insisted on binding arbitration and said she would have to pay the doctors’ legal fees if she filed a complaint and lost.

Hedy Cohen said no and was told to find another nephrologist.

That was fine with Cohen, a nurse with a master’s degree in health-care administration. “I couldn’t have a relationship with this person because they had already set the tone,” she said. “We’re adversaries before we even know each other.”

Jerry Dolchin, the nephrologists’ attorney, said the doctors began using the forms at the height of Pennsylvania’s malpractice crisis in 2003, when doctors, he said, were being “hit pretty hard by overzealous plaintiffs’ lawyers.” Since then, he said, “hundreds and hundreds and hundreds” of patients have signed the form.

Ruth Schulze, a North Jersey gynecologist, started asking patients to sign an arbitration agreement last year after she bought malpractice protection from Obstetricians & Gynecologists Risk Retention Group of America Inc., one of Rosov’s companies. She gave up obstetrics two years ago after she was told she would have to pay more than $120,000 for insurance.

Schulze said she won each of the three times she was sued, but left the trials disenchanted. “It is not really a trial of your peers,” she said. “It’s theater.”

Her patients have largely embraced the new approach, she said. She will not do surgery on anyone who refuses to sign the form, which limits pain and suffering payments.

For her, the arbitration agreement sets the groundwork for a more trusting doctor-patient relationship. Patients need to understand that bad things happen in spite of doctors’ best efforts. “Medicine is not guaranteed perfection,” she said.

Steven Barrer, a Montgomery County neurosurgeon, says he thinks he was the first in his area to start using an arbitration agreement around 2003. Barrer wanted to “somehow create malpractice reform for myself since it wasn’t coming from the courts and it wasn’t coming from the legislature.”

He got the idea for an arbitration agreement from his cell phone contract. “I figured if they can do it, why can’t I?” he said.

Out of thousands of new patients, only about 10 have refused to sign the form. He does not ask patients with emergencies.

No one knows how many doctors here use such agreements, but the practice does not appear widespread. It is common on the West Coast, and legal experts say it is spreading nationally. Many nursing homes ask residents to sign arbitration agreements, experts said. Golden Living, a national chain that operates 40 nursing homes in Pennsylvania, says about half of its residents agree to arbitration.

Doctors who join Medical Justice, another group trying to reduce malpractice expenses, do not require patients to agree to arbitration, but do ask them to sign contracts saying they will not file “frivolous” lawsuits and will use only board-certified specialists as medical experts in court.

In a project set to start next month in Montgomery County, the local medical society, bar association, and Abington Memorial are working together to solve medical disputes with mediation. While an arbitrator decides a case, a mediator shuttles between the two sides to help them reach an agreement. If they fail, the patient can still file a lawsuit.

The Rothman Institute, one of the largest and best-known surgical practices in the region, is currently mulling whether to ask patients to sign statements saying they will try arbitration or mediation.

Trial lawyers say mediation raises far fewer ethical concerns than binding arbitration, but critics of mediation say it often fails, becoming just another step to a lawsuit.

Legal experts say courts have been mixed on upholding the agreements. Barrer said two patients had tested his contract. It was upheld in one case and shot down in the other. Lawyers said requirements hidden in fine print, particularly arbitration systems that require consumers to travel long distances, are legally shaky.

John O’Donnell, senior counsel for Temple Health System, said Temple considered asking patients to sign agreements but feared most would not read them and worried that those who did would be upset. They also thought the agreements were likely to be unenforceable. The system decided instead to work harder to avoid mistakes and do a better job of dealing with mistakes that still occurred.

John O’Brien, a health-care defense lawyer, said he thought the agreements should give patients time to think and should clearly say that patients were giving up their constitutional right to a jury trial.

Critics of arbitration say it tends to benefit companies that frequently need arbitrators. It makes sense, they argue, that arbitrators would be more interested in pleasing “repeat users” than a consumer involved in one dispute.

“There are certainly companies that have their favorite arbitrators . . . and they use them and use them and use them,” said William Callaham, a Sacramento lawyer who is president of the American Board of Trial Advocates, a group seeking to protect jury trials. “Let’s face it. They use them because they get the results they want.”

Doctors have far fewer disputes than cell phone companies, but Alan Schwartz, a plaintiffs’ lawyer, still thinks malpractice victims do better in court. The arbitration system rules, he said, work against him.

“I have to play my game in their stadium with their refs.”

