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Nursing Home

Deaths

Approximately 17, 000 nursing homes exist in the U.S., housing 1.5 millionpatients over the age of 65 years. Deaths in Nursing Homes (NH) are, forthe most part, natural and usually do not fall under the medical examiner’sjurisdiction. There are exceptions, such as:

Drug Overdoses

Such deaths may be either inadvertent or intentional. The authors haveinvestigated a number of cases where a patient was given either too muchmedication or the wrong medication. This situation is probably fairly com-mon, but, in most instances, does not cause death. When death does occur,the nursing home is probably often unaware of the mix-up and assumes thedeath to be natural. In virtually all the cases where death was caused by aninadvertent overdose and the death was investigated, the circumstances ofthe case came to light only when an employee surreptitiously notified themedical examiner or the family. Insulin seems to be quite commonly involvedin these situations.

In rare instances, the drug overdose is intentional. A number cases ofhealth care workers who believed it their calling to end “suffering” by killinga patient have been reported. The only cases such as this seen by the authorsinvolved potassium chloride. In one case, it was a concentrated oral medi-cation administered via a PEG tube.

Accidents Not Involving Medications

These include asphyxial deaths caused by bedrails and restraint vests, drink-ing of cleaning fluids by senile patients, burns caused by immersion in hotbath water, falls etc. It is not uncommon for the NH staff to attempt toconceal a fatal accident.

Homicides

The perpetrators of the homicides may be NH personnel, visiting familymembers, or fellow patients. In two recent cases, patients were beaten to

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death by fellow patients who suffered from Alzheimer’s disease. Weaponsused were a metal crutch and part of a wheelchair.

Suicides

These are very uncommon. More common are the spouses of patients withchronic or fatal disease who come in, kill the patient, and then kill themselves.

Gross Neglect of Patients

Nursing homes or personnel have been charged with homicide for improperand inadequate care of patients.

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In one case involving a death resultingfrom infected decubitus ulcers (pressure sores), the care-home provider wasconvicted of manslaughter.

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In another case, an attending nurse pled guiltyto the felony offense of injury to an elderly individual, second degree, becauseshe did not promptly notify a physician or summon EMS personnel when apatient was obviously suffering a heart attack.

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In all probability, the numbersof cases in which individuals and perhaps institutions will be charged withhomicide in the death of patients will increase.

Signs of Neglect

Signs of neglect are:• Contractures • Malnutrition• Dehydration • Decubitus ulcers

Of course, these complications overlap and one can contribute to the devel-opment of another.

The biggest problem in many, if not most, Nursing Homes in this countryis staffing. Unskilled individuals are hired at very low salaries to minister tosick, debilitated and often confused patients. Employees may not be ade-quately screened and it is not uncommon for individuals with criminalrecords to be hired. Training is minimal. To make matters even worse, staffnumbers are generally inadequate. Thus, in many nursing homes a CNA(certfied nursing assistant) is required to feed seven to nine residents duringthe day and 12 to 15 at the evening meal; the ideal caseload is one CNA fortwo to three residents.

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It may take 1–2 min to feed a spoonful of food to animpaired patient —30 to 40 minutes for a meal. If you are required to feedsix patients in an hour, it is not possible. Food is rammed into the mouth,only to be spit out. The record shows, however, that the patient “consumed”100% of the meal. Thus, records will show that all food is eaten, but severeweight loss and malnutrition ensue.


Records of the administration of care should always be approached withcaution. Records will show that patients are turned every 2 h, but decubitusulcers develop, that they eat all their meals but lose weight. Medications arealways given, even when it turns out that they were not available. In someinstances, care is documented as being given even after the patient has died.

Contractures

A

contracture

is an abnormal, often permanent, condition characterized byflexion and fixation of a limb at a joint. Contractures leave the joint in anon-functional position, resistant to bending. They are caused by atrophyand abnormal shortening of muscle fibers. Their primary cause is disuse.Prolonged bed rest, even in “normal” individuals, results in loss of leanmuscle mass through lack of use. The muscles become weak, atrophic, changeshape, and shorten with disuse. The muscle decreases in diameter and in thenumber of muscle cells. Eventually, there may be replacement with fibrousconnective tissue, progressing to fibrosis and development of contractures.

Contractures are seen in NH patients with impaired sensorium who areconfined to bed. In such patients, a nurse should administer a passive range-of-motion exercises on a daily basis to prevent development of contractures.Often, this is not done and contractures develop. Development of contrac-tures indicates poor nursing care i.e., that the individual is not receivingappropriate joint exercises. Approximately 20% of nursing home residentsnationwide have contractures.

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Malnutrition

Malnutrition is manifested by a deficit, excess, or imbalance in essentialcomponents of a balanced diet. The type of malnutrition seen in nursinghomes is usually protein-caloric malnutrition. Thirty-five to 80 percent ofpatients in nursing homes are malnourished, with 30–40% of patients sub-standard in weight.

