National Quality Forum: Serious Reportable Events; Formerly "Never Events"

NQF: Serious Reportable Events: Preventing adverse events in healthcare is central to NQF's patient safety efforts. To ensure that all patients are protected from injury while receiving care, NQF has developed and endorsed a set of Serious Reportable Events (SREs). This set is a compilation of serious, largely preventable, and harmful clinical events, designed to help the healthcare field assess, measure, and report performance in providing safe care

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Elderly woman claims she was sexually abused at nursing home

An elderly nursing home patient is staying in a New Albany nursing home after family transferred her for her own safety. The elderly woman claims she was sexually assaulted at Kindred Transitional Care and Rehabilitation Center in Corydon, Ind. .

"Where this goes is unclear. I will say our victim is reported to have early onset dementia which makes things a little more challenging from the law enforcement side," Otto Schalk, Harrison County Prosecutor, said.
Serious allegations of elder sexual abuse were made by an 84-year-old woman. Schalk says despite her illness it's not something detectives take lightly. Corydon's Police Chief, James Kendall, and Indiana State troopers have Kindred Transitional Care in Corydon under a microscope.
The elderly woman said she was sexually abused in the nursing care facility at 150 Beechmont Drive, Monday of last week.

Elderly woman claims she was sexually abused at Corydon nursing home | WHAS11.com Louisville:

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Nursing Supervisor Found Guilty Of Attempted Neglect

An Ohio nursing supervisor accused of failing to provide help for an injured resident of the Monroe County Care Center was found guilty on one count of attempted patient neglect Tuesday.
Kathy Schwaben pleaded no contest to the charge. A judge sentenced her to a suspended 10-day jail sentence and imposed fines and court costs. She will remain on required probation for one year.
Agents with the attorney general's health care fraud section began investigating Schwaben in August 2011.
Investigators said an 81-year-old patient was thrown from her wheelchair and sustained several fractures while riding in an MCCC van when its driver swerved to avoid hitting a deer.
The victim did not receive immediate medical treatment because Schwaben failed to perform a physical assessment of the woman after the crash, investigators said.
The investigation also showed that the woman was not properly secured in the seat of her wheelchair with a lap or shoulder restraint. Instead, an employee of the nursing facility used a bungee cord as a restraint by placing it across the front of her wheelchair’s arm rests.

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Recognizing Elder Abuse Awareness Day

On May 31, 2012, the Centers for Medicare & Medicaid Services (CMS) announced an initiative to reduce the rampant misuse and overuse of antipsychotic drugs in nursing home facilities. The Center for Medicare Advocacy has been working to educate policy makers, advocates, and the public about the misuse of antipsychotic drugs for many years, and is part of an ad hoc coalition of advocates working with CMS and Congress to address the problem that both harms nursing home residents and costs the Medicare program billions of dollars.
CMS's press release announcing the "Partnership to Improve Dementia Care" describes several steps that CMS is taking:

• Enhanced training: CMS has developed "Hand in Hand," a training series for nursing homes that emphasizes person-centered care, prevention of nursing home abuse, and high-quality care for residents. CMS is also providing training focused on behavioral health to state and federal surveyors;
• Increased transparency: CMS is making data on each nursing home's antipsychotic drug use available on Nursing Home Compare starting in July of this year, and will update the data;
• Alternatives to antipsychotic medication: CMS is emphasizing non-pharmacological alternatives for nursing home residents, including potential approaches such as consistent staff assignments, increased exercise or time outdoors, monitoring and managing acute and chronic pain, and planning individualized activities.

