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UABDisability Justice Program

Members:•Jefferson County Medical Examiner

•UAB Dept. of Pathology

•Office of the Jefferson County District Attorney

•UAB Dept. of Justice Science

•Cumberland Law School

•Alabama Dept. of Mental Health and Mental Retardation

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Outline of Civil Monitoring of Residential LTC Facilities

Facility Type Federal Regs.

State Regs.

National Industry

Standards

Medical or Nursing

Consultant Required

Liability Insurance Required

Staff Check

Level of Risk

1. Nursing Home + + + + Required Required L

2. Assisted Living

--- Variable + Variable Required Optional L

3. Group Home --- Variable --- ---- --- --- H

4. Boarding Home --- Variable --- --- --- --- H

5. Unlicensed Residential

Care

--- --- --- --- --- --- H

Federal regs. refer to specific federal nationwide regulations that apply to the industry. State regs. refer to regulations imposed on a state by state basis. Staff check refers to background checks of employees. Risk is based on level of regulatory

scrutiny, civil or criminal safeguards, requirement for background checks of employees, and level of civil liability exposure. “Variable” indicates that requirement is based on state or local laws.

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Outline of Civil Monitoring of In-home Services

Service Type Federal Regs.

State Regs.

National Industry

Standards

Medical or Nursing

Consultant Required

Liability Insurance Required

Staff Check

Level of Risk

1. Home Health + + + Both Required Variable L

2. Hospice + + + Both Required Variable L

3. Hired Help --- --- --- ---- --- --- H

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Sites of Dying in the U.S.

• 56% - Hospital

• 21% - Home

• 19% - Nursing Home

• 4% - Other

CDC Statistics 2002

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The Reverse Abuse Pyramid 1999 Statistics (n=17 states)

• 32.0 / 1,000 – prevalence

• 8.6 / 1,000 – reports

• 5.5 / 1,000 – investigations

• 2.7 / 1,000 – substantiation

• ? - prosecution

• ?? - conviction

• ???- autopsy

Am J. Public Health 2003;93(12):2131-6.

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Outcome of Abuse

• X3 Mortality

Nursing Home

Medical Morbidity

JAMA 1998;280:428-43

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13-Year Mortality for Mistreated Elders (% Living)

• 9% - Abuse victims

• 41% - Morbidity Matched Comparison

JAMA 1998;280:428-43

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Abuse Screening

• 70% - abuse detected vs 30% self-report

• 10 - validated instruments

• 2% - report by MD

JAGS 2004;52:297-304

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ME Facts on Nursing Home Abuse

• 10% - Employees with criminal history

• 1/3 – cited for abuse

• 10% - employees admit to abuse

• 44% - residents describe abuse/neglect

• 1/2 - families unwilling to complain

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Conclusion

1. Confused persons don’t report.

2. Untrained workers struggle to gather information.

3. Law enforcement receives conflicting information.

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Nursing Home Survey Terminology and Procedures

1. MDS – minimum data set

2. RAP – resident assessment protocol

3. Incident report

4. Annual Survey

5. Deficiency

6. Jeopardy / decertification

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Psychopathology in NH Residents

• 67-80% - cognitive impairment

• 10-20% - depression

• 3-7% - delirium

Textbook of Geriatric Psychiatry

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Post Mortem Findings in 52 Demented Elders

% Post Mortem Finding

40 - MI / varying age

46 - Bronchopneumonia

36.5- Emphysema

17.3- PTE

8 - Unsuspected Malignancy

73 - ASCAD

ARCH Path Lab Med 2004;128:32-38

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Seven Deadly Sins of Long-term Care

1.Dehydration

2.Malnutrition

3.Decubiti

4.Lethal Accidental Injury

5.Adverse Drug Reactions

6.Behavior Management Catastrophes

7.Systematic Abuse and Neglect

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Feeding Problems with Dementia

• 50% unable to feed self at 8 years

• 85% institutional residents refuse food

Am. J. AD & Rel. Disor 2004;19(1):24-30

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Staffing and Feeding

• 1:3 - Desired staff / resident ratio

• 1:9 - Daytime

• 1:12- Nighttime meal

www.cmwf.org

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Accuracy of CNA Estimate for PO Resident Intake*

• 22% - Overestimate

• 53% - Missed residents with below 75% consumption

*Video Technique

JAGS 2000;40:209-213.

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Staffing in Nursing Home

• No specific minimum for CNA

• 3.5 contact hours for any nursing over 24 HS

Burger et al. Comm. Fund Report, 2000