Nursinghomes:Abuseneglectthroughoutmichigan

NursingHomes:AbuseNeglectThroughoutMichigan

November2011

Acknowledgements

MichiganProtectionandAdvocacyService(MPAS)isMichigan’sdesignatedagencytoadvocateandprotectthelegalrightsofpersonswithdisabilities,mandatedbyfederalandstatelaw. MPASreceivesfundingfromtheAdministrationonDevelopmentalDisabilities,thecenterforMentalHealthServices–SubstanceAbuseandMentalHealthServicesAdministration,theRehabilitationServicesAdministration,theSocialSecurityAdministration,theStateofMichiganandfromprivatedonations.

FundingforthisreporthasbeenmadepossiblethroughtheU.S.DepartmentofEducation-RehabilitationServicesAdministration.ThecontentsarethesoleresponsibilityoftheauthoranddonotnecessarilyrepresenttheofficialviewsoftheU.S.DepartmentofEducation–RehabilitationServicesAdministration.

2011byMichiganProtectionandAdvocacyService,Inc.Thispublicationmaybereproducedinpartorinitsentiretyfornoncommercialpurposesaslongasappropriatecreditisgiven.

MichiganProtectionAdvocacyService,Inc.4095LegacyParkway#500

Lansing,MI48911

800.288.5923

WashtenawCounty

InasurveydatedSeptember2011:Aresidentofanursinghomerequiredextensiveassistancefromfacilitystaffwithtoiletingandbathing/showering.Theresidenthadaurinarycatheterthatrequiredcathetercareeveryshiftandasneeded.Staffobservedmaggotsintheresident’spubicarea.Staffdidnotshowertheresidentimmediatelyduetolackofstaff.Twoweeksbeforethemaggotswereobserved;staffnoticedfliesontheresident’slegwoundsandaroundtheresident’sbed.Facilitystaffdidnotcompleteanincidentreportbecausefacilitymanagement“didn’tknowhowtowordit.”Thefacility’s“ClinicalCorporatePerson”wantedstafftocalltheincident“debridement”(deadtissue)insteadof“maggots.”Thefacilitycouldnotprovidedocumentationthattheresidentreceivedregularlyscheduledbedbathsorcathetercare.Theresidentstated“thereweretimesitwasweeksbeforetheycleanedmycatheter...”Staffwastoldtodocumentthattheresidentrefusedshowers.Theresidentdid,infact,refuseshowersduetocomplaintsofhippainalthoughgavepermissionforspongebaths.Itwaslaterdiscoveredat thehospitalthattheresidenthadahipfracture.Thereisnodocumentationindicatingstaffwasdisciplinedforneglectingtheresident’sbasiccareneeds.

OaklandCounty

InasurveydatedAugust2011:Aresidentofanursinghome,whowastotallydependentonstaffforallactivitiesofdailyliving,begancoughingonenight.Staffdidnotassesstheresident’sbreathingappropriatelybecausetheywere“rushed.”Theresidentcontinuedtocoughthroughoutthenight.Twostaffobserved“whitethings”intheresident’ssputum,mouth,andneartheresident’stracheostomycollar.Earlythenextmorning,astaffpersonlookedintotheresident’smouthwhileprovidingoralcareandobservedmaggotsintheresident’smouth.Emergencymedicalservices(EMS)werecontacted.EMSfoundtheresidenttohaveanabnormalbloodoxygenlevelandhadlaboredbreathingduetoapartialairwayobstruction.TheEMSstaffindicateditwasdifficulttosuctiontheresidentduetothe“veryactivemaggotsintheairway.”Theresidentwasadmittedtoahospitalforbreathingproblems,tracheostomycomplications,andmaggotinfestation.Thereisnodocumentationindicatingstaffwasdisciplinedforneglectingtheresidentsoseverely.

Overview

MichiganProtectionandAdvocacyService,Inc.(MPAS)istheindependent,private,nonprofitorganizationdesignatedbythegovernorofMichigantoimplementthefederallyauthorizedprotectionandadvocacysystems.MPASadvocatesandprotectsthelegalrightsofpeoplewithdisabilitiesinMichiganthroughservicesincludinginformationandreferral,short-termassistance,selectedindividualandlegalrepresentation,systemicadvocacy,monitoring,andtraining.Aspartofourrole,MPASmonitorsfacilitieswhereindividualswithdisabilitiesresideandalsoreceivesvariousreportsfromstatedepartmentsregardingtheuseofrestraintandseclusion,andsurveyinspectionresultsofnursingfacilities.

Statenursinghomesurveyinspections,conductedbythestate’sDepartmentofLicensingandRegulatoryAffairs(LARA)occuronayearlybasisorinresponsetoacomplaint.Duringsitevisits,residentfilesarechosenrandomlyandreviewedforcomplianceonanumberoflevels.Inaddition,otherareasarereviewedsuchasthemaintenanceandcleanlinessofthephysicalplant.

