nursing negligence case study

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As a nurse faces prison for a deadly error, her colleagues worry: could i be next.

Brett Kelman

RaDonda Vaught, with her attorney, Peter Strianse, is charged with reckless homicide and felony abuse of an impaired adult after a medication error killed a patient. Mark Humphrey/AP hide caption

RaDonda Vaught, with her attorney, Peter Strianse, is charged with reckless homicide and felony abuse of an impaired adult after a medication error killed a patient.

Four years ago, inside the most prestigious hospital in Tennessee, nurse RaDonda Vaught withdrew a vial from an electronic medication cabinet, administered the drug to a patient and somehow overlooked signs of a terrible and deadly mistake.

The patient was supposed to get Versed, a sedative intended to calm her before being scanned in a large, MRI-like machine. But Vaught accidentally grabbed vecuronium, a powerful paralyzer, which stopped the patient's breathing and left her brain-dead before the error was discovered.

Vaught, 38, admitted her mistake at a Tennessee Board of Nursing hearing last year, saying she became "complacent" in her job and "distracted" by a trainee while operating the computerized medication cabinet. She did not shirk responsibility for the error, but she said the blame was not hers alone.

"I know the reason this patient is no longer here is because of me," Vaught said, starting to cry. "There won't ever be a day that goes by that I don't think about what I did."

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If Vaught's story had followed the path of most medical errors, it would have been over hours later, when the Tennessee Board of Nursing revoked her license and almost certainly ended her nursing career.

But Vaught's case is different: This week, she goes on trial in Nashville on criminal charges of reckless homicide and felony abuse of an impaired adult for the killing of Charlene Murphey, the 75-year-old patient who died at Vanderbilt University Medical Center in late December 2017. If convicted of reckless homicide, Vaught faces up to 12 years in prison.

Prosecutors do not allege in their court filings that Vaught intended to hurt Murphey or was impaired by any substance when she made the mistake, so her prosecution is a rare example of a health care worker facing years in prison for a medical error. Fatal errors are generally handled by licensing boards and civil courts. And experts say prosecutions like Vaught's loom large for a profession terrified of the criminalization of such mistakes — especially because her case hinges on an automated system for dispensing drugs that many nurses use every day.

The Nashville District Attorney's Office declined to discuss Vaught's trial. Vaught's lawyer, Peter Strianse, did not respond to requests for comment. Vanderbilt University Medical Center has repeatedly declined to comment on Vaught's trial or its procedures.

Vaught's trial will be watched by nurses nationwide, many of whom worry a conviction may set a precedent — as the coronavirus pandemic leaves countless nurses exhausted, demoralized and likely more prone to error.

Janie Harvey Garner, a St. Louis registered nurse and founder of Show Me Your Stethoscope , a nurses group with more than 600,000 members on Facebook, said the group has closely watched Vaught's case for years out of concern for her fate — and their own.

A Doctor Confronts Medical Errors — And Flaws In The System That Create Mistakes

Garner said most nurses know all too well the pressures that contribute to such an error: long hours, crowded hospitals, imperfect protocols and the inevitable creep of complacency in a job with daily life-or-death stakes.

Garner said she once switched powerful medications just as Vaught did and caught her mistake only in a last-minute triple-check.

"In response to a story like this one, there are two kinds of nurses," Garner said. "You have the nurses who assume they would never make a mistake like that, and usually it's because they don't realize they could. And the second kind are the ones who know this could happen, any day, no matter how careful they are. This could be me. I could be RaDonda."

As the trial begins, Nashville prosecutors will argue that Vaught's error was anything but a common mistake any nurse could make. Prosecutors will say she ignored a cascade of warnings that led to the deadly error.

The case hinges on the nurse's use of an electronic medication cabinet, a computerized device that dispenses a range of drugs. According to documents filed in the case , Vaught initially tried to withdraw Versed from a cabinet by typing "VE" into its search function without realizing she should have been looking for its generic name, midazolam. When the cabinet did not produce Versed, Vaught triggered an override that unlocked a much larger swath of medications, then searched for "VE" again. This time, the cabinet offered vecuronium.

Vaught then overlooked or bypassed at least five warnings or pop-ups saying she was withdrawing a paralyzing medication, documents state. She also did not recognize that Versed is a liquid but vecuronium is a powder that must be mixed into liquid, documents state.

Finally, just before injecting the vecuronium, Vaught stuck a syringe into the vial, which would have required her to "look directly" at a bottle cap that read "Warning: Paralyzing Agent," the DA's documents state.

The DA's office points to this override as central to Vaught's reckless homicide charge. Vaught acknowledges she performed an override on the cabinet. But she and others say overrides are a normal operating procedure used daily at hospitals.

While testifying before the nursing board last year, foreshadowing her defense in the upcoming trial, Vaught said that at the time of Murphey's death, Vanderbilt was instructing nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital's electronic health records system.

Murphey's care alone required at least 20 cabinet overrides in just three days, Vaught said.

"Overriding was something we did as part of our practice every day," Vaught said. "You couldn't get a bag of fluids for a patient without using an override function."

Overrides are common outside of Vanderbilt, too, according to experts following Vaught's case.

Michael Cohen, president emeritus of the Institute for Safe Medication Practices, and Lorie Brown, past president of the American Association of Nurse Attorneys, each said it is common for nurses to use an override to obtain medication in a hospital.

But Cohen and Brown stressed that even with an override, it should not have been so easy to access vecuronium.

"This is a medication that you should never, ever, be able to override to," Brown said. "It's probably the most dangerous medication out there."

Cohen said that in response to Vaught's case, manufacturers of medication cabinets modified the devices' software to require up to five letters to be typed when searching for drugs during an override, but not all hospitals have implemented this safeguard. Two years after Vaught's error, Cohen's organization documented a "strikingly similar" incident in which another nurse swapped Versed with another drug, verapamil, while using an override and searching with just the first few letters. That incident did not result in a patient's death or criminal prosecution, Cohen said.

Maureen Shawn Kennedy, the editor-in-chief emerita of the American Journal of Nursing , wrote in 2019 that Vaught's case was "every nurse's nightmare."

In the pandemic, she said, this is truer than ever.

"We know that the more patients a nurse has, the more room there is for errors," Kennedy said. "We know that when nurses work longer shifts, there is more room for errors. So I think nurses get very concerned because they know this could be them."

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. It is an editorially independent operating program of KFF (Kaiser Family Foundation).

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Home » Law and Ethics » NEGLIGENCE IN NURSING CASE STUDY

NEGLIGENCE IN NURSING CASE STUDY

Analysis of nursing care outlined by the coroner’s findings in the inquest into the death of Christopher Hammett

Postoperative nursing care plays a significant role in the success of hospital recovery for post-operative patients. The duty of post-operative nurses is complying with regulations to provide a responsible level of standardized care to assist the patient in recovering from surgery successfully. Nursing staff providing care to post-operative patients are expected to be highly skilled in monitoring patients through observation and identifying complications to assist in the successful recovery of patients (Association of Peri-Operative Registered Nurses, 2018).

In the case scenario of the Coroner’s findings into the death of Mr. Christopher Hammett, the analysis indicates multiple violations of nursing practices of professional and responsible conduct by the nurses involved which include poor practice, unethical behaviour, and negligence. The coroner’s report states the cause Mr. Hammett’s death was reported to be a result of combined and compounded mistakes largely attributed to poor nursing care practices (Queensland Courts, 2012).

According to findings of the Coroner, the case of Mr. Christopher Hammett’s death was a result of poor practices and composited human errors of the healthcare professionals involved in post-operative care and treatment. Mr. Hammett was 41 years old. He died in April 2005 whilst in post-operative recovery following an elective operation. According to the medical documents, the surgery was performed at the Pacific Private Hospital to replace the L5-S1 disc in Mr. Hammett’s back. Respiratory care is vigorous in the postoperative patient.

The respiratory rate has been found to be the sole most imperative and dependable early warning sign of respiratory depression. Pulse oximetry is not only reliable method to monitoring those patients who has been receiving supplemental oxygen. In the legal enquiry of Mr. Hammett’s case, the Coroner found that there was deprived nursing management of oxygen level in the evening shifts. Due to this fact, error intensified from insufficient pain relief in the operation theatre (Sajith, 2018).

The task of Christopher Hammett had not bound any remarkable occasions. In activity, his oxygen level supported at 99%, however quickly it dropped to 64% while transporting from OT to the Post Anaesthetic Care Unit (PACU). As per his medical histories, he was provided with the two doses of morphine at 2mg each before the transfer to another ward. However, he was not inspected by the doctor in the transferred ward. Registered nurse (RN) Dean Manton in PACU said in one of his statements that “he was not aware of the Hammett’s desaturation event before the transfer.” According to MILBY, BÖHMER, GERBERSHAGEN, JOPPICH, & WAPPLER, (2014), Patient handovers are an intrinsic part of Health care practice as it involves Interpersonal communication which has a core value to maintain the patient-centred care. The health care staff uses handovers to report patient’s medical circumstances, completed investigations, and treatment. Complications with information transfer may lead to uncertainties about patient care and likely patient maltreatment.

During Dean Manton’s work day, it was found by the Coroner that inappropriate diagnosis and low oxygen saturation prompted the blend of sleep apnoea alongside the use of morphine. Also, it was seen on Mr. Hammett’s graph that he pressed his narcotic infusion request button for 125 times more than two and half hours, over and over at regular intervals, the medical attendant overlooked him while he was in pain. Another issue, in this case, was the RN left the ward entrusting an Enrolled nurse (EN) Jennifer Valentine with Mr. Hammett’s care, Who should have been always working under her supervisor  (Mr. Gibbon).