 

 

January 27, 2008 

By CLARK KAUFFMAN
DES MOINES REGISTER STAFF WRITER

U.S. Sen. Charles Grassley is calling for a federal investigation into the way Iowa and other states respond to complaints of poor nursing home care.

“I have an obligation to protect Iowans, and all Americans, from substandard nursing care,” the Republican senator from Iowa said in a letter Thursday to federal officials. Grassley criticized Iowa’s nursing home inspectors for failing to thoroughly investigate a complaint involving Waterloo’s Ravenwood Nursing and Rehabilitation Center.

In August 2006, Maizie Bickley was an 89-year-old resident at Ravenwood. Nurse aide Connie Rust called Bickley’s daughter, Sandra Bickley, one night to report concerns that Maizie Bickley was very ill and wasn’t being properly evaluated or treated by the nurses.

Sandra Bickley insisted that the home call an ambulance to transport her mother to a nearby hospital. Medical records show that within hours of Maizie Bickley’s arrival there, she was diagnosed with a possible bowel obstruction, an infection and dehydration. Two days later, she underwent surgery for a potentially life-threatening condition.

The owners of Ravenwood, Care Initiatives of West Des Moines, fired Rust, citing a company policy that prohibits conduct “that results in serious negative public relations.”

Sandra Bickley was furious, particularly when the Iowa Department of Inspections and Appeals looked into Ravenwood’s care for her mother and found no problems. She complained to Iowa Citizens’ Aide Ombudsman William Angrick and to Grassley.

Around that same time, Dean Lerner, who now heads the state inspections department, asked the federal Centers for Medicaid and Medicare Services to do its own review of his agency’s work on the case.

That federal review concluded that state inspectors didn’t conduct a thorough investigation of the Bickley case and didn’t interview nurses, ambulance workers or the hospital’s emergency room staff.

“I’m not satisfied with the investigation we did,” Lerner said Saturday. He said that although his department’s investigators interviewed Ravenwood residents, reviewed records and made their own on-site observations, more should have been done.

An attorney for Care Initiatives has said that federal law prohibits the company from commenting specifically on the Bickley case.

Grassley is now asking the Government Accountability Office, which is the investigative arm of Congress, to examine the nation’s state-run nursing home inspection agencies and the manner in which they respond to complaints.

He is also asking the Centers for Medicaid and Medicare Services to give him four years’ worth of investigative reports dealing with state inspections in Midwestern states such as Iowa and Nebraska. He said he wants to know whether the Bickley case is an anomaly or an indicator of a more widespread problem.

“Unfortunately, the Iowa Department of Inspections and Appeals investigation appears to have been wholly inadequate,” Grassley said.

Lerner said his department will cooperate fully with the federal agencies. Lerner said that he understands Grassley’s concern, but added that “the Department of Inspections and Appeals, under this current administration, doesn’t take a back seat to anyone when it comes to protecting the health, safety and welfare of the elderly.”

Although certified nurse aides have relatively little training compared with registered nurses, it’s the aides who provide most of the hands-on care in nursing homes. But they typically are prohibited from sharing concerns about quality of care with residents’ family members. They’re supposed to relay any concerns to administrators or licensed nurses.

In the Bickley case, Rust’s complaint was that the nurses weren’t responsive. She could have called the inspections department’s hot line, but it was after 1 a.m. and she would have received an answering machine. She eventually called Sandra Bickley at home to suggest Bickley get her mother to the hospital and then look for another care facility.

At a public hearing dealing with Rust’s claim for unemployment benefits, one Ravenwood nurse admitted that Maizie Bickley needed to be taken to the hospital’s emergency room that night, but said at the time she hadn’t thought it was necessary.

The judge in that case denied Rust unemployment benefits, saying she had made “highly inflammatory remarks” that “could result in legal liability for the home.”

Maizie Bickley is now living at the Manor Care home in Waterloo. Sandra Bickley said she is satisfied with that home and the staff’s efforts to care for her mother.

“But the problems with nursing homes are widespread,” she said. “We’re basically just warehousing our senior citizens in this country. Too many homes are owned by corporations, and for them the bottom line is profit.”

 

Clauses in nursing home agreements may violate the law

By PAUL WENSKE
The Kansas City Star

Elderly consumers and their families in Missouri should be wary when signing long and often complex nursing home agreements, according to a new study.

Although most presented few problems, some admission agreements skirt state and federal laws, misleading consumers about the care they can expect and inducing them to sign away critical consumer protections, says a study by the National Senior Citizens Law Center.