Insomecaseswhenviolationsarefound,thefacilitiesarefinedandforcedtodevelopandimplementplansofcorrections.Insomecasesstaffhasbeendisciplinedortheiremploymenthasbeenterminated.Inothercases,allegationsofabuseorneglecthavebeenreportedtolawenforcementauthoritiesandsomenursinghomeshavebeenclosed.

Additionally,facilitieswithapatternofmultipleseriousviolationsoveranextendedperiodoftimemaybeplacedonthe“SpecialFocusFacilityList”.Placementonthislistpromptsafacilitytobemonitoredtwotimesperyearanditisexpectedthatwithin18-24monthsafterbeingputonthelist,therewillbeoneofthreepossibleoutcomes:

Improvementandgraduationfromthelist,

TerminationfromMedicareadmissionsfornewresidents,or

Extensionoftimetocontinueimprovementbaseduponpromisingprogress.

MPASregularlyreceivesandreviewsLARAnursinghomeinspectionsurveysinordertoidentifyabuse,neglectandotherconcernswhereMPASadvocacymaybeappropriate.Whensurveysshowthatamorein-depthinvestigationisnecessary,MPASwillinvokeitsfederallymandatedaccessauthoritytoobtainfacilityrecords.

Inresponsetoidentifiedconcerns,MPASbeganfilingindividualcomplaintswiththeBureauofHealthProfessions(BHP)againsttheprofessionallicensesofthefacilitystaff,includingnursesandcertifiednursingassistants.Theprocessofgettingthestatetoinvestigatecomplaintsagainstindividuallicensesiscumbersomeandslowatbest.Meanwhile,thelicensedindividualscontinuetoworkandprovidecarewhiletheBureauofHealthProfessionsinvestigatestheallegationwhichmaytakeyearstocompleteandmaynotresultinanyfinding.

MPAShasfoundthatinsomecases,unlessthereisacriminalconviction,whenemploymentisterminatedforabuseorneglectoftheresidents,thereisnothingtostopthemfromworkingatanothersimilarfacility.

MPASiscallingforlocal,state,andfederalactiontobetakentoaddressthesystemicfailureswithinMichigan’snursinghomeindustryandtheregulatorystructuresthathavefailedtoassurequalitynursingcareforpeopleinneed.Michiganresidentsdeservetoreceivethebestcareandtheirfamiliesshouldhavepeaceofmindtheyarebeingtakencareofwhentheycannotdoitthemselves.

Thegoalofthisreportistodrawattentiontothisveryimportantissueandworktowardcorrectingthesystemicdeficienciesinstaffing,monitoring,andreportingthatmaycontributetoabusiveandneglectfulconditions.Thecasesusedinthisreportareexamplesandunfortunatelytheyarenotisolatedincidentsoruniquetoanyparticularnursinghome.Rather,theyareindicativeofastatewidefailuretoprovidequalitynursingcareatalltimesandprotectnursingfacilityresidentsfromharm–withoutexception.

CaseExamples

WhatfollowsareadditionalexamplesofabusiveandneglectfulcareidentifiedbyMPAS,gatheredfrom“NursingHomeSurveys”conductedandreportedbyMichiganLicensingandRegulatoryAffairs(LARA).Theterm“Survey”istheterminologyusedinthefederallawsthatallowstheCentersforMedicareandMedicaidServices(CMS)tomonitorandlicenseNursingHomes.Theexampleslistedarejustafewofthemanycaseswhereresidentsare“lucky”enoughtobeselectedduringanonsiteinspectionandtheirfilesarereviewed.

Itisnottheintentofthisreporttosuggestthatallnursingstaffandfacilitiesprovidepoorservices.Undeniably,therearethousandsofnursinghomeresidentswhoreceivethecaretheyneedanddeserve.MPAS,however,viewsevenonecaseofabuseandneglectastoomanyandcannotbetolerated.

CalhounCounty

InasurveydatedOctober2010:Aresidentwasadministeredthewrongmedications,whichresultedintheresidentfallingdownontwooccasions.Staffdidnotintervenetoprotecttheresidentfromfallingevenafterdiscoveringtheresidenthadreceivedthewrongmedications.Theresidentwastreatedatanemergencyroomforbruising,swelling,andlacerationstotheirheadasaresultofthefalls.Thereisnodocumentationindicatingnursingstaffwasdisciplinedforadministeringthewrongmedicationsorforlackofinterventionaftertheresidenthadfallen.

InasurveydatedAugust2011:Aresidentofanursinghomerefusedtoshower.Theresident’srefusaltoshowerwasreportedtothefacility’sdirectorofnursing.Thedirectorofnursingpushedtheresidentdownthehallwaytotheshowerroominawheelchair.Theresidentwasnotedasbeingnaked,screamingandkickingwhilebeingpusheddownthehallwayagainsttheirwill.Theincidentwasnotreportedtoanyonebecausethenursingfacilityadministratordidnotconsidertheincidentabusive.Thedirectorofnursingwassuspendedandfinallyterminatedforunprofessionalconduct.Itisunknownwhetherthedisciplinedemployeeisworkingelsewherewithinthenursinghomeindustry.