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A weight loss of 5% or greater in 30 d, 7.5% in 3 monthsand 10% in 6 months, indicates a patient’s nutrition should be evaluated.

The amount of nutrition required by a person to live depends on bodysize, age, health, the environment, and degree of activity. The

basal metabolicrate

(BMR) is the amount of energy required of an individual who is awakebut at rest, to maintain cellular function at the lowest rate. For a 25-year-oldmale weighing 154 lbs, it is 1744 cal; for a 132-lb, 25-year-old woman, 1281cal. The number of calories required by a person increases with activity andhealth problems. Since we are discussing bedridden patients for the mostpart, we can ignore activity. In such patients, however, health problems arefrequent. Stress caused by infections or decubitus ulcers can increase thecaloric requirement by a factor of 1.2 to 1.6. For the 25-year-old male, the


calories needed would increase to 2100–2800 cal. The BMR increases 5% forevery 1ºF rise in body temperature, which necessitates an increase in caloricintake. As to protein intake, in a normal individual, 0.8 to 1.0 g/kg/day ofprotein is needed. With infection or decubitus ulcers, this can increase up to1.2 to 1.5 g/kg/day.

Malnutrition in nursing home patients can be caused by:

• Chronic disease conditions that make eating difficult, e.g., paralysiscaused by a stroke

• Increased caloric or protein requirements due to infection or the heal-ing of wounds

• Medications that impair the desire to eat, e.g., psychotropic drugs• Failure of the nursing home to feed the patients

Obviously, the first three causes have to do with why the patient is in thenursing home. It is the duty of the nursing home to overcome these problemsand see that the patient is offered and consumes adequate amounts of food.

Malnutrition predisposes an individual to the development of decubitusulcers and infection. These, in turn, lead to increased caloric and proteinrequirements, thus making the malnutrition worse, which, again, predisposesto decubitus ulcers and infection.

While loss of weight often is an indicator of malnutrition, this is notalways the case. The easiest way of determining malnutrition is by measuringserum albumin. The level of albumin in the blood is a reflection of thenutritional status of the patient. (Table 21.1) Low levels are associated withprotein deprivation (inadequate intake of protein). They are also seen inchronic disease, infection, surgical stress, and trauma, all of which result indemand for more protein. Individuals in nursing homes suffering from theseconditions should be given additional food (calories and protein).

Low levels of albumin reflect longstanding malnutrition. The half-life ofalbumin is 12 to 20 d, but is shortened in the presence of infection.

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Thus,low levels of albumin generally reflect what happened to the patient 1–2months in the past. In contrast, acute starvation reduces the concentrationsof proteins that have a short half-life: transferrin (half-life 5 d) and pre-albumin (half-life 2 d).

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Table 21.1 Blood Albumin*

Normal 3.5 - 4.5 g/dl

Mild protein depletion 3.0 - 3.4 g/d

Moderate depletion 2.5 - 2.9 g/dl

Severe depletion < 2.5 g/dl

* There is some variation in normal ranges among laboratories.


Dehydration

Dehydration is very common in NH patients. It is caused by illness (diarrhea,fever, infection), the effects of medications (e.g., diuretics), and decreasedfluid intake. When personnel do not monitor the intake of fluid and provideextra fluids when required, dehydration develops.

Decubitus Ulcers

Decubitus ulcers (pressure sores) are entirely preventable. They need not andshould never occur. Factors predisposing to pressure sores are:

• Depressed sensory or motor function• Altered consciousness• Pressure over bony prominences• Malnutrition• Shearing forces• Moisture (fecal and urinary incontinence)

The most common cause of decubitus ulcers is

pressure

, usually overbony prominences, in an individual with altered consciousness or impairedmotor activity. When the pressure on soft tissue is greater than 32 mm ofmercury, it closes capillary blood flow. This results in deprivation of oxygento the tissue in this area and accumulation of metabolic end products. Ifthese continue to accumulate for more than 2 h, there is irreversible tissuedamage. The inability to shift one’s body because of depressed sensory ormotor function or unconsciousness leads to abnormal pressure and, thus,development of decubitus ulcers. The most common sites are the sacrum,the coccygeal areas, and the greater trochantars from lying in bed, as well asthe ischial tuberosities if the patient is able to sit.

The second major cause of decubitus ulcers is

malnutrition

. This resultsin muscle atrophy and decrease in subcutaneous tissue, reducing the paddingover the muscles, making the pressure more significant and producing ulcers.

Obesity

also contributes to pressure ulcers. A normal amount of fat protectsthe skin by acting as a cushion. Large quantities of fat, however, lead toulceration because the adipose tissue is poorly vascularized and the under-lying tissue then becomes more susceptible to ischemia.

