Our Area of Practice

Areas of Practice: What Our Nursing Home Abuse Attorneys Can Do for You at Giroux & Associates Inc.

We have only one area of practice. We limit our practice to cases against Nursing Homes and Hospitals. We only represent nursing home residents and hospital patients who have been neglected or abused. These are the cases that we concentrate on. We do not represent insurance companies, corporations or other entities. Although our focus is on abuse and neglect cases, there are many forms of abuse and neglect that can occur in a nursing home or hospital. Some examples are:

I. Bedsores

Bedsores, also known as decubitus ulcers or pressure ulcers, should rarely occur. They are preventable. A bedsore is caused by lying on a bony area for long periods of time without turning and repositioning , causing a decrease in blood flow to that part of the skin, which in turn, causes the skin to break down. If a resident or patient develops a bedsore, it is usually because the nursing home or hospital failed to provide proper care. Proper care includes:

Turning and repositioning the patient every 2 hours. This is the industry standard. Turning and repositioning is especially important if the resident is bedridden and/or unable to turn and reposition herself. If so, the staff is supposed to turn and reposition the resident every 2 hours. The staff’s failure to do so can cause a resident to develop one or more serious bedsores. A bedsore can develop anywhere on the body, but they often occur on the tailbone, buttocks and heels. Tip: Whenever you are visiting with your loved one, see if anyone comes into the room to turn and reposition him.

Keeping the patient’s skin clean and dry. If the staff fails to keep the patient’s skin clean and dry, the skin will start to break down. This is especially true for incontinent patients and patients who need assistance getting to the bathroom. When a patient is forced to lay in his own feces or urine, his skin begins to break down and a bedsore will develop—and it can happen quickly. Tip: If an incontinent patient (or a continent patient who needs assistance to the bathroom) develops a bedsore on her buttocks or tailbone, that is often an indication that the staff failed to provide timely incontinence care (or bathroom assistance) to the patient.

Applying barrier creams. The staff’s application of a barrier cream to the resident’s skin helps keep the skin protected and dry and reduces the risk of skin breakdown.

Monitoring the patient’s skin for breakdown. This seems obvious, but many times the nursing home or hospital is understaffed and as a result there is not enough staff to monitor each resident’s skin on a regular basis. Bedsores can then develop and go unnoticed by the staff. Tip: If the bedsore, when first discovered, is large and/or deep, or if it is discovered by the patient’s family rather than staff, that is often an indication that the staff was not monitoring the resident’s skin on a regular basis.

Developing and then implementing adequate care plan interventions addressing the patient’s risk for skin breakdown. Upon admission to a nursing home or hospital, a new patient/resident should be assessed by a nurse for risk of skin breakdown. This is called a Braden Assessment. Once admitted, those residents determined to be at risk should be assessed again at least quarterly, and more often (usually monthly) if the resident is at high risk. The care plan team then develops a number of strategies (“care plan interventions”) designed to reduce the resident’s risk for skin breakdown. When a resident nonetheless develops a bedsore, it is usually because the staff either failed to develop adequate interventions to address the resident’s risk for skin breakdown, or failed to consistently implement the interventions that were developed (usually because the facility is understaffed or the staff is not properly trained).

A bedsore is identified by its stage. The deeper the bedsore, the higher the stage and the more severe it is. A stage I bedsore is just an area of red skin. A stage II occurs when there is some loss of skin and a sore starts to form. A stage III occurs when

there is further loss of skin and the sore is deeper, often down to the muscle. A stage IV occurs when the sore is even deeper, often down to the bone.

Bedsores are very painful, and they can become infected especially when the nursing home or hospital fails to follow proper infection control protocol. A stage III or IV bedsore can take a long time to heal; it is a very difficult and painful process. Oftentimes, the bedsore grows progressively worse. It can develop gangrene and can even result in the amputation of a limb. Bedsores can also contribute to or cause death, especially among the elderly.