InasurveydatedOctober2010:Aresident’smedicationtotreatheartfailurewasdiscontinuedbynursingfacilitystaffwithoutaphysician’sordertodoso.Theresidentmissedatotalof44dosesofthemedicationovera22-dayperiod.Theresidentexperiencedincreasedshortnessofbreathandgainedsevenpoundsintwoweeks.Theresidentdiedafewmonthslaterfromrespiratorydistressandheartfailure.Thereisnodocumentationindicatingnursinghomestaffwasdisciplinedfordiscontinuingtheresident’smedicationwithoutaphysician’sorder.

CrawfordCounty

InasurveydatedFebruary2010:Aresidentwalkedoutofanursinghomethroughthefrontlobbydoor.Facilitystaffdidnotnoticetheresidenthadelopedfromthefacility.Theresidentwasfoundlyingontheblacktopintheparkinglot.Thetemperaturewas32degreesFahrenheitandtheresidentwasonlywearingpajamapants,asweateroverat-shirtandslippers.Theresidentcomplainedofpainintheirrighthipandhadascrapedelbow.Theresidentwassenttothehospitalandtreatedforafracturedpelvis.Thereisnodocumentationtoindicatewhetherstaffwasdisciplined.

GeneseeCounty

InasurveydatedJune2011:Aresidentrequiredsupervisionandthephysicalassistanceofonestaffmemberwhileeating.Theresidentwaseatingwithoutassistancefromstaffandbeganchoking.NursinghomestaffassessedtheresidentandincorrectlyperformedtheHeimlichmaneuverbyhittingthemonthebackseveraltimes.Staffalsoconductedablindfingersweep(attempttoremovetheforeignbodywiththefinger).Theresidentwastransportedtoahospitalwherea4oz.pieceofchickenwasremovedfromtheresident’sairway.Theresidentdiedjustanhourafterthechokingincidentbegan.Nursingfacilitystaffwasterminatedasaresultofthisincident.Itisunknownwhetherthedisciplinedemployeeisworkingelsewherewithinthenursinghomeindustry.

HuronCounty

InasurveydatedMarch2010:NursingfacilitystaffadministeredfivedosesofRoxanol(morphine)toaresidentoveraninehourperiod.Onestaffmemberadministeredthefirstthreedoses,eventhoughthedosewas“muchhigherthanshetypicallysawordered.”StafffailedtoprovidemonitoringorassessmentfollowingeachdoseofRoxanoladministeredtotheresident.AftertheresidentreceivedtheseconddoseofRoxanol,staffnotedtheywereunabletofindabloodpressureandtheresident’soxygensaturationlevelwasabnormallylow.Lessthanfourhoursafterthefifthandfinaldose,theresidentwasfounddead.Thisresident’sdeathwasnotreportedtothestateagency.ThereisnodocumentationtoindicatenursingfacilitystaffwasdisciplinedforadministeringhighdosesofRoxanoltoaresidenteventhoughthedosewasknowntobetoohigh. Thereis

also no documentation to indicate staff was disciplined for neglecting this resident(failingtomonitororassessthem)afterhighdosesofRoxanolwasadministered.

InasurveydatedMarch2010(thisisaseparateincidentfromtheonenotedabove):AresidentreceivedfivetimestheordereddoseofRoxanol(morphine)inoneday.Twohoursafterthelastdosewasadministered,theresident’sphysicianwasnotifiedoftheoverdose.Thephysicianorderedincreasedmonitoringofthisresident.NursingfacilitystaffcouldnotprovideanyevidencetheresidentreceivedanytreatmentsorassessmentsfollowingtheRoxanoloverdose.SevenhoursafterthelastdoseofRoxanolwasadministered,theresidentcouldnotbearoused,wasblueincolor,andwasinsevererespiratorydistress.Theresidentwastreatedatahospitalforamorphineoverdoseandwasadmittedforobservation,monitoring,andassessment.Thenursingfacilitydidnotreportthisincidenttothestateagency.Thereisnodocumentationindicatingstaffwasdisciplinedforadministeringanoverdoseoftheresident’smedication.

JacksonCounty

InasurveydatedMay2010:Aresidentwithahistoryofbloodclotsforwhichtheresidentwasreceivinganticoagulationmedicationbeganexperiencing nosebleeds.Nursingstaffdidnotnotifythephysicianasrequiredinaccordancewiththeresident’sindividualizedplanofcareandthefacility’sprotocolforanticoagulationtherapy.Oncethe physicianwasnotified,thephysicianorderedtestingtobedoneimmediately.Theresidentwastakentotheemergencyroomfortreatmentofalife-threateningriskofhemorrhageasevidencedby“paniclevel”laboratorytestresults related toanticoagulationtherapy.Thenursingstaffmemberwhofailedtonotifythephysicianwasdisciplinedwithatemporarysuspensionandcounselingwasprovided.