At the May 31, 2012 press briefing announcing the initiative, Shari M. Ling, M.D., CMS's Deputy Chief Medical Officer, identified additional CMS strategies – raising public awareness, strengthening regulatory oversight, and research. Dr. Ling said that residents' advocates working on the issue of antipsychotic drugs for many years had brought the issue to the forefront of public attention. She said, "We would not be here today without them."
Antipsychotic Drug Deficiencies Are Cited, But Enforcement Is Timid
Speaking earlier this month at a symposium on dementia care without drugs, sponsored by California Advocates for Nursing Home Reform (CANHR), Jonathan Evans, M.D., a geriatrician and president-elect of the American Medical Directors Association, described the CMS plan as reasonable but primarily “‘an effort to try to educate people rather than to regulate.’” CANHR attorney Tony Chicotel agreed with the need for increased enforcement. The Center for Medicare Advocacy agrees with their concerns.
Since the Nursing Home Reform Law (enacted in 1987) was implemented in October 1990, federal law and its implementing regulations and guidance have contained strong restrictions on the use of antipsychotic drugs.  Two survey and enforcement issues, however, undercut the law's effectiveness.

1. "Level of Harm" Coding Assigns a Value to Deficiencies that is Too Low Either to Provide a Meaningful Sanction for Poor Care or to Lead to Better Facility Practices.

Although some drug deficiencies are cited each year, their significance is understated and undercoded. The federal enforcement system assigns a scope and severity level to each deficiency that is cited, using a federal scope and severity grid. The grid was published in 1994 as part of the final enforcement regulations.  There are four levels of severity. Two levels indicate no harm (substantial compliance and no harm) and two indicate harm (harm and immediate jeopardy). Generally, when states cite deficiencies at a no-harm level, no financial penalty is imposed.
State survey agencies typically cite antipsychotic drug deficiencies at the no-harm level. In fiscal year 2012, 1,213 unnecessary drug deficiencies, 42 C.F.R. §483.25(l), (F329), were cited nationwide. (F329 is the tag where antipsychotic drugs are cited.) However,

• 1185 (98%) nationwide were cited at a no-harm level;
• Only 13 deficiencies nationwide (0.01%) were cited at a harm level; and
• Only 12 deficiencies nationwide (0.01%) were cited at the highest level of harm, immediate jeopardy.

As a consequence of the no-harm, no-penalty practice, FY2012 data show that most facilities cited with unnecessary drug deficiencies are unlikely to have had any financial penalty imposed.

2. The Financial Remedies that Have Been Imposed Are Trivial, In Light of the Seriousness of the Harm that Residents Suffered.

Recognizing Elder Abuse Awareness Day: Working Together to Curb Misuse of Powerful Antipsychotic Drugs in Nursing Homes || CMA

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Project to reduce antipsychotic use in nursing homes loses federal funding

Kay Lazar, a writer with the Boston Globe Staff today posted this article about the proposed program to reduce the overuse of physchotic drugs in Massachusetts Nursing Homes:

"Massachusetts nursing homes, which recently pledged to lower their rate of antipsychotic use by 15 percent this year, found out Friday that they will not be receiving a coveted federal grant that would have helped fund the initiative to drive down inappropriate use of the powerful sedatives."
Project to reduce antipsychotic use in nursing homes loses bid for federal grant - Boston Medical News - White Coat Notes - Boston.com

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Presidential Proclamation -- World Elder Abuse Awareness Day, 2012 | The White House

Every American deserves the chance to live out the full measure of their days in health and security. Yet, every year, millions of older Americans are denied that most basic opportunity due to abuse, neglect, or exploitation. On World Elder Abuse Awareness Day, we call attention to this global public health issue, and we rededicate ourselves to providing our elders the care and protection they deserve.

Victims of elder abuse are parents and grandparents, neighbors and friends. Elder abuse cuts across race, gender, culture, and circumstance, and whether physical, emotional, or financial, it takes an unacceptable toll on individuals and families across our Nation. Seniors who experience abuse or neglect face a heightened risk of health complications and premature death, while financial exploitation can rob men and women of the security they have built over a lifetime. Tragically, many older Americans suffer in silence, burdened by fear, shame, or impairments that prevent them from speaking out about abuse.

