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Maryland COMAR Regulation 10.07.02.12 sets forth the responsibilities of the Director of Nursing in Maryland nursing homes.  Pursuant to Maryland COMAR Regulation 10.07.02.12G, the Director of Nursing is responsible for, among other duties, "planning for the total nursing needs of patients to be met" and "execution of patient care policies."  This section may ultimately support a cause of action against the Director of Nursing in a nursing home negligence case involving bedsores (also known as decubitus ulcers or pressure ulcers). 

Under Maryland's nursing home regulations, nursing homes are required to file a signed copy of the agreement between the Nursing Home Administrator and the Director of Nursing that, among other things, specifies the duties of the Director of Nursing.  This information can be obtained from the State via public information request and we routinely obtain this information in our cases.

Most qualified medical experts would agree that the standard of care applicable to nursing homes requires the nursing home staff to ensure that a resident entering the facility without pressure ulcers does not develop them unless the resident's clinical condition demonstrates that they were medically unavoidable.  The nursing home staff must also ensure that a resident having pressure ulcers receives necessary and proper wound care treatment and services to promote healing, prevent infection and prevent new ulcers from developing.  The nursing home staff must relieve pressure by turning and repositioning the resident at least every two hours while in bed and every hour while in a Geri-chair or wheelchair, maintain adequate nutrition and hydration, and prevent contractures of the extremities.

Unfortunately, once a bedsore has progressed to stage 3 and stage 4, it can be difficult to achieve healing and avoid painful and life-threatening complications such as osteomyelitis (infection of the bone) and sepsis (blood infection). 

Please feel free to contact the nursing home neglect lawyers at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication error/prescription mistake, elder abuse or elder neglect.

Many nursing homes now include arbitration agreements among the mountain of paperwork that they have patients or their families sign at the time of admission to the nursing home.  These arbitration agreements attempt to prevent jury trials in the event of later allegations of injuries or death resulting from nursing home negligence. Rather, such disputes would be decided by arbitrators often chosen by the nursing home and subject to rules and procedures dictated by the nursing home.

Many people have no idea what they are signing at this very stressful time of their lives as they are focusing on ensuring that their family member or loved one gets necessary medical care.  As a result, it is common for family members to sign these arbitration agreements without reading the documents and/or giving any thought whatsoever as to later ramifications. 

Under Maryland law, if a mentally competent patient signs such an arbitration agreement at the time of admission to a nursing home, he or she will likely be bound by its terms down the road. 

It is often the case, however, that a family member or loved one signs the admitting nursing home paperwork.  Executed nursing home arbitration agreements typically are not even a precondition to the patient receiving treatment or services.  In situations where someone other than the resident signs the arbitration agreement and the patient may receive health care without signing the arbitration agreement, the Court will focus its analysis as to whether the arbitration agreement is binding upon whether the individual who signed the arbitration agreement was authorized to waive the resident's access to the courts and right to a trial by jury.  See Dickerson v. Longoria, 995 A.2d 721 (Md. 2010).  Importantly, evidence of authority to make health care decisions and financial decisions are not relevant to this analysis.  Instead, there must be evidence that the resident authorized decisions to be made on their behalf regarding access to courts and right to jury trial.      

Please feel free to contact the nursing home neglect attorneys at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication error/prescription mistake, elder abuse or elder neglect.

Under current Medicare guidelines, hospitals are no longer reimbursed for additional care resulting from pressure ulcers (also known as bed sores or decubitus ulcers) as the government has determined that development of bed sores at a hospital is a so-called "never event."  Additionally, hospitals cannot bill patients directly for such care.  The denial of reimbursement for such reasonably preventable treatment errors should provide hospitals with financial incentive to institute and implement appropriate patient safety measures geared toward preventing the development of bedsores. 

While there has been discussion about extending this policy to include long term care facilities including nursing homes and assisted living centers, nursing homes are not presently subject to these guidelines.  Nursing homes are therefore presently permitted to receive payment for care and treatment related to bedsores that develop in their facilities, while hospitals cannot.  This writer firmly believes that these Medicare "never events" guidelines should be extended to include nursing homes and other long term care facilities so that these facilities will have the same financial incentive as hospitals do to improve patient safety measures relating to preventing the development of bedsores.

Like hospital patients, nursing home residents are often at risk for developing bedsores as a result of their underlying medical problems and/or mobility issues.
 