InasurveydatedSeptember2011:Aresidentwastransferredbyacertifiednursingassistant(CNA)whodidnotuseagaitbelt.Theresident’s “Patient InformationWorksheet”revealedtheywereidentifiedasrequiringatwopersontransferwithagaitbelt.Asaresultoftheimpropertransfer,theresidentsustainedbruisingfromthemid-rightbreasttochestwall280cminlengthandfromthebottomofthesternumtomid-sternum90cm.Bruisingwasalsonotedfromtheleftbreasttotherearofchestwallundertheleftarm190cmx80cm.TheCNAwhotransferredtheresidentliedaboutusingagaitbeltduringaninternalinvestigationatthefacility.ThisCNAwassuspended.

KalamazooCounty

InasurveydatedJune2011:Nursingfacilitystaffusedphysicalforceto“pryapart”theseverelycontractedlegsofaresidentduringacatheterizationprocedure.Thephysicalforceusedbystaffcausedmuscleandligamentinjury,bruisingandpaintotheresident’slegandgroinarea.Facilitystaffwasnotdisciplinedfortheinjuriessustainedbythisresident.

InasurveydatedMarch2011:Twonursingfacilitystafffailedtofollowaresident’splanofcare,whichincludednotinvadingtheresident’spersonalspaceandalsotellingtheresidentthatstaffare‘heretokeepyousafe’.Thefacilitystaffphysicallyrestrainedtheresident’sarmsandcuttheresident’sfingernails,againsttheresident’swill.Theresidentsustainedbruisingtotheirarmsandhands,pain,emotionaldistressandfear.Thetwostaffinvolvedwerein-servicedandsuspendedasaresultofthisincident.

KentCounty

InasurveydatedOctober2008:Aresidentexperiencedsuddenrespiratorydistresswhileeatingbreakfast.Accordingtothesurvey,theresidentwas“unabletotalk”and“wasunabletocough”and“soundedasiftheresidentwaschoking”andhavingcopiousoralsecretions.Nursingfacilitystaffwasunabletolocatesuctioningequipmentthatwaseitherfunctioningproperlyorthathadallofthenecessaryequipment.Oncestaffwasabletosuctiontheresident,thesuctioningdidnotrelievetheresidentofdistress.EmergencyMedicalServices(EMS)wasnotcontactedinatimelymannerandwasnotprovidedwithaccurateinformationregardingtheresident’srespiratorydistress.Theresidentdiedinanambulanceintheparkinglot2½hoursaftertheonsetofrespiratorydistress.Thefacilitydidnotinvestigatetheincidentanddidnotreporttheincidenttothestateagency.Facilitystaffwasnotdisciplinedforbeingunabletoprovideappropriatecaretoaresidenthavingsuddenrespiratorydistress.

MarquetteCounty

InasurveydatedOctober2011:Aresidentwithaknownhistoryofsubstanceabusereturnedtothenursinghomefromaleaveofabsencearound9:00p.m.on10/11/2011withnotablelethargyandasignificantchangeinbehavior.Thenursingfacilityfailedtoimplementaphysician’sordertoobtainaurinedrugscreeninatimelymannerandfailedtoadheretoprofessionalstandardsofnursingpractice.Thisresidentwasfounddeadintheirbedlessthan7hourslater.TheMichiganStatePoliceareinvolvedininvestigatingthisincident.

MecostaCounty

InasurveydatedFebruary2009: Aresidentwaseatingbreakfastandbegantocough.

Theresidentspitoutsomeoftheirbreakfast,butwasobservedminuteslatercollapsedinachairinthehall,blueincolorandlifeless.Severalnursingfacilitystaffobservedtheresidentchokingonbreakfastalthoughdidnotcall911.OnestaffmemberperformedtheHeimlichmaneuver,butitwasnoteffective.Theresidentdiedasaresultofasphyxiaduetoaspiration. Thereisnodocumentationtoindicatewhetherstaffwasdisciplined.

MidlandCounty

InasurveydatedOctober2010:Aresidentfellduringatransferfromawheelchairtoashowerchair.Nursingfacilitystafftransferredtheresidentwiththewrongliftandwithouttherequirednumberofstafftoassist.Theresidentwastransportedtoahospitalforevaluationafterthefall.Theresidentwasdiagnosedwithaskullfracture,subarachnoidbleed,cerebralcontusionandpneumocephalus.Theresidentdiedthreedayslaterasaresultofthesubarachnoidbleed.Theresident’sfallanddeathwasnotreportedtothestateagency.Thenursinghomestaffthatperformedthetransferwasterminated.Itisunknownwhetherthedisciplinedemployeeisworkingelsewherewithinthenursinghomeindustry.