EN Valentine neglected to linkage the mask to oxygen supply while she was evolving Mr. Hammett’s nasal prongs with an oxygen mask. Within a couple of minutes, she observed that the oxygen saturation level of Mr. Hammett started to drop. In any case, this slip-up was corrected by her administrator. Though, in the absence of the supervisor, she repeatedly wrongly filled out his vitals chart concerning saturation levels. Lastly, she requested her supervisor for a review due to the dropping oxygen level. In response, Mr. Gibbons attended Christopher Hammett in between 1 am and 2 am. Gibbons analysed the entire situation at the ward. He increased the oxygen level. After that, he took a break and had a sleep. However, RN Gibbons failed to analyse the situation appropriately. He thought the patient was asleep, but in actual fact he was unconscious. At 2 Pm when the nurse checked Mr. Hammett, she discovered his eyes were incompletely open, his skin was “dusty” in shading and she couldn’t actuate him. She called an Ambulance and the patient was taken to the Gold Coast Hospital. In any case, by renaissance endeavours, the patient was pronounced dead (Queensland Courts, 2012).

In the Coroner’s report described, these sequential mistakes in nursing care of Pacific Private Hospital were noticed. The initial error was limited pain relief in the OT, due to which a proper remedy was not provided to the patient concerning his disease. After the operation theatre, the patient was transferred in PACU. In PACU nursing staff were not diligent and alert to several patient issues which occurred in the evening and night shift on the ward. Low oxygen saturation was managed by increasing oxygen therapy by nursing staff in the ward. In adding to this, high pain scores were noticed due to the deprived original pain relief in OT. The compounding of mistakes complicated the post-operative recovery of Mr. Hammett leading to the unfortunate event of his death which was entirely preventable by the staff of the Gold Coast Hospital (Queensland Courts, 2012). In this situation, the main reason for the death of the patient was the inferior standard of care and negligent conduct of nurses. At several points, many severe mistakes were made by the nursing staff involved which led to detrimental outcomes in the post-operative recovery of the patient. The death of Christopher Hammett could have been avoided if the protocols of the standard of care by nursing staff were undertaken appropriately. Due to the compounded human errors, the death of Mr. Hammett happened. Consequently, a warrant was delivered in contradiction of the medical and nursing staff by the medical punitive body.

Section 2: The Tort Of Negligence: Applicability of tort of negligence to nurses involved in this case

According to Legal Aid Queensland (2018), A tort is a breach of a duty, potentially causes harm to the innocent party. In case of Mr. Hammett. Generally, a torturous act is based on the act of negligence by an individual. To be accountable for the act of negligence in nursing care the concepts of breach of the duty of care and causing harm have to be satisfied. The first performing party ought to owe an obligation of consideration to the wronged to keep the likelihood of damage. The mission of consideration is general obligations which are normal from the reasonable individual while in the conduct. Breach of duty is the performing party failing to take standard care in their actions resulting in the claim of negligence.

According to Forrester and Griffiths (2014), The general reason for the violation of duty is the act of negligence. Actual damage or harm sustained should be a real or genuine hurt to the distressed party from the act of negligence.

Causation- As indicated by this component, an act from the performing gathering or disappointment of performing party in taking standard consideration ought to be the essential purpose behind the damage. Moreover, abused must not have any involvement in the demonstration of carelessness else they won’t have the capacity to guarantee harms for damage (Guido, 2014).

Malpractice is an equivalent word of professional negligence. Arrangement of misconduct behaviour is connected when health care professionals neglect to take standard consideration of their activities. In the present time, nursing experts are winding up likely objectives of the offended party and their lawyers for the situation of medicinal malpractice. In the present case situation conduct of negligence is observed during all the times Mr. Hammett was transferred between different medical units. Following the transfer of Mr. Hammett from PACU to the accommodation ward, RN Manton took over the care of Mr. Hammett from RN Turrell. Conferring to the declaration of Manton, Turrell did not notify him of the desaturation occurrence in PACU through the transfer. This act is considered professional negligence as it is commonly predictable that during handover of a patient, healthcare provider at the time has to be provided with all necessary crucial information about the patient. However, in this case, scenario Turrell ruined to do so (Ray, 2012).

In the accommodation ward, Ms. Valentine failed to connect the mask to oxygen supply whilst she was altering Mr. Hammett’s nasal prongs with an oxygen mask. Moreover, she repeatedly incorrectly complete his vitals chart regarding the saturation levels. This incident will also be considered an act of malpractice of the nurse. As a result of her negligence and failure to recognize and respond to the clinical deterioration, the patient had to endure further suffering (Guido, 2014).

At the accommodation ward, RN Gibbons failed to determine and conduct himself in the situation in an appropriate manner. He assumed that the patient was asleep while the patient was unconscious. The act of misinterpretation by Gibbons will be considered as a negligent act because it delayed Mr. Hammett receiving an appropriate standard of care in recovery at the Gold coast hospital. Both nurses be obliged their duty of care to Mr. Hammett. It is the general responsibility of nursing practitioners to conform to standard rules and to evade acts of negligence. In both the above circumstances, the nurses were unsuccessful to take care of their general tasks. Due to their negligence and non-compliance of the subject standards of care which should have been provided to patients recovering post-operatively, the unfortunate incident of Mr. Christopher Hammett’s death occurred.

Furthermore, the essential purpose behind damage of the patient was negligence directed by the nurses. Along with these lines, for this situation, every one of the components of negligence were perceived in the examination by the Coroner.

Section 3: Ethical Issues

In the care of Christopher Hammett, several ethical issues can be seen. Due to these issues, nursing practitioners in the case faced ethical concerns while taking care of Mr. Hammett. Initially registered nurse Turrell met the point of disclosing information (Legal Aid Queensland, 2018). It is a general dilemma of nursing practitioners how much information should be disclosed while handing over the patient to another practitioner. In the present case scenario, registered nurse Turrell was required to provide all the essential information to the handover nurse. Usually, it is a result of the possibility to disclose information to a doctor if needed, who will be talented to provide better treatment to the patient by considering the crucial facts. Additional ethical issue was tackled by EN Valentine regarding the explanation of the condition while observing the patient. At that night, Christopher Hammett had detached his oxygen mask several times and every time the mask was exchanged by EN Valentine (Nursing and Midwifery Board of Australia – Guidelines on endorsement as a nurse practitioner, 2015).

At the time of surveillance, EN Valentine thought the exchange of the oxygen mask was the key reason for low oxygen saturation levels. Other health care professionals also faced such a ethical issues as it was many likelihoods in an one situation. Furthermore, she was ignored by RN Gibson’s assistance in appropriate manner. Due to this fact, she had to smear her interpretation while writing the vitals form of Mr. Hammett. Although, she requested RN Gibson to attend Mr. Hammett due to constantly dropping of the oxygen saturation level. Ms Valentine did appropriate action at a time though she was an accountable for the act of negligence. Because of the above portrayed ethical issues, the nursing professionals included did not deal with the patient at a sensible standard and way.

Nursing professionals are vastly qualified to offer the best conceivable standard of care to the patients. Yet, in this case, the injury and destruction caused to the patient was a result of deprived ethical conduct and negligence by the nursing staff.

The primary reason for the death of the patient was the negligence of nursing practitioners. The unfortunate outcome of the death of Mr. Hammett could have been avoided if standard nursing care was provided to Mr. Hammett. Nursing practitioners should be obliged to undertake their duties and responsibilities to benefit the patient ultimately. They should comply with the standards of ethical and legal care. If they fail to do so, they will be held liable for their misconducts. Misconduct of nursing practitioners will result in cases of civil and criminal law. In the current case of death of Christopher Hammett, establishment of civil law was applied.

• Dunwoody, D. R., Jungquist, C. R., Chang, Y., & Dickerson, S. S. (2019). The common meanings and shared practices of sedation assessment in the context of managing patients with an opioid: A phenomenological study. Journal of Clinical Nursing, 28(1-2), 104-115. doi:10.1111/jocn.14672
• Forrester, K., & Griffiths, D. (2014). Essentials of Law for Health Professionals-eBook. Elsevier Health Sciences. Retrieved from   https://books.google.com.au/books?hl=en&lr=&id=VlqmBgAAQBAJ&oi=fnd&pg=PP1&dq=Forrester,+K.,+%26+Griffiths,+D.+(2014).+Essentials+of+Law+for+Health+Professionals-eBook.+Elsevier+Health+Sciences.&ots=ajGVt4NgNi&sig=xI_adR9Ohe1q5ELS9L35rY-NQ4I#v=onepage&q&f=false
• Guido, G. W. (2014). Legal and ethical issues. Leading and Managing in Nursing-E-Book, 70. Retrieved from https://books.google.com.au/books?hl=en&lr=&id=Dm_XBQAAQBAJ&oi=fnd&pg=PA70&dq=Guido,+G.+(2006).Legal+and+ethical+issues+in+nursing.&ots=Fj5y2nBNHI&sig=5NJ9QzsmV_GHErByUXk-SknM3P4#v=onepage&q&f=false
• Legal Aid Queensland (2018). Negligence, duty of care and loss. Retrieved from http://www.legalaid.qld.gov.au/Find-legal-information/Personal-rights-and-safety/Injury-loss-and-compensation/Negligence-duty-of-care-and-loss
• MILBY, A., BÖHMER, A., GERBERSHAGEN, M. U., JOPPICH, R., & WAPPLER, F. (2014). Quality of post-operative patient handover in the post-anaesthesia care unit: A prospective analysis: Post-operative patient handover in the PACU. Acta Anaesthesiologica Scandinavica, 58(2), 192-197. doi:10.1111/aas.12249
• Nurses, A. (2018). Guidelines for Perioperative Practice – Clinical Resources – Association of periOperative Registered Nurses. Retrieved from https://www.aorn.org/guidelines
• Nursing and Midwifery Board of Australia – Guidelines on endorsement as a nurse practitioner (2015). National competency standards for the registered nurse. Retrieved from file:///C:/Users/User/Downloads/Nursing-and-Midwifery-Board—Standard—National-competency-standards-for-the-registered-nurse.PDF
• Queensland Courts. (2012). Inquest into the death of Christopher Hammett (File No. 2005/33). Retrieved from https://www.courts.qld.gov.au/__data/assets/pdf_file/0008/169343/cif-hammett-c-20121128.pdf
• Ray, M. A. (2012). The theory of bureaucratic caring for nursing practice in the organizational culture. Caring in Nursing Classics: An Essential Resource, 309. Retrieved from https://books.google.com.au/books?hl=en&lr=&id=yTuv-tEuGE0C&oi=fnd&pg=PA309&dq=Nursing+liability+and+nursing+malpractice+(2012).&ots=L7Cgi3ruPD&sig=S6nOXlI6pHYkxC_rn2qgBDxQVZQ#v=onepage&q=Nursing%20liability%20and%20nursing%20malpractice%20(2012).&f=false
• Sajith, B. (2018). Respiratory depression. Clinical Journal of Oncology Nursing, 22(4), 453-456. doi:10.1188/18.CJON.453-456

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20 Most Common Examples of Negligence in Nursing + How to Prevent Them

The very nature of a nurse's job means being held to a high standard of professional conduct. Nurses are expected to act with great regard for patient safety and well-being and promote favorable outcomes for the patient, healthcare team, and organizations for whom they work. Unfortunately, even the best nurses make mistakes. When those mistakes result in injury or harm to a patient, it is called negligence. Perhaps you have heard of nursing negligence but do not have a clear understanding of what it is. Maybe you have wondered, "What constitutes negligence and what are the most common examples of negligence in nursing?” In this article, you will learn what nursing negligence is, find out the 20 most common examples of negligence in nursing + how to prevent them.

