1 UAB Disability Justice Program Members: Jefferson County Medical Examiner UAB Dept. of Pathology Office of the Jefferson County District Attorney UAB Dept. of Justice Science Cumberland Law School Alabama Dept. of Mental Health and Mental Retardation

2 Outline of Civil Monitoring of Residential LTC Facilities Facility TypeFederal Regs. State Regs. National Industry Standards Medical or Nursing Consultant Required Liability Insurance Required Staff Check Level of Risk 1. Nursing Home++++Required L 2. Assisted Living ---Variable+ RequiredOptionalL 3. Group Home---Variable H 4. Boarding Home---Variable--- H 5. Unlicensed Residential Care --- H Federal regs. refer to specific federal nationwide regulations that apply to the industry. State regs. refer to regulations imposed on a state by state basis. Staff check refers to background checks of employees. Risk is based on level of regulatory scrutiny, civil or criminal safeguards, requirement for background checks of employees, and level of civil liability exposure. “Variable” indicates that requirement is based on state or local laws.

3 Outline of Civil Monitoring of In-home Services Service TypeFederal Regs. State Regs. National Industry Standards Medical or Nursing Consultant Required Liability Insurance Required Staff Check Level of Risk 1. Home Health+++BothRequiredVariableL 2. Hospice+++BothRequiredVariableL 3. Hired Help H

4 Sites of Dying in the U.S. 56% - Hospital 21% - Home 19% - Nursing Home 4% - Other CDC Statistics 2002

5 The Reverse Abuse Pyramid 1999 Statistics (n=17 states) 32.0 / 1,000 – prevalence 8.6 / 1,000 – reports 5.5 / 1,000 – investigations 2.7 / 1,000 – substantiation ? -prosecution ?? - conviction ???- autopsy Am J. Public Health 2003;93(12):

6 Outcome of Abuse X3  Mortality  Nursing Home  Medical Morbidity JAMA 1998;280:428-43

7 13-Year Mortality for Mistreated Elders (% Living) 9% - Abuse victims 41% - Morbidity Matched Comparison JAMA 1998;280:428-43

8 Abuse Screening 70% - abuse detected vs 30% self-report 10 - validated instruments 2% - report by MD JAGS 2004;52:

9 ME Facts on Nursing Home Abuse 10% - Employees with criminal history 1/3 – cited for abuse 10% - employees admit to abuse 44% - residents describe abuse/neglect 1/2 - families unwilling to complain

10 Conclusion 1.Confused persons don’t report. 2.Untrained workers struggle to gather information. 3.Law enforcement receives conflicting information.

11 Nursing Home Survey Terminology and Procedures 1.MDS – minimum data set 2.RAP – resident assessment protocol 3.Incident report 4.Annual Survey 5.Deficiency 6.Jeopardy / decertification

12 Psychopathology in NH Residents 67-80% - cognitive impairment 10-20% - depression 3-7% - delirium Textbook of Geriatric Psychiatry

13 Post Mortem Findings in 52 Demented Elders %Post Mortem Finding 40 -MI / varying age 46 -Bronchopneumonia 36.5-Emphysema 17.3-PTE 8 -Unsuspected Malignancy 73 -ASCAD ARCH Path Lab Med 2004;128:32-38

14 Seven Deadly Sins of Long-term Care 1.Dehydration 2.Malnutrition 3.Decubiti 4.Lethal Accidental Injury 5.Adverse Drug Reactions 6.Behavior Management Catastrophes 7.Systematic Abuse and Neglect

15 Feeding Problems with Dementia 50% unable to feed self at 8 years 85% institutional residents refuse food Am. J. AD & Rel. Disor 2004;19(1):24-30

16 Staffing and Feeding 1:3 - Desired staff / resident ratio 1:9 - Daytime 1:12- Nighttime meal

17 Accuracy of CNA Estimate for PO Resident Intake* 22% - Overestimate 53% - Missed residents with below 75% consumption * Video Technique JAGS 2000;40:

18 Staffing in Nursing Home No specific minimum for CNA 3.5 contact hours for any nursing over 24 HS Burger et al. Comm. Fund Report, 2000