II. Fractured Bones From Falls

A fall can cause serious injury to a nursing home resident or hospital patient, especially elderly residents because they are susceptible to fractures, especially hip fractures. A fractured hip requires major surgery and extensive rehabilitation, and can cause permanent disability and even death in elderly residents.

Most nursing homes and hospitals take the position that the elderly are going to fall at one point or another, and that the goal is not to prevent all falls because that is impossible. Our position, however, is that we do not expect nursing homes and hospitals to prevent all falls. But what we do expect and insist upon is that preventable falls not occur. A preventable fall is one that could have been prevented had the staff provided proper care to the resident. The following are some examples of preventable falls:

Failure to provide toileting assistance. Many residents are continent and just require a little assistance from the staff getting to the bathroom. A resident typically presses a call light button to request assistance, but many times no staff person responds. This can continue for 15 to 20 minutes (or longer) until the resident, who just can’t wait any longer, attempts to walk to the bathroom unassisted and then falls. The fall could have been prevented had the staff timely provided the resident with assistance to the bathroom. Tip: On one of your visits, try entering your family member’s room without the staff knowing. Press the call light button and see how long it takes the staff to respond.

Improper transfers. Preventable falls can also occur during transfers—usually transfers from a bed to a wheelchair. These falls can occur when the aide who is assisting the patient out of bed fails to lock the wheels on the wheelchair. Or, the aide puts the bed’s side rails down and then leaves the patient unattended to do something else and the patient falls to the floor. Or, only one aide is available to

transfer the patient when two aides are required and the patient falls during the transfer. These are all preventable falls.

Medication – Related falls. Some preventable falls occur when the staff administers medications improperly. This can occur, for example, when a nurse mistakenly gives a resident the wrong dosage of his medication, and the resident falls shortly thereafter. Or, a nurse for whatever reason fails to give a resident her required daily medication, and the resident later falls. Or, a nurse administers a resident his medication knowing that the medication’s side effects include dizziness and weakness, yet there is no supervision provided to the resident who later falls because she was dizzy and weak. All of these falls could have been prevented had the staff followed proper protocol when administering medications.

Infection – Related falls. Many times a preventable fall occurs because of an infection that the patient contracts at the hospital or nursing home. For example, if a patient develops a urinary tract infection that goes unnoticed by the staff (despite its obvious symptoms), then that undiagnosed and untreated urinary tract infection can cause an alteration in the patient’s mental status, which in turn, can result in the patient falling. The fall could have been prevented had the staff timely diagnosed the urinary tract infection and treated it.

Most preventable falls occur because the staff failed to provide adequate supervision of the resident; or the nursing home was understaffed; or the staff was not properly trained. When a fall occurs, the nursing home should call the family and advise them of the fall. Tip: When you are called, ask questions—when did the fall occur; how did it happen; and whether there were any injuries. If possible, visit the resident the same day you are called to see for yourself what the injuries are. Ask the resident how the fall occurred, and ask the caregivers who were on duty at the time how the fall occurred and whether there were any injuries. Tip: If you suspect an injury, insist that the resident be sent to the hospital for x-rays and an evaluation. In our opinion, some nursing homes are reluctant to send a resident to the hospital for an evaluation after a fall because of what the hospital might find—i.e. not just an injury from the fall, but evidence of neglect as well, such as a bedsore; a bad infection; old bruising; an old fracture of unknown origin; dehydration; malnourishment; etc.

III. Infections

Infection is a serious problem in both nursing homes and hospitals. Pneumonia, MRSA and sepsis are all too common. These infections are serious and can be deadly—especially in older residents. Infection occurs when the staff fails to

consistently implement proper infection control measures to minimize the risk of infection. For example, if the staff fails to wash their hands between patients, or fails to wear a gown or gloves when necessary, or fails to isolate residents who have infections, then infection will likely spread throughout the facility. Infection can also develop in a bedsore or other wound of the resident, which can seriously compromise the resident’s medical status. An infection in a bedsore, if not timely diagnosed and treated, can spread to the bone (called osteomyelitis), which often results in amputation of a limb, especially if the bedsore becomes gangrenous.