What Is Negligence In Nursing?

What is the difference between incompetence and negligence in nursing, what is the difference between malpractice and negligence in nursing, what every nurse needs to know about the 4 elements required to prove negligence in nursing, 1. duty of care:, 2. breach of duty:, 3. causation:, 4. damages:, what are the most common examples of negligence in nursing, example #1: not responding to a patient in a timely manner, about the negligence:, how to prevent this negligence:, example #2: failure to administer medication, example #3: not reporting a change in patient status, example #4: administering the wrong medication, example #5: injuring a patient with medical equipment, example #6: not speaking up when action is required, example #7: administering medication using the wrong route, example #8: failure to monitor the patient, example #9: failure to document, example #10: not implementing patient-appropriate safety measures, example #11: abandonment of patient care, example #12: not monitoring the effects of restraints, example #13: failure to provide discharge instructions/education, example #14: documenting incorrect or incomplete information, example #15: not verifying patient allergies, example #16: nurse preceptor fails to supervise nursing student, example #17: failure to get informed consent, example #18: not performing a follow-up assessment, example #19: failure to act as a patient advocate, example #20: using damaged equipment to assess or care for a patient, 7 possible consequences of negligence in nursing, 1. injury to or death of a patient:, 2. loss of job:, 3. loss of nursing license:, 4. legal action against the nurse:, 5. financial loss:, 6. tarnished professional reputation:, 7. compromised professional and nurse-patient relationships:, 7 steps you can take if you have committed an act of negligence in nursing, 1. do not try to cover up your mistake, 2. report to your supervisor right away., 3. make sure an incident report is filled out and that you write your version of what happened exactly as you remember it., 4. talk to your facility’s safety committee or safety officer., 5. notify the patient and/or caregiver., 6. document everything you say and who you say it to., 7. consider speaking with an attorney., bonus things nurse leaders can do to help prevent negligence in nursing practice, 1. establish clear standards to guide nursing practice:, 2. create an atmosphere where nurses are comfortable asking for help and guidance:, 3. use experienced, competent nurses as preceptors:, 4. be a safe person for patients and nurses to talk to:, 5. create opportunities for continued learning:, my final thoughts, frequently asked questions answered by our expert, 1. what is criminal negligence in nursing, 2. is nursing negligence an ethical or legal issue, 3. what is gross negligence in nursing, 4. does a medical error always mean negligence, 5. can a nurse be sued for negligence, 6. how often do nurses get sued for negligence, 7. can a student nurse be held liable for negligence, 8. how can a nurse become negligent with medication administration, 9. can a nurse go to jail for negligence, 10. can an act of negligence in nursing become malpractice.

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• v.55; Jan-Dec 2018

Failure to Meet Nurse Staffing Standards: A Litigation Case Study of a Large US Nursing Home Chain

Charlene harrington.

1 University of California, San Francisco, USA

Toby S. Edelman

2 Center for Medicare Advocacy, Washington, DC, USA

Large for-profit nursing home chains in the United States have generally reported low nurse staffing levels. This historical case study examined a class action litigation case regarding staffing levels, resident rights, and quality outcomes in 12 Arkansas nursing homes owned by a large for-profit chain. The questions were as follows: (1) How did the residents’ care needs compare with actual nurse staffing levels? (2) How did the staffing levels compare with federal and state nurse staffing requirements and professional staffing standards? (3) Did the facilities comply with state and federal residents’ rights and quality of care requirements? The findings showed staffing levels marginally above state minimum standards, staffing shortages that violated state standards, staffing levels not adjusted for resident acuity, and shortages that resulted in omitted care. Staffing levels were lower than needed according to nursing directors, lower than average facilities in the state, and lower than professional standards. The findings showed many resident grievances regarding basic care and residents’ rights, clinical measures of poor quality, and state deficiencies. A large settlement was agreed on to compensate the residents. The case shows that chain’s management, as well as the regulatory system, failed to ensure adequate staffing levels that took into account regulatory requirements and professional standards and resulted in violations of residents’ rights, health, safety, and well-being.

• What do we already know about this topic?
• Many nursing home staffing studies have shown the positive relationships among staffing levels and resident rights and quality outcomes, but few studies have examined nursing home litigation cases that involve staffing levels and standards.
• How does your research contribute to the field?
• The study examines a litigation case that challenged a nursing home chain’s failure to meet professional standards.
• What are your research’s implications toward theory, practice, or policy?
• Researchers, nursing home managers and owners, and policy makers need to consider professional nursing standards that ensure adequate staffing levels to meet the specific care needs of facility residents.

Introduction

Quality problems have been endemic in nursing homes in the United States. 1 - 4 Under current government prospective payment systems, nursing homes make choices on how to allocate their resources. About 70% of nursing homes are for-profit facilities with an orientation to maximizing profits for owners and shareholders. 5 The profit incentive is linked to low staffing because for-profit homes and for-profit chains operate with lower staffing and more quality deficiencies (violations) than nonprofit and publicly owned facilities. 6 - 8 Facilities with the highest profit margins have been found to have the poorest quality. 9 Because federal and state enforcement of nursing home regulations has historically been weak in protecting residents, 1 - 4 , 10 residents have sometimes used litigation to obtain relief from poor nursing home care. 11 , 12

In this study, we examined a class action case that involved the impact of staffing levels on the delivery of care, residents’ rights, and quality outcomes in a large for-profit nursing home chain. The plaintiffs were residents of 12 Golden Living nursing homes (hereafter called Golden Living) located in Arkansas during the period of December 2006 through June 2009. The residents alleged that the chain’s chronic understaffing practices caused routine and widespread failures to provide quality care and violations of rights in all 12 facilities. The defendants denied the charges, and a lengthy legal process ensued followed by a settlement in 2017. 13 , 14

The specific research questions were as follows: (1) How did the residents’ care needs compare with actual nurse staffing levels? (2) How did the staffing levels compare with federal and state nurse staffing requirements and professional staffing standards? (3) Did the facilities comply with state and federal residents’ rights and quality of care requirements? The study used a single historical case study of the class action against Golden Gate National Senior Care (GGNSC) LLC, which owned Golden Living. GGNSC (formerly Beverly Enterprises) was purchased by Fillmore Capital Partners (a private equity real estate investment trust) in 2006 (for $1.85 billion). 15 , 16 Golden Living was the third largest for-profit nursing home in the United States in 2016, with 295 nursing homes and more than 30 000 nursing home beds, 17 and is similar to other large for-profit US nursing home chains. 7 , 15 , 16 , 18

Records were drawn from plaintiff and defendant reports and documents, depositions, and multiple other government sources on resident care needs, staffing levels, regulatory actions, grievances, and quality reports. 13 These documents provide data on the corporate actions, strategies, and outcomes over time. The findings and conclusions should be of interest to nursing home owners, policy makers, researchers, regulators, attorneys, and advocates in addressing staffing and quality issues.

Research on Nurse Staffing

Research evidence on nurse staffing levels and quality.

Many research studies have been conducted on nursing home staffing. 19 - 22 When using complex analytical models and/or longitudinal analyses, research findings consistently show higher staffing levels are related to higher quality of care. 23 - 25 Higher registered nurse (RN) and certified nursing assistant (CNA) staffing have been associated with improved quality indicators, including physical restraints, catheter use, pain management, and pressure sores. 26 Higher staffing levels and professional staff mix, along with lower turnover and use of agency staff, were found to be associated with higher quality on 15 of 18 measures. 27 The strongest relationship has been found between higher staffing levels and fewer deficiencies (violations of regulations) issued by state surveyors. 22 , 23 , 28 - 30

Expert recommendations for minimum staffing levels

A Centers for Medicare & Medicaid Services (CMS) study in 2001 established the importance of having a minimum of 0.75 RN hours per resident day (hprd), 0.55 licensed nurse (licensed practical nurse [LVN]/licensed vocational nurse [LPN]) hprd, and 2.8 CNA hprd, for a total of 4.1 nursing hprd to meet federal quality standards. 30 As part of this study, a simulation model was used to determine the minimum number of CNAs needed to provide 5 basic activities of daily living care. The results found a minimum of 2.8 CNA hprd to ensure consistent, timely care to residents. 30 These findings were later confirmed in an observational study. 31

A more recent simulation study found that 2.8 CNA hprd is needed in nursing homes with low workloads to have less than 10% omissions in care, and 3.6 CNA hprd is needed in nursing homes with high workloads. 32 The simulation evidence clearly established that there are critical ratios of CNAs to residents in nursing homes below which residents have omitted care and are at substantially increased risk of quality problems. 31

A number of organizations have endorsed the minimum of 4.1 hprd standard, have recommended that at least 30% of total nursing care hours be provided by licensed nurses, and have recommended that RNs should be on duty 24 hours per day. 33 - 35 Some experts have recommended higher minimum staffing (a total of 4.55 hprd) to improve the quality of nursing home care, with upward adjustments for resident acuity (case-mix). 36

CMS expected staffing levels adjusted for resident acuity

The CMS Medicare Nursing Home Compare 5-star rating system developed a method to determine what nurse staffing levels are needed for each nursing home based on its resident acuity. 29 , 30 The CMS calculated “expected hours” of care based on the resident acuity obtained from the Resource Utilization Group (RUG) scores reported by each facility for every resident and CMS’s Staff Time Measurement Studies published in 2000. 37 - 39 The recent analysis by CMS of “expected” staffing levels taking into account resident acuity indicated that the average nursing home should have 4.17 total nursing hprd, including 1.08 RN hprd. 37 , 39

Federal and State Staffing Requirements

Federal nursing home requirements.