Although industry officials criticized the study’s findings, advocates for the elderly said it raised serious questions about how some nursing homes operate.

“People are signing these agreements in a crisis situation, assuming they are legal, and then when there is a problem down the line, they are being told they agreed to this,” said Andrea Routh, a former director of the Missouri Division of Aging and now a health-care consultant.

Jon Dolan, executive director of the Missouri Health Care Association, the state’s largest nursing home trade group, called the report statistically flawed. He said it relied on incomplete data and misapplied federal law to fit a preconceived effort to put nursing homes in a bad light.

“To paint with such a broad brush is suspect right off the bat,” Dolan said. “We believe we are following state and federal law and have not been advised of anything different.”

However, Denise Clemonds, head of the Missouri Association of Homes for the Aging, which also represents nursing homes and other residential care services, said her organization supports the study.

“Whether it’s statistically valid or not, we can learn from it,” she said.

The National Senior Citizens Law Center, a Washington-based nonprofit legal advocacy group for seniors and elder-care lawyers, reviewed 175 admission agreements voluntarily provided by nursing homes. The study found agreements which improperly limited a nursing home’s obligations. Others allowed discharges for vague reasons, or stuck relatives with bills they legally didn’t owe.

Eric Carlson, the study’s author, said that some of the agreements conflict with the federal Nursing Home Reform Law and state laws. The federal law requires nursing homes to provide care that helps residents reach the “highest practicable” level of functioning.

But Carlson said some agreements instead seek to get seniors or their families to lower their expectations of care and assume more of the risks of injury, such as falling or choking.

The study was requested by the Missouri long-term care ombudsman’s office.

State Ombudsman Carol Scott said the findings will be presented to health-care providers around the state. She said most nursing homes provide good care, but “for the ones not providing good care, I hope they hold this (study) up as a mirror.”

Toby S. Edelman, a spokesman for the Center for Medicare Advocacy in Washington, said similar studies in other states also show “ongoing concerns” with nursing home agreements.

The Missouri study found that nursing homes sometimes protect themselves by persuading seniors to waive legal remedies. In 18 percent of the agreements, seniors were required to submit a dispute to arbitration, rather than sue in court.

Industry officials maintain that the waivers deter frivolous lawsuits. But trial lawyers contend they have successfully fought the provisions in court as unconstitutional and unenforceable in health-care cases.

Lawyers noted, however, that consumers often don’t know the waivers can be challenged.

“A lot of people read it and say, ‘There is nothing I can do,’ ” said attorney Derek Potts, who represents residents and their families in neglect and abuse cases against nursing homes.

The study contends the agreements also thwart federal law by inserting provisions making it easier to evict residents. Federal law sets out six conditions that justify evicting a resident.

But according to the study, 17 percent of the agreements allowed evictions without a reason, and 46 percent included at least one reason contrary to federal law. One allowed evicting residents who are unduly noisy, uncooperative or destructive — behavior sometimes associated with Alzheimer’s disease.

However, Dolan disputed that residents were unlawfully discharged. “We are heavily regulated on who we can discharge and when,” he said.

While most of the Missouri study’s findings relate to seniors, it also found that their families are sometimes stuck with bills they are not legally required to pay.

Carlson, the study’s author, said that under the federal reform law nursing homes cannot require a relative or a friend to become financially liable for nursing home expenses. Yet, the study found that 19 percent of the admission agreements required a financial guarantee “in direct violation” of federal law.

Elder-care lawyers said such “co-guarantor clauses” are becoming more common.

Advocates for seniors acknowledged that nursing homes face growing financial strains. But they said seniors and their families still need to be dealt with fairly at vulnerable times in their lives.

“It’s fanciful to suggest seniors and their families are in a position to read carefully and negotiate these agreements,” Carlson said. “They are signing without knowing any better.”

Know your rights. State and federal laws provide important rights to ensure top quality nursing-home care. Chief among them are the rights:

•To understand the wording of an admission agreement before you sign it.

•To take an active role in developing your own or a family member’s care plan.

•To have reasonable adjustments made to accommodate health-care needs.

•To visit a family member in the home at any time of the day.

•To decline to submit disputes to arbitration rather than file a lawsuit.

•To decline to sign a waiver of liability for injuries or lost property.

•To decline to become a co-guarantor of a resident’s nursing home bills.

•To be protected from evictions that specifically violate federal law.