As the COVID-19 pandemic continues to rage, nursing home residents are among the hardest hit demographic and make up a large portion of the fatalities nationwide. Though the virus is undoubtedly deadly, especially for elderly individuals and those with compromised immunity, the concentration of deaths in nursing homes is concerning. Adding to that concern is the fact nursing homes are currently permitted to self-inspect as a result of the pandemic. The lack of oversight presents numerous issues we’ll explore more.

Independent Inspections Suspended

At the outset of the pandemic, the Centers for Medicare and Medicaid Services (CMMS) decided to temporarily stop regular inspections at over 15,300 nursing home facilities nationwide to focus instead on the coronavirus threat. Instead, routine inspections were developed and implemented as a way to safeguard the residents. Unfortunately, when the government halted its own inspections, it authorized nursing home facilities to self-inspect.

https://www.californiaelderabuselawyer-blog.com/wp-content/uploads/sites/132/2020/06/20.05.25-300x300.jpgWhen COVID-19 began to spread, it was a largely unknown foe. Hospitals, doctors, pharmacies, nursing homes, and long-term care facilities were all struggling to find ways to stop the spread, protect patients and employees alike, and understand more about the virus. Now, lobbyists for California’s healthcare providers have asked Governor Newsom to use emergency powers and grant them civil and criminal immunity for their handling of the pandemic. This raises a number of interesting points and issues as it relates to transparency at California nursing homes and concerns of abuse or neglect during the pandemic.

Immunity Request

Not only are hospitals, doctors, nurses, and healthcare plans asking for immunity, California Assisted Living Association and LeadingAge California have joined in the request for an Executive Order to make facilities, plans, doctors, and healthcare employees immune from administrative sanction, criminal liability, or “civil liability or claim for any injury, death, or loss” stemming from care provided during the state of emergency. The protection from liability, however, will “not excuse willful misconduct.”

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Nursing homes have been a hotbed for the spread of coronavirus during the current pandemic, putting not only elderly residents but employees at these facilities in danger as well. In California, interim regulations have been put in place granting these employees the right to be protected at work if their job exposes them to Covid-19 or other airborne infectious diseases. Here is an overview of the current rights of protection for employees in California’s skilled nursing and long-term care facilities (Facilities).

Cal/OSHA Requirements

Currently, California’s Division of Occupational Safety and Health (better known as Cal/OSHA) protects employees by setting and enforcing standards to keep workers safe on the job. Under the Aerosol Transmissible Diseases (ATD) standard, requirements are set to protect employees from diseases, including Covid-19, transmitted by aerosols. The ATD standard applies to Facilities. At these Facilities, the requirements for employee protection vary depending on whether the employer does or does not transfer suspected and confirmed Covid-19 positive patients to hospitals for airborne infection isolation.

COVID-19, also known as the Coronavirus, has put a stop to the regular structure of our lives. We no longer are able to move about freely and often find ourselves having not spoken to another person for hours at a time. This isolation that has been imposed upon us is what our elderly loved ones feel on a daily basis living in their homes as they age. One way we have all tried to combat this symptom of aging is to place our elderly loved ones into a nursing home. Often times this is out of necessity due to medical concerns, but it also allows for them to have human interaction on a daily basis.

Unfortunately, with COVID-19 spreading throughout our world, we have had to place great restrictions on nursing home visitations. Therefore, while so many of us would go visit our loved ones at their nursing homes on a daily or weekly basis to ensure their treatment and medical concerns were being met, we now are literally locked out of their care. In addition, the nursing homes are experiencing a shortage of workers due to illness and fatigue leaving us to wonder if our loved ones are being properly cared for. Understaffing is a growing problem in the United States and has been for a long time. With the new novel Coronavirus, the rate of understaffing is at an all-time high.

While we understand the need for the lockdown in the facilities to try to ensure the virus does not enter these facilities where many patients have compromised immune systems, the distance is hard for all involved. There are some things that you can still do to see your elderly loved one and ensure their proper care is continuing.