All nursing homes certified for Medicare and Medicaid residents are required to comply with 42 C.F.R. § 483.35 to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. 40 Under these requirements, nursing homes are required to add more staff when residents require more basic and skilled nursing care. Federal minimum staffing requirements also specify that the director of nursing must be an RN and a full-time employee for 40 hours a week and another RN must be employed for 16 hours a week to ensure coverage 7 days a week (.08 hours for 100 residents). Registered nurses and LVPs/LPNs provide services that require advanced education and training. 40

All residents must have a comprehensive resident reassessment (minimum data set [MDS]) completed on admission and at least annually and whenever there is a significant change in the resident’s condition. 41 The assessments must be completed by an RN in cooperation with the resident’s multidisciplinary team and used to develop each resident’s individualized, comprehensive care plan. Minimum data set assessments must be submitted quarterly to CMS, and they are used for Medicare payment purposes, which pays more for residents assessed as having higher care needs.

State staffing requirements

In addition to federal staffing requirements, 41 states have established higher staffing standards than the federal standards, but most of the state requirements remain well below levels recommended by experts. 25 The Arkansas Protection of Long-Term Care Facility Residents Act requires that nursing homes comply with the following minimum direct care staffing ratios, determined solely on the basis of the number of residents in the facility (census) 42 :

• Day shift—1 direct care staff to 6 residents and 1 licensed nurse to every 40 residents
• Evening shift—1 direct care staff to 9 residents and 1 licensed nurse to every 40 residents
• Night shift—1 direct care staff to 14 residents and 1 licensed nurse to every 80 residents

The facility must post the daily staffing at the beginning of each shift and sign the staffing sheets and submit a monthly written report identifying all shifts that failed to meet the minimum staffing requirements. The Arkansas Office of Long Term Care (OLTC) may assess a fine for a pattern of staffing violations. 42 All nursing homes are also required to provide sufficient staff to meet the needs of residents on a continuing basis and to adjust direct care staffing levels upward from the minimum standards if residents have higher acuity to meet the needs of residents in the facility. 42 The Director of Nursing is responsible for recommending the number and levels of nursing personnel to meet the needs of residents. Arkansas law and provider agreements require a nursing home to admit only those residents whose needs can be met by the facility. 42

Methodology

Study design.

A historical single-case study was selected for this research because this methodology allows for an in-depth, focused analysis of a nursing home chain. A case study is ideal for examining “what” and “why” questions about a contemporary set of events and allows investigators to analyze real-life events. 43 Standard case study procedures were used to developing research questions and a study design, collecting data, and conducting the analyses. We examined multiple qualitative and quantitative measures to identify confirming and disconfirming evidence. 43

The data for this article came from voluminous records on file in the Arkansas Circuit Court for the 12 Golden Living facilities over the period of December 1, 2006, through June 30, 2009, with the exception of El Dorado, which was sold in September 30, 2007. 13 Specifically, plaintiffs’ counsel conducted 150 depositions in 8 states; reviewed and analyzed thousands of documents, including 180 000 e-mails, 7.5 million time card entries, and 51 million electronic activity of daily living entries, from resident’s medical records; and retained and prepared 10 expert witnesses to testify at trial. 44 The data analyses involved the plaintiffs’ legal team and a number of experts, including an accounting firm, 45 a team to conduct simulation analyses of resident care and staffing needs, 46 , 47 as well as medical and other experts. 48 Detailed data as well as reports and summary data from these sources were used by the authors for the article. The data collection focused on 3 major areas described below: (1) resident care needs, (2) nurse staffing levels, and (3) residents’ rights and quality of care indicators.

Resident care needs

Two sources of CMS data were used to identify resident care needs: (1) CMS form 672 data reported by each facility to the state at the time of its annual state licensing and certification survey from the On-Line Survey Certification and Reporting System (OSCAR), and (2) monthly CMS MDS resident data from each facility’s assessment of each resident at 8 Golden Living facilities on the last day of each month during the 31-month time period. 46 , 47 While some residents may get worse over time, others improve and are eventually discharged; an average of each resident’s monthly status shows the overall resident care needs in the facilities.

Nursing staffing hours

Staffing levels for all RNs, LPNs, and CNAs were determined for the 12 facilities during the period of 2006-2009 from 8 sources: (1) Golden Living’s employee time cards, (2) Golden Living’s weekly focus reports, (3) minimum staffing reports (MSRs) submitted by Golden Living for each facility to the Arkansas OLTC, (4) all facility MSRs reviewed and corrected by OLTC, (5) Golden Living’s time clock adjustment reports which identified nursing staff who did not get a break on their shift, (6) staffing reports (CMS Form 671) made by each facility at the time of annual survey between 2006 and 2009, and (7) depositions and e-mails regarding staffing levels from facility directors of nursing, clinical nurse specialists, and the corporate director of clinical operations.

Residents’ rights and quality of care

Arkansas requires facilities to keep a log of all grievances from residents, family, and other persons by date along with the facility resolution to the grievances and make these available to state surveyors. The grievance logs were obtained from each facility. Arkansas OLTC data were collected on the number of deficiencies and serious deficiencies (those that have the potential for or actually cause harm or immediate jeopardy to residents). Medical records were obtained for 41 residents who were plaintiffs in the class action litigation case. Deposition data and e-mails were obtained for directors of nursing, clinical nurse specialists, and the corporate director of clinical operations.

Analytical plan

The analysis of qualitative and statistical data focused on (1) resident care needs, (2) nurse staffing hours, and (3) residents’ rights and quality of care to address each research question. For the resident care needs, a descriptive analysis identified the acuity level of residents in each facility during the study period. The facility workload used each resident’s MDS data in each facility, which were based on whether care was needed for 5 basic activities of daily living (ADLs): (1) incontinent and toileting assistance, (2) repositioning assistance, (3) eating assistance, (4) dressing and hygiene assistance, and (5) exercise or range of motion assistance.

The amount of omitted care was estimated using discrete event simulation (“DES”), described in previous research, to calculate the labor burden resulting from a resident’s ADL needs quantified through simulation, applying minimum, maximum, and mode times for each ADL task. 32 The simulations of the staffing levels necessary to provide ADL care were estimated using the time needed for each of the 5 basic ADL tasks after categorizing residents into 7 workload categories from lightest to heaviest care using Golden Living resident MDS assessment data. 32 The actual CNA hours worked at Golden Living on each day and shift (based on time card data) were used in the simulation and compared with the CNA hours that were needed to deliver the basic care. 46 , 47

To calculate the actual staffing hours, descriptive statistics were compiled from each facility over time from the employee time cards, weekly focus reports, and MSRs submitted by Golden Living to determine the total number of RNs, LVNs, and CNAs on a per day and per shift basis divided by the census data to compute hprd. The data were used to examine staffing on the specific shifts that each facility reported it failed to comply with state minimum staffing ratios. 45 The MSRs reviewed and corrected by OLTC showed each shift where a facility had not reported a violation of state minimum staffing ratios or “short staffing.” Finally, Golden Living staffing data were compared with the average nursing home in Arkansas, with staffing levels recommended by experts, and with staffing levels that CMS expected based on resident acuity.

Each nursing facility’s number and type of grievances and facility responses to these grievances were summarized and analyzed. Descriptive data on the number of deficiencies and serious deficiencies were analyzed, as well as the medical records for 41 plaintiffs. 48 Deposition data and e-mails were summarized and categorized for directors of nursing, clinical nurse specialists, and the corporate director of clinical operations to identify quality of care problems and responses to complaints about quality problems and understaffing and whether these resulted in a change in staffing levels at facilities. Because these descriptive quality indicators were not available from other nursing homes in Arkansas, we examined whether the residents’ rights and quality problems identified at Golden Living facilities were related to the staffing levels identified in Golden Living facilities.

Resident Care Needs

Using data from CMS (Form 672s) from the 12 facilities, residents had high needs for bathing (97% needed assistance or were completely dependent), dressing (87%), transferring (78%), toileting (82%), and eating (60%) in the 2006-2009 period (no table shown). Of the total residents, 57% had bladder incontinence, 50% had bowel incontinence, 27% needed help from staff with ambulation, 18% had contractures, and 50% were chairbound. In addition, 38% of residents had dementia, 58% had depression, 25% had psychiatric disorders, and many residents had pressure ulcers (5.7%), pain (24%), weight loss (6%), and psychoactive medications (66%).

The analysis of MDS resident data from 8 Golden Living facilities at the end of each month over 31 months showed that on average, 91.8% of residents needed assistance with toileting, 91.7% need assistance with repositioning, 96.2% need assistance with transferring, and 94.1% needed assistance with transferring ( Table 1 ). In addition, 30% required the assistance of 2 staff members for toileting, repositioning, and transferring. In addition, 37% of residents had swallowing difficulties that required additional time for eating assistance. These overall data showed that Golden Living residents had high needs for basic care.

Average Percentage of Residents With Care Needs Obtained From MDS Data for Each Facility Over 31 Months (December 2006 Through June 2009).

Source. MDS summary data derived from monthly snapshots on all active residents on the last day of each month from each facility obtained from Centers for Medicare & Medicaid Services (CMS). El Dorado reports were from December 1, 2006, to June 30, 2007.