A pressure sore/decubitus ulcer is a bedsore caused by unrelieved pressure on the skin that comes from lying in the same position too long and is associated with pain.  Patients experience pressure from their bed and/or chair to certain points on their skin preventing the blood from flowing into those points.  Because the blood is not allowed to flow into those points, the skin, deprived of nutrients and oxygen, can become injured and susceptible to infection.

A stage 1 ulcer presents as redness of the skin without a break in the skin and represents tissue injury that does not disappear when pressure is relieved.  A stage 1 ulcer is classified as nonblanchable erythema with intact skin.  Erythema is redness of the skin produced by congestion of the capillaries.  Erythema is the initial reactive hyperemia caused by pressure, and nonblanchable erythemia represents stage 1 pressure ulcer.

A stage 2 ulcer is characterized by partial-thickness skin loss, that is, the epidermis is interrupted as an abrasion, blister or shallow crater.

A stage 3 ulcer features full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend to, but not through, the underlying fascia.  The ulcer appears as a deep crater, with or without undermining of adjacent tissue. 

A stage 4 ulcer involves full-thickness skin loss (exposing bone or muscle) with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., a tendon or a joint capsule).

Once a bed sore has progressed to stage 3 and stage 4, it is difficult to achieve healing and avoid painful and potentially fatal complications.   With stage 3 or stage 4 pressure sores, the extent of the disease may not be evident because of covering necrotic material or eschar.  To establish the extent of the disease and promote healing, the necrotic material needs to be removed and surgical consultation may be required.  When ulcers develop over bony prominences, osteomyelitis is a potential complication.  Pressure ulcers are chronically contaminated wounds and the combination of bacteremia and pressure sores can be painful and life threatening.

Fortunately, as reflected by Medicare's "never event" guidelines, pressure ulcers may be entirely avoidable so long as proper care and preventative measures are instituted and implemented by the health care provider.  The time is right to extend these "never event" guidelines to include nursing homes and other long term care facilities.

Please feel free to contact the nursing home neglect attorneys at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication error/prescription mistake, elder abuse or elder neglect.

Family members who wish to complain regarding the care and treatment provided to their family member or loved at nursing homes in Maryland have several potential options.

First, the family can complain to the nurse in charge of the unit, and then to the Director of Nursing, Administration or Medical Director of the nursing home.  Under Maryland law, the Nursing Home Administrator is required to investigate complaints within thirty days.

If there is a concern that such complaints to the nursing home could negatively impact the patient's safety or well-being, it may be advisable to contact the Maryland Office of Health Care Quality/ Department of Health and Mental Hygiene.  To make a complaint, call the Maryland Office of Health Care Quality at (410) 402-8000.

The State's nursing home inspection results are considered public information and can be obtained from the Maryland Office of Health Care Quality.  Requests for such results should be forwarded to:

Office of Health Care Quality
Spring Grove Hospital Center
Bland Bryant Building
55 Wade Avenue
Catonsville, Maryland 21228
Attn: Public Information Request
(410) 402-8000

Finally, families can make complaints to their local county nursing home ombudsman.  
Under the Maryland Long Term Care Ombudsman Program, each county in Maryland is served by a local nursing home ombudsman.  An ombudsman is a government official  who helps people resolve problems with nursing homes and assisted living facilities. 

The Maryland State Ombudsman's Office can provide the contact information for the local county Ombudsman office.  The contact information for the Maryland State Ombudsman's Office and several local county offices follow:

Maryland Department of Aging
State Long Term Care Ombudsman
Patricia Bayliss--Chief Ombudsman
301 West Preston Street, Room 1007
Baltimore, Maryland 21201
(410) 767-1100
(800) 243-3425, ext. 71108 (toll free)

Baltimore City   (410) 396-2273
Baltimore County  (410) 887-2594
Prince George's County (301) 265-8450
Anne Arundel County  (410) 222-4527
Howard County  (410) 313-5980
Montgomery County  (240) 777-3000
Harford County  (410) 638-3025

Please feel free to contact the lawyers at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of elder neglect or abuse.

Section 14-302 of the Family Law Article of the Maryland Annotated Code requires Maryland health practitioners, police officers or human service workers who have reason to believe that the a vulnerable adult has been subject to abuse, neglect, self-neglect, or financial exploitation to report such abuse immediately to the local department of social services.  This statute would include reporting of nursing home abuse/neglect.  Any other person (other than health practitioners, police officers or human service workers) who has reason to suspect elder abuse/neglect may also make a Complaint.  