Village Square Healthcare Center, a nursing home located in San Marcos, California, received 29 citations for health and safety deficiencies in its most recent inspection, on February 14, 2019. According to Centers for Medicare and Medicaid Services records accessed on February 26, 2020, that figure numbers more than twice the statewide average of 12.8 citations, and more than three times the U.S. average of 8.0. A for-profit corporation owned by GC Holding Company LLC., Highland Springs Care Center is a Medicare and Medicaid participant with 118 certified beds and an average of 117.8 residents at the facility per day. The deficiencies described in the February 2019 citations include the following:

  1. The nursing home did not ensure residents were adequately protected from accidents. Federal code requires nursing homes to maintain a resident environment free of accident hazards and with adequate supervision to prevent accidents. An inspection found that Village Square Healthcare Center did not provide such in two capacities. According to this citation, an inspector observed water temperatures in resident bathroom sinks that exceeded safe levels. The inspector separately observed that a paraplegic resident was not provided with adaptive equipment to call facility staff. The resident stated in an interview that when he calls the facility’s main number using Alexa and his computer, these calls “go to voicemail 50% of the time,” and that he cannot use his soft touch pad call light provided by the facility “because he cannot turn his head enough to use his chin to turn it on.” The resident stated additionally that while he sends text messages to staff when he requires assistance, “in an emergency his only option would be to call 911.” A Certified Nursing Assistant stated in an interview that she did not know how to retrieve voicemails left by the resident, and that the current system for the resident to contact staff “is not safe.”
  1. The nursing home did not implement adequate measures to prevent and control infection. Federal code requires nursing homes to establish and implement infection prevention and control protocols. An inspection determined that Village Square Healthcare Center failed to do so in three capacities. In one, an inspector observed a staff member assisting residents during mealtime without conducting proper hand hygiene between residents. In another, an inspector observed a staffer moving between residents and providing them assistance without conducting proper hand hygiene. In a third, an inspector observed a resident’s urinary catheter drainage bag lying on the facility’s floor, in contravention of policy.

Meadowbrook Health Care Center, a nursing home located in Hemet, California, received 20 citations for health and safety deficiencies in its most recent inspection, on April 20, 2019. According to Centers for Medicare and Medicaid Services records accessed on February 26, 2020, that figure numbers more than the statewide average of 12.8 citations, and more than U.S. average of 8.0. A for-profit corporation owned by Johnre Care Inc., Meadowbrook Health Care Center is a Medicare and Medicaid participant with 64 certified beds and an average of 48.8 residents at the facility per day. The deficiencies described in the April 2019 citations include the following:

  1. The nursing home did not ensure residents were provided with appropriate treatment. Federal code requires nursing homes to provide residents with “appropriate treatment and care according to orders, resident’s preferences and goals.” An inspection found that Meadowbrook Health Care Center did not provide such in an instance when the facility did not “ensure signs and symptoms of bleeding were monitored” per the plan of care of a resident reviewed for side effects of blood thinner medication. The citation states further that the failure to ensure such “may have contributed” to the resident being sent to the emergency room for rectal bleeding. According to the citation, the resident was receiving an anticoagulant agent to prevent blood clots, and the plan of care stated that they should be monitored for signs and symptoms of excessive anticoagulation. A Licensed Vocational Nurse confirmed to state authorities, however, that “there was no documentation” the resident was being monitored such during the month in question, and “should have been monitored” in the period leading up to the resident being sent to the hospital.
  1. The nursing home did not ensure the competencies of food and nutrition services staff. Federal code requires nursing homes to ensure that its staff have “appropriate competencies and skills sets to carry out the functions of the food and nutrition service.” An inspection found that Meadowbrook Health Care Center failed to ensure its supervisory staff failed to carry out their key functions in an instance wherein the facility’s Dietary Manager and Registered Dietitian “did not provide management and oversight to ensure food was stored, prepared, and served according to facility and industry standards,” as well as that equipment and other food service items were maintained in good working condition. The citation goes on to state specifically that an inspector found that the facility’s RD did not ensure residents were provided with “a comparable in nutrient content alternate” when they requested one instead of the “main entrée.” The inspector also found that the RD did not “report the poor condition” of certain food service items, and that cutting boards and cooking pans were not maintained in good condition. The citation states that these deficiencies resulted in the potential for the facility’s residents to experience “food borne illness and nutritional related health complications.”

In recent years the Centers for Disease Control and Prevention has drawn attention to a source of increasing concern for nursing home residents: Candida auris, also known as C. auris, a fungus that causes “bloodstream infections and even death” in those it affects. Like many infections, C. auris infections are particularly dangerous for those who are already suffering from other conditions. Described by the CDC as “a serious global health threat,” C. auris poses a special risk for nursing home residents.