Note. MDS = minimum data set.

Staffing Levels

Average staffing hours were marginally above the state minimum requirements.

Table 2 shows the staffing hours from weekly focus reports (excluding administrative nurses). The average CNA staffing was 2.08 hprd and total direct care nursing staffing was 2.98 hprd. The average total direct nursing care reported to the state on Minimum Staffing Reports (MSRs) and corrected by the state OLTC was slightly lower (2.93 hprd). Thus, these facilities had total nurse staffing at close to or marginally above the lowest staffing ratios permitted by Arkansas law (a total of 2.78 hprd).

Golden Living Facility Reports of Average Direct Caregiver Hours Based on Weekly Focus Reports, MSR Hours, and Budgeted Nursing hprd for 2006-2009.

Source. Golden Living Weekly Focus Reports, Minimum Staffing Reports (MSRs) reported to the Arkansas Office of Long Term Care, and total budgeted nursing hprd. El Dorado data were for December 1, 2006, to June 30, 2007.

Note . hprd = hours per resident day; CNA = certified nursing assistant; RN = registered nurse; LPN = licensed vocational nurse.

Shift staffing reports showed many shortage of CNAs and violations of state standards

Table 3 shows staffing on Golden Living facilities self-reports (in the MSRs submitted to OLTC) were short on CNAs to provide direct care on 3087 shifts and total minimum staffing ratios for total direct care nursing staff were violated on at least 3119 shifts. The OLTC-corrected MSRs revealed that Golden Living facilities were short on CNA staffing on 6260 shifts and that the facilities violated minimum staffing ratios for total staff on 3561 shifts during the 2006-2009 period. Moreover, the shortages and violations occurred in all 12 Golden Living facilities over the time period.

Number of Golden Living Shifts With CNA Short Staffing and Total Minimum Staffing Ratio Violations Reported by Golden Living and Identified by Arkansas Office of Long Term Care in 2006-2009.

Source. Facility submitted MSRs and OLTC reviewed MSRs. El Dorado reports were from December 1, 2006, to June 30, 2007.

Note. CNA = certified nursing assistant; GL = Golden Living; OLTC = Arkansas Office of Long Term Care; MSRs = Minimum Staffing Reports.

Arkansas OLTC issued deficiencies for inadequate staffing

Throughout the class action period, the Arkansas OLTC issued a total of 53 staffing deficiencies across the 12 facilities and documented specific shifts and days when the facilities had inadequate staffing. Sometimes the pattern of short staffing was for more than 20% to 45% of the shifts, and some fines were issued.

Staffing levels were lower than average facilities in the state

Golden Living facilities had staffing levels that were far lower than the average nursing facility (excluding hospital-based facilities) in Arkansas. Specifically, Golden Living’s self-reported average CNA hours were 2.18 hprd compared with an average of 2.66 in Arkansas facilities (or 81% of average) in 2008 (which was similar to the hours in 2007). In addition, the Golden Living reported average total nursing, including the administrative nurses, was 3.42 hprd compared with 3.93 for all Arkansas facilities on December 31, 2008 (or 87% of average).

Resident acuity compared With CNA staffing hours showed omitted care

The simulation model for resident dependency (acuity) compared CNA actual staffing hours with needed CNA hours. For example, during the 31-month period under study, DES testing showed that the Arkadelphia facility had an estimated 168 386 hours of basic care that were omitted (see Figure 1 .). 46 , 47

Discrete event simulation (DES) test results for Golden Living—Arkadelphia, December 1, 2006, to June 30, 2009.

Overall, the 8 facilities, including Arkadelphia, examined during every day of the class period (December 2006 through June 2009) had omitted an estimated 33% to 58% of the basic care hours needed by the residents (no figure shown). The cumulative gap between CNA labor hours needed and CNA actual labor hours exceeded 1.2 million hours across the 8 facilities. These findings were consistent with findings from the CNA charting for every resident on each shift, which revealed a high rate of undocumented ADL care. The average missing documentation was 15.6% across all shifts for the facilities reporting, with an overall range of 2.6% to 31.5%.

Staffing levels were below the expected staffing calculated by CMS

In 2009, CMS’s 5-star nursing home compare report card calculated that “expected” staffing levels taking into account resident acuity for 11 Golden Living facilities should have been 0.99 RN hprd and 3.96 total staffing hprd (no table shown). The staffing hours reported to CMS were far below this level (0.37 RN hprd and 3.48 total staffing hprd in 2009). Reported RN staffing was only 37% of expected staffing.

Staffing levels were below the levels recommended by experts

An examination of the staffing levels showed that Golden Living facilities did not meet staffing levels for minimum care recommended by scientific studies and the Institute of Medicine recommendations. On average, the facilities ran 15% below the recommended total minimum staffing levels for RNs, LPNs, and CNAs. The total nursing average was 3.48 hprd, compared with the recommended minimum of 4.10 hprd, and CNA staffing was 2.09 hprd, compared with the recommended minimum of 2.80 CNA hprd. Registered nurse staffing (0.37 RN hprd) was only 49% of the minimal level recommended by experts (0.75 hprd recommended).

Staffing levels were inflated

Three data sources suggested that Golden Living inflated its staffing reports to the state. First, CNA staffing levels reported in the MSRs were inflated on 17 336 shifts across the 12 facilities when compared with employee time cards. Second, a total of 394 time clock adjustments at Golden Living data facilities were submitted because nursing staff were not able to take meal breaks related to “insufficient staff.” In addition, 69% (270) of the 394 time clock adjustments for short staffing were not reported by Golden Living as short staffing on its MSR shift reports. Third, e-mails at different facilities reported that the company increased nursing staff during its annual state surveys by bringing in staff from other facilities and available managers. Staff members were asked to come early and stay late (and sometimes skip meals), and some put in 12-hour shifts while surveyors were in the facilities. Department heads and managers were asked to stay on the floors and out of their offices and to immediately address surveyor concerns. At least 17 e-mails in 2006-2008 were identified from corporate leaders regarding staffing up and adjustments for the state surveys.

Nurse staffing levels were not adjusted for resident acuity

A review of Golden Living’s policies and procedures found no policies, procedures, instruments, or staffing acuity tool for adjusting the numbers of staff to meet the needs of residents or for taking into account changes in resident acuity. Depositions of 4 directors of nursing and 2 clinical service directors confirmed the absence of procedures or a staffing acuity tool for adjusting staffing to meet residents’ acuity/care need levels. Numerous e-mails between the Golden Living facilities and corporate managers revealed that staffing was based on census, not on acuity, and each facility’s budgeted staffing. Deposition testimony of directors of nursing reported that the staffing budgets were not based on or adjusted for resident acuity.

Nurses reported frequent understaffing and poor quality care

In depositions, 7 directors of nursing reported that their facilities were understaffed and that it resulted in many staff and resident complaints and poor quality of care. They stated that they reported understaffing to the corporate Director of Operations and asked for more staff, but they were not given additional staffing. Depositions by 3 Clinical Service Consultants who worked directly for the corporate office reported they were aware of facilities repeatedly violating the Arkansas minimum staffing regulations, that facilities were frequently understaffed, and that residents and staff made many complaints. They also reported that the corporate Director of Operations was aware of the understaffing and state violations but that the Director did not agree to increase facility staffing levels or the staffing budgets.

Directors of nursing lacked authority to adjust staffing

Arkansas law required that the directors of nursing be involved in the determination of the numbers of nursing personnel and recommend these numbers based on the needs of residents. Deposition testimony of 3 Golden Living directors of nursing reported they had no authority or involvement in staffing decisions. These directors of nursing and 2 clinical service consultations reported that only the corporate Director of Operations had the authority to increase staffing levels.

Residents’ Rights and Quality of Care

Facilities received frequent grievances.

There were extensive complaints and grievances filed with Golden Living nursing facilities by residents and their family members and/or caregivers. Out of a total of over 3000 grievances reported, more than 700 grievances were filed by families or residents about lack of staff, basic care, and skilled care that occurred in the 12 facilities over time. According to 2 directors of nursing, the grievances produced by Golden Living to the Court represented only a small portion of the total grievances received by facilities.

The most serious grievances involved failures to provide basic care, including many call lights not being answered in a timely manner and residents not being assisted to the toilet when needed, resulting in incontinence of bowels or bladder and residents being left in urine and feces for long periods of time. Resident grievances also included not being cleaned and bathed properly or as scheduled, being left in the same soiled clothes for several days, beds that were not made, linens that were often not changed, and bad odors in the rooms and hallways (urine and feces odors). Other grievances were about residents being left in bed and not helped to get up and dressed, poor oral care (including not brushing residents’ teeth), not washing and caring for residents’ hair, not turning and repositioning every 2 to 4 hours, and not provided assistance with walking. Some residents filed grievances about the lack of adequate assistance at meal times with food and drinks reporting they often did not get enough to eat and drink and did not receive water and fresh water at the bedside. Although the complaints about poor basic care indicated a shortage of CNAs and poor supervision, most resolutions to the grievances were reported by the facilities as planning to give more in-service training to the CNAs.

Grievances about licensed nursing care included not giving pain medications in a timely way, poor pain management, and not giving other medications on time; not sending patients to the hospital soon enough; and not notifying the family members and physicians about changes in conditions, hospitalizations, emergency visits, and appointments. Complaints about the development of skin tears and pressure ulcers were reported along with problems of dirty bandages, and colostomy and catheter bags not being changed. Finally, rudeness and abrasive comments by CNAs and licensed nurses to residents were reported. In addition to written grievances, there were telephone hotline calls regarding understaffing and poor care. Although the grievances at Golden Living facilities could not be compared with grievances at other Arkansas facilities because electronic records were not kept, the grievances identified staffing and quality problems in the Golden Living facilities.