To make a complaint, call the following telephone number - 1-800-917-7383.   

A State investigation is conducted in response to every complaint of neglect/abuse.  If abuse is substantiated, Maryland Adult Protective Services may intervene.

Please feel free to contact the lawyers at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury as a result of nursing home neglect or abuse.

A recent Clinical Research Study entitled "The Safety of Warfarin Therapy in the Nursing Home Setting" published in the American Journal of Medicine, Volume 120, No. 6 (June 2007) examined the preventability of adverse warfarin (also known as Coumadin) events in the nursing home setting.  This study concluded that the use of warfarin (Coumadin) "in the nursing home setting presents substantial safety concerns for patients.  Adverse events associated with warfarin therapy are common and often preventable in the nursing home setting.  Prevention strategies should target the prescribing and monitoring stages of warfarin management."   

Coumadin (generic name: warfarin) is an anticoagulant, or blood thinning medication, that is prescribed to many nursing home patients who are at risk for developing blood clots that could result in heart attacks or strokes.  It is a very powerful drug that is also still used as rat poison and requires careful monitoring in humans.  In our practice, we have seen the devastating results when nursing homes fail to take the proper steps to ensure that their residents receive proper administration and/or monitoring of their Coumadin therapy. 

Patients taking Coumadin require periodic blood samples to measure their clotting time, or INR (International Normalized Ratio), and may require periodic adjustments of their daily dosage of Coumadin in order to ensure that their blood remains within their predetermined therapeutic range.  The physician overseeing a patient's Coumadin therapy will set a target INR range usually between 2.0 to 3.0.  Patient's with mechanical heart valves may require target INR in the range of 2.5 to 3.5.    

If a patient takes too much Coumadin, they can suffer life-threatening complications due to excessive bleeding.  If a patient takes too little, their blood will clot and they can suffer a heart attack or stroke. 

The nursing home staff must ensure that the resident takes the appropriate dosage and receives regular INR testing.  The nursing home staff must also ensure that the doctor overseeing the care timely receives the testing results, and is immediately made aware of all significant changes in the patient's condition.  In the event that the physician cannot be reached, residents experiencing significant changes in condition should be transported to a hospital immediately.

The nursing home staff must also ensure that patients taking Coumadin are provided with the appropriate diet because some foods interact with the drug.  Many commonly used medications such as antibiotics also interact with Coumadin.  Additionally, the nursing home staff must institute and implement fall precautions because residents taking Coumadin may have increased bleeding risk.

Ultimately, Coumadin administration and/or monitoring errors may be avoidable so long as nursing homes develop and implement policies and protocols aimed at: (1) ensuring that the resident receives proper INR testing, and that the results are timely analyzed and acted upon; and (2) ensuring there is a clear flow of information provided to all health care providers (especially the prescribing doctor) who interact with the resident.

Please feel free to contact the nursing home neglect lawyers at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of Coumadin administration and/or monitoring errors, bed sores (also known as pressure sores or decubitus ulcers), dehydration/malnutrition, nursing home falls, elder abuse or elder neglect.

I just read a disturbing article in the October 1, 2009 online edition of the Chicago Tribune entitled "Nursing Homes a Risky Business - Dozens of Mentally Ill Felons Are Housed in Facilities Tied to 2 Executives."  This article discusses the practice of nursing homes admitting mentally ill criminals (often in order to receive Medicaid reimbursement) who go on to harm other residents.  The incidents cited in the article include allegations of physical assault and rape.

As if families forced to put their loved ones into nursing homes didn't already have enough to worry about, they must now consider the possibility that dangerous, mentally ill fellow nursing home residents may harm their loved one.

Ultimately, a nursing home may be responsible for injuries caused by fellow nursing home residents as the nursing home must institute appropriate protocols and policies that protect the safety and welfare of their residents.

Please feel free to contact the attorneys at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injuries inflicted by a fellow nursing home resident. 

Non-ambulatory patients residing in nursing homes are at risk of developing pressure sores on their heel and ankle areas as a result of unrelieved pressure and friction.

Once these sores develop, it can be difficult to achieve healing and avoid potentially painful and fatal complications including sepsis (blood infection), osteomyelitis (bone infection), amputation, surgical wound debridement and even ultimately death.