InasurveydatedFebruary2010:Nursingfacilitystaffwaspushingaresidentinawheelchairwithoutfootpedalstoanotherbuilding.Theresident’swheelchairhitsomethingonthesidewalkandtheresidentfelloutofthewheelchair,landingface-firstonthesidewalk.Theresidentwastransportedtoahospitalwheretreatmentwasprovidedforafaciallaceration,handlacerations,andtwofracturesoftheneck.Theinjuredresidentdiedthreedayslaterasaresultoftheinjuriesincurredfromthefall.Thereisnodocumentationthatstaffreceiveddisciplinefortransportingtheresidentinawheelchairwithoutfootpedals.

MuskegonCounty

InasurveydatedJuly2011:Nursinghomestaffrestrainedaresidenttoawheelchairwithagaitbeltforseveralhours.Therewasnoorderforstafftorestraintheresident.Thegaitbeltwassecuredaroundtheresident’sribcageandthewheelchair.Thebuckleofthegaitbeltwasatthebackofthewheelchairwheretheresidentcouldnotreachit.Theresidentwasunabletostandorremovethegaitbelt.Asaresult,theresidentsustainedseriousbruisingontheirentirechestandribarea.Thisrestraintincidentwasnotreportedtostateauthoritiesandwasnotinvestigated.

OaklandCounty

InasurveydatedOctober2010: AresidentfellwhilebeingtransferredwithaHoyerlift.

Thisnursingfacility’spolicyrequirestwostafftoassistduringtransfers.Stafftransferredtheresidentaloneandwithoutassistance.Theresidentwasadmittedtoahospitalandreceivedtreatmentforribandspinalfracturesasaresultofthefall.Thereisnodocumentationtoindicatethestaffpersonwasdisciplinedforfailuretofollowfacilitypolicy.

InasurveydatedMarch2011:Aresident,whohaddifficultyswallowing,requiredapureeddiet.Itwasalsorecommendedtheresidentreceiveone-to-oneassistancewhileeating.Nursingfacilitystaffprovidedthisresidentwithatrayconsistingofbeefstroganoff,fruitcocktailandbroccolispears.Minutesafterthetraywasserved,theresidentwasfoundonthefloorwithnopulseandnotbreathing.Emergencymedicalservices(EMS)werecontactedandstaffperformedcardio-pulmonaryresuscitation(CPR).WhenEMSarrived,onetechnicianwasunabletointubatetheresidentduetoafour-inchpieceofbroccoliblockingtheresident’sairway.Thepieceofbroccoliwasremovedandtheresidentwasintubated.CPRcontinued,butwaseventuallystoppedandtheresidentwaspronounceddead.Thereisnodocumentationtoindicatethatnursinghomestaffwasdisciplinedforfailingtoprovidetheresidentwithanappropriatetrayorsupervision.

InasurveydatedMay2010:Nursinghomestafffailedtodevelopaplanofcareforaresidentwhowasidentifiedasat-riskforelopingfromthefacility.Theresidentattemptedtoelopefromthefacility,staffintervenedandtheresidentwenttotheirroom.Staffwenttocheckontheresidentlaterthatsameeveningandtheresidentwasnowheretobefound.Theresidenthadelopedfromthefacilitybyjumpingoutoftheirsecondstorybedroomwindow.Theresidentwastransportedtoahospitalwheretheyreceivedtreatmentforafracturedfemur,rightandleftanklefracturesandasternalfracture.Thereisnodocumentationtoindicatewhetherstaffwasdisciplined.

SaginawCounty

InasurveydatedDecember2009:Aresidentelopedfromanursingfacilityandwasobservedsittinginawheelchaironthesideofabusyroad.Theresidentwasobservedgoingintotheroadandcarshadtoslowdownandgoaroundthem.Theresidentwasreturnedtothefacility,andstaffwastoldnottowriteanincidentreportaboutthis.Theresident’sfamilyandphysicianwerenotcontacted.Theresidentwasnotassessedforinjuries.Theincidentwasnotreportedtothestateagency.Thereisnodocumentationindicatingstaffwasdisciplinedforfailingtoreporttheincidentandneglectingtheresidentupontheresident’sreturntothefacility.

ShiawasseeCounty

InasurveydatedJune2010:Aresidentwastransferredimproperlywithamechanicalliftbynursingfacilitystaff.Theresidentslippedandfelloutofthelift.Theresidentfellbackward,hittingtheirheadonthefloorandsustainingalaceration.Theresidentwastransportedtothehospitalwheretheyweretreatedforalargeacutesubduralhematoma,extensivesubarachnoidbleed,andsofttissueinjurytotheskull.Thisresidentdiedfivehourslaterasaresultoftheinjuriesincurredfromthefall.Thefacilitystaffpersonwhoimproperlytransferredtheresidentresignedfromherposition.Itisunknownwhetherthedisciplinedemployeeisworkingelsewherewithinthenursinghomeindustry.