State surveys found problems with quality of care

The Arkansas OLTC issued many deficiencies for poor basic care that violated resident dignity and were associated with inadequate staffing. These deficiencies included the failure to prevent pressure sores and skin breakdown, inadequate assistance with transfers that could result in accidents and injury, inadequate toileting and incontinence care, inadequate bathing and dressing and grooming, inadequate assistance with resident transfers in lifts that caused or could have caused harm and jeopardy, and failure to protect the dignity of residents. The deficiencies cited by OLTC ranged from no actual harm to immediate jeopardy for residents, and many were directly and indirectly related to understaffing. Specifically, El Dorado and North Little Rock were issued immediate jeopardy deficiencies for violating the accident and supervision requirements related to the physical transfer of residents in lifts, a fine was imposed, and a finding of substandard care was issued. These state deficiencies for poor quality were consistent with the low staffing levels reported by Golden Living facilities.

Medical records of residents showed serious quality problems

An expert review of 41 class action residents’ medical records showed serious quality problems. 49 These problems included pressure ulcers, contractures, falls, injuries, infections, and other conditions or outcomes regarded by CMS as quality indicators. There were many violations of residents’ rights, including the failures to treat pain, failures to notify the treating physician of significant changes, failures to comply with physician’s orders, and failures to provide nursing intervention in response to fall risk, weight loss, and skin breakdown. After a posthospital procedure, 1 patient who was groggy from sedation later died of aspiration pneumonia and a broken hip after falling from his wheelchair when he should have been kept in bed and not fed. Many problems identified in the medical records were not reported on the MDS assessments, suggesting deliberate underreporting by staff of quality indicators to CMS.

Previous lawsuits

During the period of 2006-2012, a total of 92 individual lawsuits were separately filed in Arkansas counties against the 12 Golden Living facilities for low staffing and poor quality of care. Although data were not available on the number of lawsuits in other Arkansas facilities, these cases clearly constituted a warning to management about quality problems in its Golden Living facilities.

Corporate leaders knew that staffing levels were insufficient

Golden Living nursing home administrators and the Arkansas Corporate Offices received a number of warnings about understaffing in the 2006-2009 period, which included the short staffing reports, survey deficiencies, e-mails reporting understaffing, and the grievances and deficiencies the facilities received. The corporate knowledge of the problems was confirmed by numerous e-mails between local facility staff and corporate supervisors and in depositions by directors of nursing, clinical service directors, and the facility administrators. Data from depositions of Golden Living nurses linked the quality concerns to low staffing levels. A review of the corporate e-mails revealed corporate pressure to keep staffing levels at or below budget.

In addition, Clinical Service Consultants conducted routine facility visits and facility performance assessments (in part to prepare for state surveys) and reviewed monthly facility scorecard reports sent to them by facilities. The visits, assessments, and scorecard reports showed repeated problems at the Golden Living facilities with falls, pressure sores, weight loss, failure to respond to grievances, failures to provide skilled and basic care, and other quality of care issues. The Clinical Service Consultants prepared reports from their routine facility visits and facility performance assessment that were sent to each facility and corporate Director of Operations. The Clinical Service Consultants reported the clinical problems were related to low staffing in the facilities as well as poor training and supervision.

Admissions were not reduced when understaffing was reported

Frequent e-mail evidence showed that corporate management exerted consistent pressure to increase the census at all Golden Living facilities. According to depositions by directors of nursing at facilities as well as the marketing directors, there was no self-imposed cut-off of resident admissions regardless of the staffing levels at facilities. Many corporate e-mails encouraged facility administrators to admit residents, even when facilities had staffing violations and shortages. Corporate officials designed and implemented financial bonus programs as incentives to facility leaders to build their census, including payments for every resident admission, with additional bonuses for reaching certain census levels. The resident admission records show that facilities continued to admit residents throughout the class period (with a total of 2219 admissions between December 2006 and June 30, 2009).

Litigation Action and Settlement

In the class action, plaintiffs alleged that Golden Living violated 3 specific requirements: (1) Arkansas Deceptive Trade Practices Act (Ark. Code Ann 4-88-101 et seq), (2) the Protection of Long Term Care Facilities Residents’ Act (Ark Code Ann Section 20-10-1201 et seq), and (3) the Defendants’ standard admission agreement. 13 The complaint charged that these violations occurred because the nursing homes failed to meet the minimum staffing requirements and violated residents’ rights, causing injury to the residents of the facilities. The defendants denied the charges and argued that plaintiffs legally failed to state a claim for punitive damages and failed to establish a prima facie case for punitive damages. The defendants argued that the plaintiffs failed to connect any alleged understaffing to patient outcomes, that the facilities did not repeatedly violate Arkansas staffing laws, and that there was no intentional concealment or false representation to the state OLTC. 49

Following a lengthy 5-year legal process, a settlement agreement was reached in 2017 for a total of $71 986 816 which included a cash payment for each class member’s duration of stay multiplied by the subject days ($55 per patient day × 877 040 patient days or $48 237 000) and $5000 for the contribution of each of the class representatives. In addition, the defendants also agreed to pay $19.295 million in attorney fees and $4.2 million for litigation expenses. 14

Summary and Discussion

This case study showed a chain with 12 facilities where resident care needs were high and nurse staffing levels were too low to meet the needs of residents. Although Golden Living gave the appearance of complying with federal and state staffing requirements, a careful review found the facilities did not meet the minimum state staffing standards, did not provide sufficient care to meet basic resident needs, did not adjust staffing for resident acuity, and did not meet the necessary nurse staffing levels shown in research and recommended by experts. As a result, residents experienced many quality of care problems, injuries, and deaths, as well as violations of their rights to human dignity.

The low staffing at Golden Living was similar to staffing reported at other large for-profit chains that have been documented to have the lowest staffing levels of any ownership group. Many large for-profit chains appear to use low staffing as a basic corporate strategy for making profits. 7 , 8 , 12 , 15 , 16 , 18 This case study should be a cautionary tale that nursing home companies with understaffing are legally responsible for the negative effects on residents. Nursing homes must meet the federal requirements to meet the needs of its residents as well as professional standards to ensure adequate quality of care. 30 - 35

Although the staffing levels in the 12 Golden Living facilities were lower than the average nursing home in Arkansas, this study could not determine whether the grievances, deficiencies, medical record review, and litigation history at Golden Living were substantially worse than other comparable facilities in Arkansas. Certainly, the descriptive information showed a pattern of violations of residents’ rights and harm and jeopardy to residents associated with its low staffing levels.

In the Golden Living case, the state OLTC documented frequent violations of the state staffing law and issued some penalties and warnings. The penalties imposed were not as strong and not issued as frequently as allowed under the state law. The lack of effective enforcement by state officials allowed the understaffing to persist in the Arkansas Golden Living facilities over the 2006-2009 period. Arkansas’ weak regulatory enforcement was consistent with studies that show deficiencies for inadequate staffing levels are rarely issued by state inspectors, and CMS does not have guidelines for penalties for staffing violations. 1 - 4 , 10 , 12 The regulatory failure to ensure adequate staffing and quality in this case had a detrimental impact on residents and led to the class action litigation. Although the settlement of the lawsuit resulted in a large financial penalty to Golden Living, the management employees were not held accountable for the low staffing and poor quality of care. These management employees included the Arkansas Director of Corporate Operations, the Clinical Nurse Specialists, the nursing home administrators, and the nursing home directors of nursing. If the Arkansas regulatory system had more clearly identified the low staffing and quality problems at the time they were occurring, stronger sanctions could have been imposed, including fines for violations and holds on resident admissions. Stronger sanctions may have forced the corporation to hold employees accountable and to take action to improve the staffing.

The findings showed that corporate management was aware of the staffing and quality problems in its facilities from facility reports by managers as well as from regular clinical reviews of residents conducted by corporate Clinical Nurse Specialists, but management actions were not taken to make substantial improvements. Some management practices appeared to contribute to the facility problems, including failure to delegate staff budgeting and management to the facility directors of nursing, verbal pressures from corporate leaders along with financial bonuses to administrators to keep each facility’s resident census high and to stay under the corporate staffing budget for each facility, allowing facilities to fall below the state minimum staffing requirements and to inflate their staffing reports, failure to establish a system to determine staffing needs and to set staffing based on resident care needs, and failure to address the quality problems identified by the chain’s own Clinical Nurse Specialists, the grievance system, and the state deficiencies.

With the regulatory and management failures in this case, litigation was an option that was eventually used by residents. Although lawsuits represent a potential or actual threat, the impact of litigation on chains may not be as great as might be expected because many chains have liability insurance. Moreover, large chains have extensive legal and financial resources that can be used to fight and prolong litigation cases, making such cases financially challenging to plaintiffs and their attorneys. 12 An aggressive defense may deter plaintiffs, but it may also have deterrent effects on the defense when it is expensive to mount. One corporate strategy for nursing homes with quality and or litigation problems appears to be to sell troubled facilities. A recent study reported that nursing homes that had a transaction (a sale, acquisition, or merger) during the 1993-2010 period were more likely to have deficiencies preceding and following transactions than nursing homes with common ownership. 50 After the class action case was filed, Golden Living sold 13 Arkansas nursing homes in 2009 but remained liable for the actions of its facilities before they were sold. 51 Golden Living also sold 10 nursing homes named in a 2015 lawsuit by the Pennsylvania state attorney general, 52 and recently, the chain reported divesting its operating interest in nearly 200 nursing homes across the country, leaving only about 100 facilities under its management. 53 Because poor quality nursing homes owned by chains are more likely to be involved in sales, researchers have urged greater government regulatory oversight of chains, along with improved ownership reporting and transparency. 7 , 8 , 12 , 50

The settlement in this Golden Living case has significance beyond its recognition that nursing facility residents who did not receive the care and services needed should receive meaningful compensation. The settlement more broadly illustrates the importance of both professional standards of practice in determining staffing needs at nursing facilities and the new facility assessment process that is required by the revised Medicare and Medicaid Requirements of Participation 54 nationwide.