What makes C. auris so dangerous? A few things. The CDC notes that the fungus is frequently resistant to numerous antibiotic medications; that it is “difficult to identify with standard laboratory methods”; and that it is even prone to misidentification by laboratories without certain technology. This places elderly populations, especially those in nursing homes and other long-term care facilities, at heightened risk. A New York Times report published in September 2019 described a June 2019 study that found “patients and residents in long-term care settings have alarmingly high rates of drug-resistant colonization, which means they carry the germs on their skin or in their bodies, usually without knowing it, and can pass them invisibly to staff members, relatives or other patients.” The study in question “focused on Southern California,” finding that 85% of nursing home residents “harbored a drug-resistant germ.” The CDC has also found that the infection proliferates in long-term healthcare centers

The Times reported that 800 cases of C. auris infection have been identified in the US since the fungus was first reported here in 2015. In August 2019, the CDC updated that count to 806. That includes 388 confirmed cases in New York; 227 confirmed cases in Illinois; 137 confirmed cases in New Jersey; 24 confirmed cases in Florida; and five confirmed cases in California. The Times attributes C. auris’ easy spread through nursing homes to a few factors, in addition to the prevalence of nursing home patients on multiple antibiotics to which the infection has already developed a resistance. Nursing homes are frequently understaffed and under-resourced, according to the Times, and struggle to “enforce rigorous infection control.” They often cycle infected persons in and out of hospitals, putting those hospitals’ patients at risk of the infection too. One health expert told the Times, “You’ll never protect hospital patients until the nursing homes are forced to clean up.” Basic hygienic measures, such as “using disposable gowns and latex gloves,” are essential to combating the infection, yet often unfollowed by long-term care centers, according to the Times. Experts also attribute the infection’s spread in the US to healthcare economics “that push high-risk patients out of hospitals and into skilled nursing homes.” Under the US’s healthcare system, these experts told the Times, “nursing home facilities are reimbursed at a higher rate to care for these patients… providing an economic incentive for poorly staffed or equipped facilities to care for vulnerable patients.”

Each year, more than one in three seniors in San Diego sustain falls and serious injuries. In some instances, falls are the result of elder or nursing home abuse and/or neglect. But in other instances, falls are purely accidental.

More and more elders (defined by California statute as those over the age of 65) are choosing to reside in their own home versus living in an assisted living facility or with relatives. Although there are wonderful reasons to live in your own home as long as possible, it’s important to note that elders are at risk of suffering injuries from a fall, which often times could have been prevented.

Typically, falls are responsible for 60% of in-home injuries. However, statistics show that programs to help prevent falls in the home are effective.

A recent study has found that a class of drugs known as anticholinergics may increase the risk of dementia in patients aged 55 years and older. Commonly used in antidepressants, antihistamines, and antimuscarinics, the drugs have long been associated with side effects like confusion and memory issues. The new study, published in JAMA Internal Medicine, suggests more powerful side effects than medical professionals have previously understood.

As a report by the New York Times explains, anticholinergics encompass a variety of medications. Examples include clozapine, an antipsychotic; diphenhydramine, an antihistamine used in Benadryl, among other products; paroxetine, an antidepressant; tizanidine, a muscle relaxant; and scopolamine, an anti-nausea medication. Anticholinergics owe their wide range of applications to their function in blocking acetylcholine, a neurotransmitter involved in nervous system functions like muscle regulation, respiratory activity, digestion, and the opening and contraction of blood vessels. “Older adults are more likely to be prescribed many of these medications,” the Times explained, “simply because they tend to have more health issues.”

The JAMA Internal Medicine study examined 58,769 patients who had been diagnosed with dementia, with 225,574 matched control patients. Researchers examined dementia patients’ medical records, scrutinizing what medications doctor prescribed them between eleven years and one year before they were diagnosed with dementia. The study took into account 56 separate anticholinergic drugs, accounting for the dosage patients were prescribed and the length they were prescribed the drugs in question. What researchers ultimately discovered was a 50% increase in the risk of dementia in patients “who used a strong anticholinergic drug daily for about three years within that 10-year period,” according to the Times. This risk was strongest in patients who used anticholinergics to treat depression, psychosis, epilepsy, and bladder regulation issues. The study also found a stronger association between anticholinergics and dementia in patients who received their dementia diagnoses before they reached 80 years of age, and in patients with vascular dementia in comparison to those with Alzheimer’s disease.

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