Another major factor causing ulcers is

shearing forces

. Here, there issliding of one tissue layer over another with stretching and angulation ofblood vessels, which results in injury and thrombosis. This commonly occurswhen the head of the bed is raised too high and the individual’s body tendsto slide downward. Friction and perspiration cause fixation of the skin and


the superficial fascia to the sheets, while the deeper fascia slides down. Shear-ing forces in the elderly are aggravated by the loose skin common in theelderly because of loss of subcutaneous tissue and dehydration.

Moisture

, usually caused by urinary and fecal incontinence, is also amajor factor predisposing to development of pressure sores. Moisture reducesskin resistance to the other factors and increases the possibility of decubitusulcers fivefold.

Decubitus ulcers (pressure sores) are divided into four (4) stages basedon their clinical appearance and extent.

Stage 1

— The initial lesion seen following compression of skin andtissue is

reactive hyperemia

(reddening of the skin). The redness is causedby sudden increase in blood flow to the area compressed, after relief fromthe pressure of compression. If there is no injury to the tissue, the rednesswill disappear in less than 1 h. If the compression is long enough to produceischemia but not irreversible injury, then you have an abnormal reactivehyperemia, which can last several hours. If the pressure is maintained longenough, one then has a stage 1 pressure sore manifested by erythemia thatlasts longer than 24 h, does not blanch on pressure, and shows indurationof the tissue caused by edema. These sores can occur in a matter of a fewhours. In our opinion, while stage 1 pressure sores are an indication of apotential problem, they do not in themselves indicate neglect. They arereadily treatable and should not progress.

Stage 2

— These range in severity from a blister to ulceration of the skin.They may involve the full thickness of the skin but do not penetrate into thesubcutaneous fat. These lesions are in a grey zone as indicators of neglect.They shouldn’t occur, but do. They are readily treatable.

Stage 3

— These are full-thickness ulcers extending through the skin andsubcutaneous fat up to the fascia. There is usually undermining of the skin.The base of the ulcer is usually necrotic, foul-smelling and infected.

Stage 4

— Here the ulcer extends down through the fascia into muscle,often to the bone. Osteomyelitis may develop (Figure 21.1).

Stage 3 and Stage 4 ulcers, in our opinion, indicate poor or lack of nursingtreatment and thus neglect. Preventive measures involve basic nursing tech-niques. In bed, the patient should be turned or repositioned at least every 2 h;in wheelchairs, every hour. Adequate nutrition and hydration should be given;the skin must be kept dry by preventing patients from lying in their urine andfeces; the head of the bed should not be raised to such a degree that the patientwill slide down and, if necessary, extra padding over bony prominences shouldbe provided. If a sore develops, the physician should be notified immediately.

The incidence of pressure sores in individuals in nursing homes varies fromstudy to study. A conservative approximation is 7–8%. Tsokos et al. conducteda prospective study of 10,222 bodies coming to cremation in Hamburg,


Germany, from various sources including nursing homes, hospitals and privateresidences.

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Pressure sores were observed in 11.2% of the individuals. Thedistribution of the sores by grades was Stage 1–6.1%; Stage 2–3%; Stage 3–1.1%and stage 4–0.9%. Stage 3 and 4 sores were found principally on the sacrum(69.6%). Seventy-three percent of all Stage 4 sores were in individuals 80 yearsof age and older. For Stage 4 sores, the place of death was:

• 36.2%: senior citizen or nursing home • 23.4%: private home • 17%: hospital • 23.4%: unknown

The site where the individuals developed the sores was not necessarily thesame as where they died.

Figure 21.1

Stage IV decubitus ulcers


Both the presence of pressure sores and deaths caused by them are under-reported. The authors have reviewed hospital admission records of patientswith pressure sores where the sores are not mentioned at all in the physicalexaminations by the physicians or in the diagnoses. Pressure sores are dis-missed as inevitable by many physicians. In fact, there is no doubt thatpressure sores can be successfully prevented by determining the patients atrisk for development of sores, consistently monitoring them for developmentof sores and instituting prophylactic procedures to prevent their develop-ment. If sores develop, they can be effectively treated by conservative orsurgical means.

Decubitus ulcers, Stages 2–4, lose both fluids and proteins. The more severethe lesion, the greater the loss. These open sores are invariably colonized bybacteria. The resultant infection can cause septicemia. The exact incidence ofthis complication is unknown, because many physicians fail to attempt toconclusively determine the source of a fatal septicemia in these patients.

Homicide by Decubitus Ulcers

How can one defend a ruling of homicide in a death from decubitus ulcers?In these cases, what one attempts to show is that the patient died of thedecubitus ulcers and that the ulcers developed secondary to gross neglect, orfailure to provide the most basic nursing services. Quite commonly in suchcases, a pattern of falsified records is found, delay in notifying attendingphysicians of the presence or severity of the ulcer, and failure to promptlyinstitute therapy ordered by the physician.