Since 1991, the nursing standard in the Requirements of Participation has required each nursing facility to have “sufficient nursing staff . . . .” 40 The revised Requirement expands on this language and now provides (new language underlined) that

The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e). 55

The new facility assessment process, which CMS describes as “a central feature” of its revisions to the Requirements, 55 requires the facility “to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies” and to address, specifically, among other factors, “The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population.” 54

The CMS does not contemplate a one-size-fits-all staffing pattern; it does not mandate uniform staffing ratios that all facilities must meet. Instead, CMS requires facilities to use professional expertise to determine both the specific care and services their residents need and how they can competently meet those individual resident needs.

The Golden Living case shows that rigorous analysis by professional nurses is essential to determining adequate and appropriate nurse staffing levels and competencies. Going forward, nursing facilities must provide nursing staff to ensure that all residents receive care and services to attain and maintain their highest practicable level of functioning and well-being. In the future, nursing homes with low staffing and poor quality may find themselves facing increased risk for regulatory actions and litigation.

Acknowledgments

The authors would like to acknowledge David Marks at Marks, Balette, Giessel & Young, Plaintiff attorneys, for making court documents, e-mails, depositions, and other records available for the data analysis.

Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The lead author on the paper was a paid consultant to the plaintiffs on the case. The second author had no financial conflicts of interest.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Nurse Medical Malpractice: Case Studies and Risk Management

Legally Reviewed and Edited by: Terry Cochran

Although they do not have as many responsibilities as doctors, nurses of all certifications and specializations can still commit medical malpractice. Many nursing malpractice case studies show that a hospital or other provider can minimize risks, but ultimately, individual decisions by nurses often still cause harm to the patient.

Case after case has shown that hospitals and medical malpractice insurers will fight hard to keep from losing, and will often propose settlements that are worth far less than what you deserve. Even if your malpractice case doesn’t have life-altering consequences, you still deserve full compensation for the new medical expenses and pain and suffering.

Getting a thorough understanding of your case requires extensive legal and medical knowledge, and teaming up with an attorney who doesn’t specialize in medical malpractice will only hurt your case in the end. No matter what your case looks like, you need an experienced personal injury lawyer who has experience dealing with Michigan’s medical malpractice laws.

Why Does Medical Malpractice Happen?

Hospitals are often given risk management recommendations to keep the staff from making errors. These include auditing documentation, training doctors and nurses on new best practices, and implementing adequate support and reporting processes for patients with complaints. Over the past few decades, hospitals have made great strides in improving the practices of their healthcare practitioners, including nurses.

However, since hospitals and clinics cannot supervise every doctor or nurse all the time, medical malpractice can happen even if the best risk management strategies are implemented. Individuals may make poor or incorrect decisions due to inexperience, fatigue, or other factors.

Nurses face many challenges during their jobs, and understaffing may be a contributing factor to some malpractice cases. Failure to adequately document patient needs and care can contribute to cases, as can a nurse’s general failure to listen to patient complaints.

Who Causes Medical Malpractice?

In some cases, the attending physician may ultimately be held responsible for errors. One of our largest medical malpractice cases ultimately found that the resident and attending physicians’ errors caused an infant’s cerebral palsy. The plaintiff, in this case, was able to show that a basic failure to monitor the patient while in labor contributed to oxygen deprivation and resulting harm to the fetus.

However, in many cases, errors by nurses can contribute much more, especially in longer-term care settings like nursing homes and even long stays in the ICU. Even though nurses cannot diagnose conditions, they can still make medication errors , failure to notify a doctor of changes in the patient’s condition, or otherwise neglect patients in their care.

Most states do not require doctors or nurses to strictly operate within their area of specialization. A vascular surgeon, for example, is technically allowed to do other types of surgeries, and a neonatal nurse may be allowed to work in many other areas. This can lead to mistakes resulting in medical malpractice, so hospitals often try to minimize risk by keeping staff in their areas of expertise.

How Medical Malpractice Lawsuits Work

Malpractice claims may be asserted if the patient or the family of a deceased victim believes that the medical practitioner violated the standard of care expected for the patient’s medical condition. For example, a patient who suffers an injury due to circumstances outside a nurse’s control cannot sue the nurse for malpractice.

Medical malpractice cases must establish who is responsible for the violation of standard of care that led to the patient’s injuries. Typically, the attending physician cannot be held responsible for mistakes made outside of his supervision.

Healthcare practitioners carry medical malpractice insurance that covers their responsibilities. An insured Nurse Practitioner (NP) who is allowed to write prescriptions can be sued for prescribing the wrong medication, for example. Nurse Practitioner medical malpractice cases can still add up to several hundred thousand dollars, even if their duties are not as extensive as those of physicians.

Verdicts and Case Studies

Case studies involving nurses show that the cause of the malpractice doesn’t matter nearly as much as the final impact on the patient. Even a minor clerical error can result in serious complications that rack up hundreds of thousands of dollars in medical costs.

Our law firm has tackled medical malpractice cases with verdicts of a million dollars or more. These cases have ranged from pharmaceutical errors to birth trauma resulting in cerebral palsy.

Medical malpractice claims asserted against any healthcare provider take time to work their way through the courts and require extensive evidence to prove. While some of that evidence will inevitably be in your own existing medical documentation, cases will still require extensive expert witnesses in order to win in your favor.

Winning Your Case

The best medical malpractice law firms use a range of physicians who are experts in their field to win cases, but it also takes experience and significant legal expertise in order to win. At Cochran, Kroll & Associates, P.C., we’re proud to have a winning team that has the best of both worlds.

Our team includes senior partner, Eileen Kroll , an attorney who’s also a former nurse. Her extensive knowledge and experience allow us to gain an in-depth understanding of your case quickly, so we can advise you and get your case moving as soon as possible.

The statute of limitations on medical malpractice cases in Michigan is just two years, so you need to act quickly. Contact us today at 866-MICH-LAW for a free consultation to talk to our team. Our law firm never charges a legal fee unless we win a settlement in your case.

Disclaimer : The information provided is general and not for legal advice. The blogs are not intended to provide legal counsel and no attorney-client relationship is created nor intended.

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WHAT HAPPENED:

A young couple from Monroe, Michigan, was awarded a $15.8 million verdict as the result of their baby son, Jason, being inflicted with Cerebral Palsy as the result of an error during the final stages of a labor.

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Medical malpractice/wrongful death.

Oakland County, Michigan

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While in the hospital a mother of three was not properly treated for a closed-head injury causing her untimely death.

Result: $1 Million

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Livonia, Michigan

A Livonia pedestrian recovered $1.4 million when he was struck by a commercial van resulting in a traumatic brain injury in Redford, Michigan.

Result: $1.4 Million

Medical malpractice / misdiagnosis.

Wayne County, Michigan

Patient suffered cardiac arrest and brain damage when a hospital failed to recognize internal bleeding and treatment was delayed for more than 14 hours.

Result: $9 Million

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Tuscola County, Michigan

A Tuscola County jury awarded $3.3 million to a severely brain injured motorist as the result of a defective Michigan highway.

Result: $3.3 Million

Accidents & injuries/construction site injury.

Flint, Michigan

A seventeen-year-old construction worker suffered a traumatic brain injury resulting from a fall in Flint, Michigan, and was awarded $1.25 million.

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Medical malpractice.

Middle-aged woman suffered severe disfiguring facial burns from a simple surgical procedure.

Result: $1.9 Million

Medical malpractice / birth trauma.

Southern Michigan

Child developed cerebral palsy with developmental delays due to lack of oxygen and brain injury during labor and delivery.

Result: $3.8 Million

Accidents & injuries/construction site/workplace injury.

Westland, Michigan

A Westland construction worker recovered $1.5 million after sustaining a traumatic brain injury while on a construction site in Detroit, Michigan.

Result: $1.5 Million

Accidents & injuries/truck accident.

Marlette, Michigan

A Marlette, Michigan, family reached a $1.3 million settlement in the traffic death of their 5-year-old son when they were struck by a semi truck.

Result: $1.3 Million

Medical malpractice/cancer misdiagnosis.

Redford, Michigan

The misdiagnosis of breast cancer resulted in a Redford, Michigan, woman recovering $225,000.

Result: $225,000

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Detroit, Michigan

A construction worker redeemed his worker’s compensation case for $125,000 in Detroit, Michigan.

Result: $125,000

A paraplegic woman from Monroe, Michigan, recovered Michigan no-fault benefits including the purchase of a new home and attendant care in excess of $400,000.

Medical Malpractice/Birth Injury

Brighton, Michigan; Detroit, Michigan

A Brighton family recovered $1.3 million and a Detroit family recovered $900,000 as the result of birth injuries and medical malpractice to their children.

Result: $2.2

Bay City, Michigan

A Bay City grandmother was awarded $80,000 following an auto accident resulting in a broken leg.

Result: $80,000

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Educating Injury Victims

• Assault and Abuse
• Elder Abuse and Neglect
• Case Example: Nursing Home Negligence

Case Example: Nursing Home Negligence and Abuse

Charles R. Gueli, Esq.

Licensed Attorney

Charles is a practicing attorney with over 20 years of experience in personal injury law. He was recently selected as a SuperLawyer by Thomson Reuters, an exclusive honor awarded to the top 5% of attorneys.

When a nurse violently attacks her elderly patient, the victim’s family sues the nursing home for negligence.

Statement of facts, the incident of abuse, lawsuit against the nursing home, important points about nurse negligence.

This review examines an incident involving nurse negligence and physical abuse. After a nurse beats an elderly man, the resident’s family filed suit against the nursing home, claiming that the facility had failed to properly screen and monitor its staff.

This case study is for educational purposes only. It is based on actual events, although names have been changed to protect those involved. Any resemblance to real persons or entities is purely coincidental.

We’ll cover how our victim was injured, criminal penalties for elder abuse, the family’s civil lawsuit, and the final resolution to the nursing home case.

Our study finishes up with a list of important points about elder abuse in nursing homes .

On a sunny Monday in March, 71-year-old Mark Galer moved to the Bellarme Nursing Home.

Bellarme was a nursing home facility licensed to provide residential care to patients. State law only required that there be at least one Registered Nurse on staff. Most direct patient care was handled by Licensed Practical Nurses (LPN) and certified nursing assistants.