We owe it to our seniors to expose elder abuse wherever we find it and take action to bring it to an end. Two years ago, I was proud to sign the Elder Justice Act, which was included in the Affordable Care Act, and marked a major step forward in the fight against elder abuse, neglect, and exploitation. With the Department of Health and Human Services, we are partnering with State and local authorities to ensure seniors can live their lives with dignity and independence. With the Consumer Financial Protection Bureau, we are working to empower older Americans with tools and information to navigate safely through financial challenges. And with the Department of Justice, we are protecting older Americans by prosecuting those who would target and exploit them.

Every day, State and local agencies, protective services professionals, law enforcement officers, private and non profit organizations, and leaders throughout our communities help protect older Americans from abuse and provide care to those who have already been affected. Together, all of us can play a role in addressing this public health crisis that puts millions at risk. Today, let us keep faith with a generation of Americans by speaking out against elder abuse, advancing justice for victims, and building a Nation that preserves and protects the well being of all who call it home.

NOW, THEREFORE, I, BARACK OBAMA, President of the United States of America, by virtue of the authority vested in me by the Constitution and the laws of the United States, do hereby proclaim June 15, 2012, as World Elder Abuse Awareness Day. I call upon all Americans to observe this day by learning the signs of elder abuse, neglect, and exploitation, and by raising awareness about this public health issue.

IN WITNESS WHEREOF, I have hereunto set my hand this fourteenth day of June, in the year of our Lord two thousand twelve, and of the Independence of the United States of America the two hundred and thirty-sixth.
Presidential Proclamation -- World Elder Abuse Awareness Day, 2012 | The White House

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Celebrate World Elder Abuse Awareness Day!

On World Elder Abuse Awareness Day, individuals and organizations from across the world are urged to raise awareness of the various types of abuse to which older individuals are subjected. This year, take a stand in the fight against elder abuse and take a stand for dignity and respect of our elders.
To support the ongoing work that you’re doing to protect the rights of older people, the National Center on Elder Abuse (NCEA) has made available a virtual ‘toolkit’ that includes creative ways your state and local communities can get involved in raising awareness of this issue, as well as support materials such as factsheets that can be handed out during your World Day activity. These materials are available at:
The National Consumer Voice for Quality Long-Term Care :: Celebrate World Elder Abuse Awareness Day!

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Texas nurse aide bites Alzheimer's patient's

Then, in a moment of pointed retaliation, the witness “unequivocally testified” that the nurse aide bent over and bit the resident on the forehead, court documents say.
A medical assessment of the resident determined that she had a bite mark with two open skin wounds on her forehead.
The nurse aide said she didn’t bite the woman and that she fainted from the pain of being bitten. She argued that it was possible her teeth hit the resident as she raised her head and tried to stand up.

Read more here: http://blogs.star-telegram.com/investigations/2012/05/arm-to-the-teeth-texas-nurse-aide-bit-on-arm-chomps-alzheimers-patients-head.html#storylink=cpy

Arm to the teeth: Texas nurse aide bit on arm chomps Alzheimer's patient's head - Watchdog Bytes

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Massachusetts cites 3 hospitals for denial of care of patients

Health officials cited three Massachusetts hospitals in the past six months for wrongly sending away patients from their emergency rooms, in one case resulting in the death of a patient while en route to another facility.

In that episode, caregivers at Charlton Memorial Hospital in Fall River failed to provide needed medical treatment before transferring the patient, who was unstable and in respiratory distress, state investigators concluded.

In a case at St. Vincent Hospital in Worcester, an on-call surgeon refused to come in late at night to perform an emergency operation on a patient with flesh-eating bacteria, investigators found. The patient was transferred to another hospital, and the surgeon no longer operates on patients at St. Vincent, hospital officials said.

Hospitals that break federal rules ensuring public access to emergency services can face especially tough sanctions. Flagrant or repeat violators risk losing their right to treat Medicare and Medicaid patients, which can cost a hospital millions of dollars.

Massachusetts cites 3 hospitals for inappropriate care of patients in emergency rooms

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