It is therefore critical that nursing homes develop and implement wound prevention care plans and perform risk assessments at the time of admission.  In addition to daily monitoring and regular skin assessments, the nursing home staff must ensure that pressure and friction in the heel and ankle areas are reduced and relieved.  This may be accomplished as simply as through the use of pillows to offload the heels.  The nursing home staff must, however, be on the lookout for patient movement that may displace the pillow.  Other preventative measures include heel protectors, boots and pressure relieving mattresses.  Heel protectors may help to provide continuous pressure relief, and also act to minimize friction and shear on feet, ankles and heels. 

Families must be advocates for their loved ones and they should be on alert for these issues and regularly visit the nursing home resident and inspect their skin.  Families should also discuss preventative heel ulcer care with the nursing home staff.  As the saying goes, "the squeaky wheel gets the grease."

In our practice, we have seen the tragic results of the failure of nursing homes to implement effective and proper heel pressure ulcer prevention protocols.  In one situation, a vulnerable, mentally challenged individual was admitted to the nursing home with no skin breakdown for short-term rehabilitation services.  He had previously resided in a group home environment and was able to participate in an adult day program.  The plan was for him to return to his previous living arrangements and level of functioning upon his discharge from the nursing home.    During his stay at the nursing home, he did not receive visits from family members.  He was not provided with heel ulcer preventative care and, unfortunately, developed a heel wound that became infected and necrotic, and progressed to stage 4.  He went on to develop severe osteomyelitis of his heel.  In an effort to prevent the potentially fatal spread of osteomyelitis, doctors performed an above-the-knee amputation of his leg.  Sadly, this mentally challenged individual became bed-ridden, requiring permanent nursing home care and never returned to his previous level of functioning.

The good news is that heel pressure ulcers are entirely avoidable so long as proper care and preventative measures are instituted and implemented by the nursing home.  Under new Medicare guidelines, hospitals are no longer even reimbursed for additional care resulting from pressure ulcers as the government has determined that development of bed sores at a hospital is a so-called "never event."

Please feel free to contact the nursing home neglect attorneys at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication error/prescription mistake, elder abuse or elder neglect.

We frequently speak with families who wish to have potential nursing home negligence cases investigated while their family member or loved one simultaneously continues to reside in the target nursing home.  A typical scenario involves a nursing home resident who develops bedsores (also known as pressure sores or decubitus ulcers) during their stay at the nursing home.  The family eventually learns of the wounds and become frustrated as they continually find that their loved one: (1) has soiled themselves, and is dirty and not receiving adequate hygiene care; (2) has not been repositioned or turned; (3) is not receiving adequate hydration and nutrition; (3) is being left in a wheelchair or a Geri-chair without being repositioned for long periods of time; and/or (4) is not receiving regular wound care or medical attention.  The family complains to the nursing home staff regarding these issues, but their complaints are ignored.  The resident's bedsores continue to get worse, become infected and progress to stage 3 and then stage 4.  The resident is in and out of the hospital for wound care, wound debridement and treatment of osteomyelitis (bone infection) and sepsis (blood infection), and then transferred back to the nursing home.

We counsel families faced with these difficult circumstances to focus on the health and immediate well-being  and safety of their loved one.  Putting aside the merits of any potential lawsuit, a family considering suing a nursing home has obviously lost complete confidence in the nursing home's ability to care for their loved one.  As such, in a perfect world, the family should try to locate alternative care arrangements and have the resident transferred as soon as possible.  Everyone knows, however, that the world is far from perfect and that it can be extremely challenging to locate alternative care for many reasons including health insurance coverage issues, Medicare or Medicaid coverage issues, and/or the location of the facility.

In those circumstances where it is not feasible to move the patient, the family should be very careful that the nursing home does not become aware that a potential lawsuit is being investigated so that the patient's care is not compromised.  In these circumstances, our law firm may request medical records from outside hospitals and wound care centers in order to obtain additional information regarding the patient's condition and prognosis.  Based upon the information contained in the medical records, our firm's lawyers can help further counsel the family through this difficult situation in a manner that protects the resident from potential harm.  In the right circumstances, the family may also be directed to request medical records from the nursing home in order to help further facilitate the investigation. 

At the end of the day, these are very difficult issues and each circumstance must be evaluated and treated on a case-by-case basis.  The first concern must always be the health, safety and well-being of the nursing home resident.  The potential lawsuit is secondary and appropriate steps should be taken to ensure that the nursing home resident's health and safety are not jeopardized. 

Please feel free to contact the nursing home neglect lawyers at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication administration error/prescription mistake, elder abuse or elder neglect.