St.JosephCounty

InasurveydatedFebruary2009:Aresidentwasfoundsittingoutsideinthesnowintemperaturesrangingfrom6.8-12.2degreesFahrenheit.Theresidentwasonlywearingflannelpajamas,shoes,andsocks.Thelengthoftimetheresidentwassittinginsnowisunknown.Thenursingfacility’sdirectorofnursinginstructednursingstaffnottosendtheresidenttothehospitalandrather“trytoheattheresidentupin-house.”Theresident’sphysicianwasnotcontactedandnursingstaffdidnottreattheresidentappropriatelyforpossiblehypothermia.Nursingstaffdidnotcommunicatetostaffonthenextshiftoftheresident’scondition.Thereisnodocumentationindicatingstaffweredisciplinedfornotsendingtheresidenttothehospitalforpossiblehypothermia,forfailuretocontacttheresident’sphysician,andforfailingtotreattheresidentappropriatelyforhypothermia.

WashtenawCounty

InasurveydatedJuly2010: Facilitystaffattemptedtoinsertalatexcatheterintoaresidentwithaknownlatexallergy.Theresidenttoldthenursinghomethecatheterwasnotintherightspotbecauseofthepain.Asecondnursinghomestaffassistedwithre-insertingthecatheter.Theresidentwasshortofbreathandcomplainedofpressureinthelowerabdominalarea.Onestaffmemberremovedtheoriginalcatheterandnoteditlookedasifithadcoiledupduringinsertionbecauseitwascurledandkinkedinsomeparts.NursingfacilitystaffdidnotknowiftheFoleycatheterwasalatexcatheter.Thisresidentexperiencedabdominalpain,bloodintheirurineandaroundtheirpenisforsixdaysbeforebeingtakentotheemergencyroom.Duringaprocedureintheemergencyroom,itwasnotedtherewasobvioustraumatotheresident’surethraandthenormalcourseoftheurethraltractcouldnotbefollowedtoallowforpassageofthecatheterintothebladder.Thereisnodocumentationtoindicatewhetherstaffwasdisciplined.

InasurveydatedDecember2009:Anursingfacilityresidentreceiveddialysistreatmentatadialysiscenter.Theresidenthadasurgicalfistula(aport)fordialysistreatment.Nursingfacilitystaffneverassessedtheresident’sfistulasiteanddidnotevenknowthelocationoftheresident’sfistulasite.Nursingfacilitystaffobservedtheresidentsittingin

thedoorwayofthediningareaunresponsiveandsurroundedbyalargepoolofblood.Theresident’sdialysisfistulahadruptured.Nursingfacilitystaffdidnotprovidetheresidentwithcardiopulmonaryresuscitation(CPR)andothernecessaryemergencyremedies,despitetheresidentbeinga“fullcode”status.Theresidentdiedasaresultoftherupturedfistula.Nursingfacilitystaffwasnotdisciplinedforneglectingtheresident’sbasiccareneedsandfornotprovidingCPRwhentheresidentwasdiscovered.

InasurveydatedJuly2011:Nursinghomestaff“dove”ontoaresident’supperchestwhentheresidentbeganswingingtheirarmsatstaff.Thestaffpushedtheresidentintothemattressandplacedtheirhandsaroundtheresident’sneck,chokingtheresident.Asaresult,theresidenthadreddenedareasontheirarmandthecenteroftheirchest.Staffwassuspendedandarrestedforassault.

InasurveydatedJanuary2010:Nursinghomestaffdiscoveredantsonaresidentwhiletheresidentwaslyinginbed.Ants“wereallovertheresident.”Nurse’snotesread,inpart,“Uponenteringroom(staffmembers)hadsheet/gownpulledbackandantsnotedeverywhereonresidentfromlowerbilateralbreastarea/abdomen/groinareaandalsonear/aroundG-tubesite.Residentcleanedantsoffwithsoapandwaterthenturnedoverandantswerealloverthebed(coveringmattress)andalloverresident’sback.Alldressingsremovedandinspectedandnoantsfoundthere...”Antswereobservedinthebuildingbefore,butnotonaresident.Thereisnodocumentationtoindicatestaffwasdisciplined.

WayneCounty

InasurveydatedOctober2010:Nursingfacilitystaffusedalatexglovetorestrainaresident’sprotectivehandmitttotheresident’swrist.Thelatexglovewasfoundtiedtightlyaroundtheresident’swrist,causingapressure-relatedinjury, decreasedcirculation,alargeamountofswelling,deepindentation,andblisters.Adifferentfacilitystaffreceiveddisciplinarywarningsfornotfollowingthroughontheinvestigationregardingtheincidentandreceivedone-to-onecounselingrelatedtodocumentingincidents. Thereisnodocumentationregardingdisciplineforthestaffwhoinappropriatelyrestrainedtheresident.