It is the staff’s duty to notify the physician of signs and symptoms of an infection so that appropriate treatment orders can be entered. It is also staff’s duty to implement the treatment orders. When staff fails to timely notify the physician of an infection, or fails to timely and consistently implement the treatment orders, the infection can spread and usually results in serious consequences to the patient

IV. Malnutrition and Dehydration

The risk of malnutrition and dehydration among the elderly and the sick is well known. Malnutrition and dehydration are two of the most common signs of nursing home neglect. When a nursing home resident suffers from malnutrition or dehydration, it is often because the nursing home staff has failed to adequately address the nutritional and hydration needs of the resident.

Inadequate hydration, or dehydration, occurs when a resident’s loss of fluids is greater than his fluid intake. As a person ages, his risk for developing dehydration increases. Thus, nursing home residents are usually more susceptible to dehydration. It is therefore vital that the nursing home staff take preventative measures to ensure that the residents, who are at increased risk for dehydration, are adequately hydrated. This can be as simple as assisting a resident with drinking; encouraging fluids during meals and between meals; monitoring for symptoms of dehydration; timely notifying the physician; and providing IV fluid replacement when necessary. Tip: Look for a pitcher of water on the resident’s night stand. If the nursing home does not provide one, bring in your own and monitor whether staff keeps the pitcher filled with water.

When staff fails to implement measures to help ensure the residents are adequately hydrated, dehydration can occur, which in turn can lead to serious medical complications, including urinary tract infections; pneumonia; bedsores; disorientation; and confusion. Dehydration can also cause an electrolyte imbalance which can lead to seizures. Reduced blood flow is another complication of dehydration, which can lead to organ malfunction, coma and even death.

Malnutrition, or lack of proper nutrition, can also be life-threatening to elderly residents. Malnutrition includes not only inadequate food intake, but also the failure to receive necessary vitamins, minerals and supplements. According to statistics, about half of all nursing home residents require staff’s assistance with eating. Many times, however, the nursing home lacks sufficient staff to feed all the residents who need assistance. Or, the staff is not adequately trained in meeting the nutritional needs of the residents. Tip: If your family member needs staff’s assistance with meals, try visiting during lunch or dinner and see whether staff is providing that assistance. A full tray that is left untouched well after mealtime is over is an indication that the staff is not providing assistance with meals.

A resident who is malnourished usually suffers from increased weakness as well,

which can result in falls and injuries. Residents suffering from malnutrition are also at increased risk for developing bedsores, pneumonia, urinary tract infections, confusion and memory loss. Malnutrition can also lead to serious medical problems, including organ malfunction, a weakened immune system, loss of muscle mass, anemia and even death.

V. Medication Errors

Hospital patients and most nursing home residents have extensive medical needs and require professional care. They also typically require multiple medications on a daily basis. The residents and the patients rely on the staff to properly administer these medications. When an error occurs in the administration of a resident’s medications, the damage can be devastating.

Common medication errors include:

Giving a resident the wrong medication
Giving the correct medication, but the wrong dosage
Administering a medication late
Failing to administer a medication at all
Failing to monitor a resident for side effects or adverse reactions
Failure to timely discover the medication error
Failure to timely notify the physician of the medication error

When a medication error occurs, it is often because the staff or the facility was negligent in some way. For example, if the facility is understaffed—which means the staff on the floor is overworked—medication errors will inevitably occur. Or, the staff may not be adequately trained; an inexperienced nurse is more likely to commit a medication error than an experienced one. Or, there may be a lack of supervision of the floor nurses who are administering the medications. Or, the staff may be agency staff. Agency staff are RNs and LPNs who are employed by an agency and are assigned on a temporary basis to a nursing home when a nursing home employee fails to show up for work on a particular day or there is some other staff shortage. Typically, agency staff knows nothing about the residents they are caring for, and as a result, mistakes occur. Regardless of the cause of the medication error, the consequences to the resident can be catastrophic.