Bellarme hired Sheila Willis as a Licensed Practical Nurse. Her duties included: giving medications to patients, wound care, delivering food trays, assisting patients with meals, and direct patient care, including bathing, dressing, and other personal care.

Bellarme’s standard hiring procedure was to run a criminal background check and verify at least three of the applicant’s references.

By the time Mr. Galer moved to Bellarme, Willis had worked there for six months and had been verbally reprimanded on three separate occasions for negligently ignoring patient requests.

Willis had also been written up twice for nurse negligence. The first written reprimand was for pushing a client in a wheelchair into a nearby wall. The patient wasn’t seriously injured, and Willis said she “slipped on a wet floor, causing her to accidentally push” the patient’s wheelchair into the wall.

The second written reprimand for nurse negligence was for striking a patient who was complaining about Willis’s rudeness. Willis contended she didn’t hit the man but instead was trying to keep him from getting up and possibly injuring himself. She said as she was attempting to “settle the man down, my hand may have accidentally hit his face.” In that incident, as well, the man was not seriously injured.

In January, Galer underwent hip replacement surgery . He remained in the local hospital for three days before he was released to Bellarme.

Galer was confined to his bed or his wheelchair. The nurses helped him get into bed and helped him get out of bed and into his wheelchair.

Three days after his return, Galer rang his call bell to ask for a nurse to help him get into his wheelchair so he could go to the bathroom. As his need for the bathroom became urgent, Galer called out many times and received no response.

That day Willis was assigned to take care of eight patients. Galer was one of them.

Finally, after Galer had been yelling for help for over five minutes, Willis entered his room. According to other staff who were with Willis just before she responded to Galer’s shouts for help, Willis was upset with having to break away from the television show she and some other nurses regularly watched during their shift.

Willis went into Galer’s room, followed by a nursing assistant who came to check on another patient.

At that point, Willis was heard shouting at Galer, saying, “I’m tired of your ass!” Immediately after making that statement, Willis picked up a telephone book and struck Galer in his face, breaking his nose.

Galer tried to fend off the attack, but Willis continued to strike him about his head and mouth with the telephone book and her hands. Galer began screaming for help.

The nursing assistant who followed Willis into the room had been tending to another patient when she heard Willis tell Galer she was “ tired of [his] ass .” Turning to see what was happening, she saw Willis strike Galer in the face with the telephone book and hit his head and face with her hands.

The nursing assistant immediately attempted to restrain Willis from further attacking Galer. Willis was 5’6″ and weighed almost 200 pounds, while the nursing assistant was only 5’4″ and weighed about 110 pounds.

The commotion could be heard down the hall and was simultaneously registering on the hospital’s surveillance system. Within one to two minutes, several staff members ran into Galer’s room. They were finally able to restrain Willis. She continued to curse and yell at Galer the entire time, even spitting on him as she was pulled away.

Galer was slumped in his bed with blood spewing from his mouth and nose. One of the nurses immediately called 911. Within minutes the police and paramedics arrived. Galer was stabilized and rushed to the local hospital.

Willis was placed under arrest for assault and battery . She was later found guilty of criminal assault against an elderly person and sentenced to five years in jail.

Galer’s family retained a personal injury attorney who specialized in nursing home abuse. She filed suit against Bellarme and Willis, citing nurse negligence, nursing home neglect, assault, breach of contract, and negligence.

Soon after filing suit, Galer’s attorney took the deposition of each staff member who was on duty the day of the attack and the nursing home administrators. She also issued a subpoena to Bellarme requesting Willis’s personnel records and the security system videotape that captured the sounds from Willis’s attack on Galer.

During her deposition, the Chief Administrator of Bellarme admitted during questioning that she did not run a criminal background check or contact Willis’s references before hiring Willis.

The attorney for Galer then produced a copy of Willis’s criminal record. The attorney asked the administrator if she could identify the mug shot attached to the paper. She also asked the administrator to read aloud the criminal charges and convictions listed on the record.

The administrator said there appeared to be three convictions for assault, with one a felony conviction for assault on an elderly person. Galer’s attorney asked the administrator if the person whose criminal record she was holding was Sheila Willis. The administrator said, “It appears so.”

Finally, the attorney played the security video that captured the assault and asked the administrator if she could confirm that the tape was an accurate portrayal of Galer’s assault. The administrator agreed it was.

Three days after the administrator’s deposition, the attorneys for Bellarme entered into a settlement agreement with Mr. Galer. The amount of the settlement was undisclosed.

• Elderly and dependent adults are particularly vulnerable to abuse by caregivers, so most states have robust laws to punish abusers.
• Elder abuse may be physical, mental, sexual, or financial.
• Neglect is a form of abuse in nursing homes that can result in an elderly patient’s wrongful death .
• Nursing home abuse victims and their families often have the right to file a civil lawsuit , even if no criminal charges are filed against the wrong-doer.

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Nursing Home Negligence: A Case Study

A recent Hyatt & Weber client, a disabled woman in her 50s, was admitted to the hospital for increased weakness and decreased level of functioning. She was later transferred to a nursing home for rehabilitation. In her medical chart, it was clearly expressed that she needed to receive special care and attention due to her health condition.

Because of the state of her health, our client needed assistance moving, turning over, and other basic physical functions. The medical records also documented she was at high risk to develop pressure ulcers To avoid the ulcers, the care plan and physician orders stated that the nurses should have performed weekly skin assessments and document the changes. The plan also indicated that she needed to be repositioned regularly so that there would be no extensive pressure or blood loss to any part of her body.

Sadly, the poor documentation and inability to follow the care plan led to the client developing an unstageable, odorous pressure ulcer on her sacrum, a triangular bone that sits between the two hipbones of the pelvis. An unstageable pressure ulcer is one that envelops the full thickness of the skin tissue and the wound is covered by a thick, yellow layer of slough making it hard to determine the true depth. The pressure ulcer was so severe, she developed sepsis and lost much of her ability to walk. Several surgeries were required—surgeries that could have easily been avoided with the proper care.

Upon investigation, the nursing home’s negligence was impossible to miss. Records showed that she spent significant time in a wheelchair around the nursing home, and there was no effort of thenursing home staff documented to reposition her or to reduce the pressure on the sacrum by offloadinbg through the use of cushions and a specialty mattress. Additionally, there was no account of any skin breakdown or symptoms of a potential pressure ulcer until it was too late. In fact, nursing assessments and notes stated that the skin was intact and there were no problems within hours of transfer for surgery.

Armed with the clear evidence of neglect, the medical malpractice team at Hyatt & Weber was able to successfully advocate for our client’s right to quality nursing home care. The case was settled out of court in the amount of $535,000.

Do not let nursing homes mistreat your love ones. In their final years of life, they deserve the best care that can be offered. If your loved one is being neglected in a nursing home and you’re ready to take legal action, call Hyatt & Weber at (410) 384-4316.

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Never a fee unless we win., nursing home negligence in southern california: a case study, march 12, 2021.

Many of our loved ones, whether family or friends, live or will live in a nursing home at some point in their lives. Nursing homes are supposed to provide useful services such as housing, housekeeping, personal care, skilled nursing and other medical care. Additionally, nursing homes often include special programs for elderly individuals suffering with Alzheimer’s or various forms of dementia.

Luckily, many nursing homes around Southern California provide skilled staff who perform their duties without any neglect or other negligent acts. However, situations do arise when elderly nursing home patients are injured or even die due to the negligence of a nursing home and nursing home staff. Sadly, this occurs everywhere from Los Angeles to Orange County to Sacramento. If this happens, the injured patient, or their family, may bring various claims against the nursing home or nursing home staff such as negligence, wrongful death or elder abuse. In this blog post, we provide a case study involving nursing home neglect and negligence that went before the California Supreme Court.

In Delaney v. Baker (“ Delaney ”), a daughter (“Daughter”) placed her 88-year-old mother (“Mother”) into a nursing home after the Mother fractured her ankle. ( Delaney v. Baker (1999) 20 Cal.4 th 23) Four months after the Mother entered the nursing home, the Mother died. Upon the Mother’s death, the Daughter examined the Mother’s body and found pressure ulcers (“bed sores”) all over the Mother’s ankles and feet. The daughter investigated and learned that the nursing home had left the Mother lying in urine and feces for extended periods of time. The daughter also learned that the nursing home had failed to adequately train employees and failed to properly monitor the Mother.

The Daughter sued the nursing home and medical professionals (“Professional”) for a number of causes of action including negligence and neglect of an elder. The jury found for the Daughter and awarded damages, including heightened damages and attorney’s fees under California’s elder abuse statute (“Elder Abuse Statute”). On appeal, the California Supreme Court considered whether the trial court properly entered heightened damages under the Elder Abuse Statute. The nursing home’s attorneys argued that the trial court had erred because the professional negligence statute restricted heightened damages. The Supreme Court considered the purpose of the Elder Abuse Statute, which they analyzed as “protecting a particularly vulnerable portion of the population from gross mistreatment from abuse and custodial neglect.” (Id.) Indeed, in 1982 the California Legislature recognized that dependent adults may be subjected to neglect, or abandonment and [California] has the responsibility to” protect [elders].” (Id.) Ultimately, the Supreme Court upheld the Court of Appeals’ decision and permitted the heightened damages.

Delaney involved a complex analysis of statutory interpretation and legislative intent. However, the fact pattern has sadly been repeated time and time again. Nursing home patients and elders are regularly injured due to nursing home negligence and neglect.

As discussed, there is no area of Southern California that is immune from nursing home negligence, neglect and elder abuse. Negligence, wrongful death and elder abuse claims are regularly brought in Los Angeles, Orange County, San Diego and Ventura County. The attorneys at MKP Law Group, LLP have years of experience litigating cases against nursing homes and nursing home staff throughout California. If you or a loved one has been injured due to nursing home negligence, neglect or elder abuse , you may have a right to be compensated for the injures. Contact MKP Law Group, LLP for your 100% free consultation today.

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