InasurveydatedSeptember2010:Aresidenthadphysician’sorderstoreceivecontinuousoxygenattwolitersperminutebywayofanasalcannula.Theresidentwasobservedonthreedifferentoccasionswithouttheorderedoxygen.Nursingstaffdeterminedtheresidentdidnotrequireoxygen,sostaffdidnotapplytheoxygenwhentheresidentwasoutsideofthebedroom,despitethephysician’sorderthatstatedotherwise.Thereisnodocumentationindicatingstaffweredisciplinedforfailuretofollowaphysician’sorderforoxygen.

InasurveydatedJune2009:Aresidentofanursingfacilitywasfounddeadonemorningafternotreceivingappropriatediabeticmanagementthedaybefore.Facilitystafffailedtoadministertheresident’sinsulin,monitorbloodglucoselevels,andreview

theresident’sfoodacceptancerecord.Whennursinghomestafffoundtheresidentdeceasedshecalledforassistancefromanurse.Thenursedidnotrespondandshewasobservedsleepingatthenurse’sstation.Facilitystafffalsifiednursingnotesattherequestoftheassistantdirectorofnursing,whowasalsothemotherofthenursefoundsleeping.Thenursefoundsleepingwasnotterminatedforsleepingonduty;rathershewastransferredtoanotherfacilitymanagedbythesamecorporation.Theassistantdirectorofnursingwasdisciplinedfornotfollowingdefinedproceduresalthoughwasnotdisciplinedforfalsifyingdocumentation.

InasurveydatedSeptember2010:Aresidentwithatracheostomywasidentifiedbyfacilitystafftobeat-riskfordevelopingrespiratorydistress.Toensuretheresident’sairwayremainedopen,nursinghomestaffhadtoensureappropriateplacementandcareoftheresident’stracheostomy,theoutertracheostomytube,andtheinnercannula.Staffweretoprovidetheresidentwithtracheostomycareeveryshiftanddeliveroxygenviatracheostomymask.Facilitystaffwerealsotopositiontheresident’sbedatacertainangleandensuretheresidentwasnotlyingflatonthebed.Duringstaffrounds,theresidentwasobservedlyingflat,nothavinganopenairwayandbothtracheostomycannulaswerenotintheresident’strachea.Theresident’soxygenandaircompressorwerealsoturnedoff.Thisresidentwaspronounceddead.Nursingfacilitystaffdidnotfollowtheresident’soxygenordersanddidnotdocumentanytracheostomycareasbeingprovidedtotheresidentonthedaytheydied.Thereisnodocumentationindicatingstaffweredisciplinedforneglectingthisresident.

InasurveydatedJune2010:Aresidentwasrequiredtobetransferredbymechanicalliftwithassistancebytwostaffmembers.Theresidentwastransferredwithamechanicalliftbyonestaffmember.Duringthetransfer,thestaffmembermaneuveredtheliftandtheslingandtheresidentscreamedout.Thestaffmemberthoughttheresident’slegstrucktheheadboardofthebed.Theresidentwastransferredtothehospitalandreceivedtreatmentforafemoralfracture.Thestaffmemberwhoimproperlytransferredtheresidentwasnotdisciplined.

InasurveydatedMay2010:Aresident’scareplanrequiredstaffto“turnandre-positionresidenteverytwohours”and“keepresident’slinenfreeofwrinkles.”Oneeveningtheresident’sfamilymemberpositionedaplasticheatingpadundertheresident’sbackwhiletheywerelyinginbed.Anhourandahalfaftertheheatingpadwaspositionedundertheresident,staffobservedtheresidentsleepinganddidnotassesstheresident,intervene,orre-positionthemasrequired.Nursinghomestaffdidnotentertheresident’sroomagainuntilalmostfivehourslater.Staffdidnotprovidetheresidentwithanynecessarycareorsupervisiontoensuretheirneedsweremetortopreventinjury.Asaresult,thisresidentsustainedmultiplefirstandsecond-degreeburnscoveringaseveninchbyten-inchareaofthebackafterlyingonthehearingpadforseveralhours.Thetwostaffmemberswhofailedtoprovidecaretothisresidentarenolongeremployedatthisfacility.Itisunknownwhetherthedisciplinedemployeeisworkingelsewherewithinthenursinghomeindustry.

InasurveydatedJune2010:Aresidentelopedfromanursingfacilitywithnoidentificationbraceletandwearingonlyasweatshirt,pajamapants,socks,andslippers.Staffwereunawaretheresidentwasmissinguntiltheresident’sfiancéinformedthem.Theresidentwasmissingfromthefacilityforovertwo-anda-halfhours.Theresidentwalkedoutofthefacilityandspokewithtwostaffmemberswhodidnotquestiontheresidentaboutwhytheywereoutsideandwhytheywereunattended.Thisresidentwasdiscoveredsittingontheporchofahouselocatedtwoblocksfromthenursingfacility.Thereisnodocumentationtoindicatestaffwasdisciplined.