The overmedication of a resident can be particularly egregious. If a resident is overmedicated because he was given the wrong dosage, that’s negligence. If a resident is overmedicated in order to restrain him, that’s not a medication error, that’s intentional. It is a chemical restraint and it should not occur unless medically necessary and ordered by a physician. The trend today, of course, is to avoid the use of restraints, both physical and chemical, whenever possible. But overmedicating residents because it is easier for the staff to care for them should never occur.

Failure To Assist With ADLs

ADLs are activities of daily living—dressing, eating, bathing, toileting, ambulating, etc. Hospital patients and many nursing home residents, either because of advanced age or poor health or both, require staff’s assistance with their ADLs. An assessment is completed by the staff on admission to determine the extent to which a resident will need the staff’s assistance with her activities of daily living. The resident’s need for ADL assistance is supposed to be documented on the care plan, and interventions or measures are developed by the staff explaining how and when that assistance will be provided to the resident. If the staff fails to document the care plan in this way, that omission can be evidence of negligence. However, most of the time the nursing home documents the care plan appropriately. In fact, when it is sued, the nursing home is quick to point out its detailed care plan for the resident. The real question, however, is whether the staff consistently implemented the care plan.

The staff’s failure to timely and consistently implement the care plan interventions often results in neglect and abuse, usually with severe consequences for the resident. Here are some examples, based on actual cases:

a resident who requires staff’s assistance with eating and reminders to drink lots of fluids repeatedly does not get that assistance, experiences a rapid weight loss, becomes malnourished and dehydrated, and has to be admitted to the hospital for IV therapy, and while at the hospital contracts MRSA and sepsis, prolonging her stay at the hospital.
a resident needs the staff’s help walking to the bathroom, uses her call light for 30 minutes but no one comes, so she tries to walk to the bathroom on her own and falls and fractures her hip, requiring major surgery and rehabilitation.
a resident requires the staff’s assistance ambulating in general, yet he is allowed to wander unsupervised and falls and fractures a leg, requiring surgery, and while at the hospital, develops pneumonia and dies.
an incontinent resident who is unable to clean himself after each incontinent episode needs staff’s assistance but doesn’t get it, and has no choice but to lay in his own feces and/or urine for an extended period of time and eventually develops a large and very painful bedsore on his buttocks, which later becomes infected.
a bedridden resident who is unable to turn and reposition herself must rely on the staff to turn and reposition her every 2 hours to help prevent skin breakdown, but the staff consistently fails to do so and she ultimately develops a deep bedsore on her heel, which later becomes infected and develops gangrene, requiring amputation of the resident’s leg above the knee.

Many of the injuries that nursing home residents suffer could be avoided if the staff would just monitor the residents more closely. The problem, however, is that the nurses and aides are overworked because the nursing home is understaffed. Or, the staff is not adequately trained. Or, the nursing home has excessive turnover and must rely on agency staff. Whatever the reason, the residents are the ones who suffer the consequences. Tip: Gaps in a resident’s nurses’ notes for weeks or months at a time is an indication that the staff is not adequately monitoring the resident.

VII. Wandering and Elopement

Wandering refers to a cognitively-impaired resident who ambulates unsupervised within the nursing home without any purpose and without any regard for his personal safety. The concern is that such a resident could wander into a hazardous situation and injure himself—in a stairwell for example, or a kitchen, or a supply room.

Elopement occurs when a cognitively-impaired resident actually leaves the nursing home (exits the building) unnoticed by the staff and without supervision. Again, the obvious concern is injury or danger to the resident—wandering into traffic for example, or getting lost.

Alzheimer residents in particular are prone to wandering and are at greater risk for elopement. The staff has a duty to take precautions to help prevent wandering and elopement to ensure the resident’s safety. Staff supervision is essential. Alzheimer units should be locked at all times and should require a code to unlock the door before leaving or entering the unit.

Wandering and elopement occur when:

there is not enough staff on duty to supervise the residents
the staff is not properly trained in resident supervision
the nursing home failed to install door alarms or other safety devices to alert the staff when a resident is leaving the unit
the staff failed to respond, or timely respond, to a door alarm