Physicians, both clinicians and forensic pathologists, have a tendency towrite off the deaths of nursing home patients as inevitable. Some individualsand institutions argue that, because of the patients’ condition (i.e., they arebedridden, do not have control of their bowels, and cannot feed themselves),then it is expected that they will become malnourished and develop contrac-tures and bed sores. There are two problems with this argument. First, ifthese same individuals were moved into institutions where they were pro-vided good nursing care the decubitus ulcers would heal; the patients wouldgain weight and overall health would improve. Second, infants are bedridden,have no control over their bowels and can’t feed themselves. If a caretakerstarved a child, leaving it in its urine and feces so that it developed sores andinfections, that caretaker would be arrested; charged with child abuse, andput in prison. A death in such circumstances would be ruled homicide.

Deaths Caused by Hospital Bed Side-Rails

Bed side-rails are intended to prevent patients from injuring themselves.They are not suitable for and will not restrain individuals who are active


or ambulatory, no matter the mental status. Bed rails cause injury indirectlyin that most falls from beds in elderly individuals occur when they attemptto climb over the rails. On occasion, bed rails may cause death directly byentrapment.

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The majority of such cases involve nursing homes, wherethe patients are elderly and tend to have cognitive and physical disabilities.

Parker and Miles reviewed 74 deaths attributed solely to bed rails. In 52(70%) of the cases, there was entrapment between the mattress and bed rail,with the face pressed against the mattress.

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Thirteen (18%) of the deaths werecaused by entrapment of the neck within the rails (eight had inserted theirheads between the vertical bars; the bed-rail latch failed and the rail droppedon their necks; five patients died because their heads and necks were drapedover the top of the rails). Nine (12%) of the 74 patients died when they slidpartially off the bed. This resulted in their being suspended by either theirheads or pelvises with, in the latter circumstance, the necks hyperflexed orhyperextended by contact with the floor.

In a number of deaths involving bed rails seen by the authors, attemptsto conceal the cause of death were made. This involved placing the individualback in bed and notifying the attending physician that the patient had diednaturally. Such cases were uncovered only when NH personnel reported thedeaths to the medical examiner or a member of the family.

Deaths Caused by Medical Restraints

Restraints are mechanical devices, materials, or equipment that restrict indi-viduals’ freedom of movement or normal access to their bodies. If individualsattempt to escape from such devices, they run the danger of ligature stran-gulation or traumatic/positional asphyxia.

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Miles and Irvine reviewed 122deaths caused by vest and strap restraints, in which 85% occurred in nursinghomes.

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The victims were elderly, with a median age of 81. They were foundsuspended from chairs in 58% of the cases and from beds in 42%. Typically,there was a history of sliding down in or escaping restraints. Victims areplaced in a vest or strap restraint and left alone. They then slide off the bedor chair, with the restraint catching them across the chest or, less commonly,under the chin. Unfortunately, they do not slide down far enough to reacha weight-bearing surface. If the restraint catches them under the neck, theystrangle. If the restraint stops at the chest, their weight on the restraintreduces chest movement, causing traumatic asphyxia.

References

1. Long S,

Death Without Dignity

, Texas Monthly Press, Austin TX 1987.

2.

State of Hawaii v. Bermissa

, 2000.


3.

State of Texas vs. Jo Ann Maddox,

1999.

4. Burger SG, Kayser-Jones J and Bell JP, Malnutrition and dehydration innursing homes: Key issues in prevention and treatment. June 2000. Researchsupported by the Commonwealth Fund. http://www.cmwf.org/pro-grams/elders/burger_mal_386.asp.

5. Neale G, Diet and disease. In Tomlinson S, Heagerty AM and Weetman AP(Eds).

Mechanisms of Disease

. Cambridge University Press Cambridge, UK1997.

6. Tsokos M, Heinemann A, and Puschel K, Pressure sores: epidemiology, med-icolegal implications and forensic argumentation concerning causality.

Int JLegal Med

, 2000 113:283-287.

7. Todd JF, Ruhl CE and Gross TP, Injury and death associated with hospitalbed side-rails: Reports to the U.S. Food and Drug Administration from 1985to 1995.

Am J Pub Hlth

, 1997; 87(10):1675-1677.

8. Parker K and Miles SH, Deaths caused by bed rails.

J Am Geriatrics Soc

. 1997;45(7):797-802.

9. Di Maio VJ, Dana SE, and Bux RC, Deaths caused by restraint vests.

JAMA

1986; 255:905.

10. Miles SH and Irvine P, Deaths cause by physical restraints.

Gerontologist

. 1992;32:762-766.

http://www.cmwf.org/programs/elders/burger_mal_386.asp

http://www.cmwf.org/programs/elders/burger_mal_386.asp

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