InasurveydatedJune2009:Nursingfacilitystaff indicated a resident, who wasdependentonaventilator,keptpullingthemselvesofftheventilatorandstaffcouldnot“geteverythingdone.” Staffadmittedtotyingoneoftheresident’sarmswithagownandtheotherwithasheet,extendingtheresident’sarmsouttothesides.Therewasnoorderorconsentfortheuseofwristrestraintsortyingtheresidenttothebed.Itwasestimatedtheresidentwastiedtothebedforapproximatelythreehours.Duringthattime,the residenthadnowaytocallforassistanceandwas placed at high risk forasphyxiation.Thereisnodocumentationthatstaffweredisciplinedfortyingtheresidenttothebedwithoutanyorderorconsenttouserestraints.

InasurveydatedJune2009:Aresidentnotedtohavepoorsafetyawarenesspulledouttheirtracheostomythreetimesoveratwomonthperiod.Thethirdtimetheresidentpulledoutthetracheostomy,nursinghomestafffoundtheresidentintheirroominrespiratorydistress.Staffattemptedtore-enterthetrachwithoutsuccessand911wascalled.Theresidentwastakentotheemergencyroomandpronounceddeadduetolackofoxygen.Facilitystaffdidnotcreateacareplanforsupervisionorhandmittrestraintstopreventtheresidentfromremovingtheirtracheostomy.Thereisnodocumentationindicatingstaffwasdisciplined.

Recommendations

AllnursinghomeresidentsinMichiganmustbeassuredasafeandhealthyenvironmentinwhichtoreceivenursingcare.Inaddition,allresidentsofnursinghomesmustbeinneedofnursingcare.Thestateshouldensurethatallindividualswhoneednursingcarewillbeassuredofreceivingqualitynursingcarebycertified/licensedandcompetentstaff,inhighlyregulatedfacilitiesinMichigan.

MPASproposesthefollowingrecommendationstostrengthenthesystemandincreaseaccountabilityofallresponsibleparties:

PasspendingStatelegislationtorequirebackgroundchecksonallemployeesofnursinghomesandprohibitthehiringofanyindividualwhohashadalicensingcomplaintinvolvingabuseorneglectvalidatedfollowinginvestigationbyastateagency.

PassSenateBill462,whichexpandsthereportingobligationtoreportabuse,neglectormistreatmenttonursinghomeadministrator/directorofnursingandthestate’sDepartmentofLicensingandRegulatoryAffairs(LARA).

Allprofessionalpersonnelwhoaremandatedreportersofabuseorneglectandwhohavefailedtoreport,asidentifiedthroughthenursinghomesurveyinspections,musthavetheirprofessionallicenserevokedandcriminalchargesmustbefiledagainstthem.

Increasesanctionpenaltiesandensurefinesarecollected.

ReviewnursinghomesforfraudulentbillingofMedicareandMedicaidforservicesrenderedwhenithasbeendetermined,throughtheinspectionreports,thatresidentcarehasbeenneglected.

Nursinghomeswithaconsistentratingbelow5shouldnotbeallowedtocontinueoperatinginMichigan.Michiganneedstore-evaluatethesuitabilityandeffectivenessofthe“5Star”ratingsystemtoassurepropercareandtreatmentofnursinghomeresidents.Anythinglessthana5StarshouldnotbeacceptableinMichigan.

Operatorsandadministratorsofnursinghomeswhofailtoprotectresidentsfromabuseandneglectshouldbecriminallychargedandtheirlicensetooperateshouldbeimmediatelyrevoked.OperatorsofsuchfacilitiesshouldnotbeallowedtoreorganizeoroperatewithintheStateofMichigan.

MCL750.145m,theVulnerableAdultAbuseAct,shouldbeamendedtomakeitacrimetocausesomeonetoexperiencesignificantpain.

Increasethenumberofnursinghomeombudsmen.Currentlyeachombudsmanisresponsibleforaverylargenumberoffacilities.

Increasenursinghomediversionanddischargeplanninginitiatives.ThefundingfortheMiChoicewaiverprogramisskewedinfavoroftransitioningresidentsoutofanursinghome,insteadofkeepingthemoutinthefirstplace.Thisdisparityshouldbeeliminatedandpeopleshouldreceivetheservicestheyneedintheircommunitiesinsteadofenteringanursingfacility.Otheradvocacyorganizations(e.g.CentersforIndependentLiving)shouldbeactiveinallareasofthestateinworkingtogetpeopleoutofnursinghomes.

Amendthecurrentreceivershipstatute.Presently,thelawallowsthestateorresidentstopetitionacourttoplaceanursinghomeinreceivership;however,thisisonlyallowedwhenthestatehasgonethroughmostoftheadministrativeprocess.Residents,and/orMPAS,and/ortheStateLong-termCareOmbudsmanshouldbeallowedtopetitionthecourtdirectlyforreceivershipwhenongoinglackofcare,abuse,orneglecthasbeendemonstrated.

Amendoutdatedminimumstaffingrequirementsfornursinghomessostaffinglevelsaresetatrealisticlevelsneededtodeliverqualitycaretoallnursingfacilityresidents.