This is the Nursing Home Abuse Podcast. This show examines the latest legal topics and news facing families whose loved ones have been injured in a nursing home. It is hosted by lawyers Rob Schenk and Will Smith of Schenk Smith LLC, a personal injury law firm based in Atlanta, Georgia. Welcome to the show.
Schenk: Hello out there and thanks for joining us. My name is Rob Schenk.
Smith: And I’m Will Smith.
Schenk: And we are Georgia trial lawyers focusing in the areas of nursing home abuse and neglect, and we are also your co-hosts of the Nursing Home Abuse Podcast. We are so honored and so thankful that you have joined us for this particular episode. This particular episode is going to cover infections, that is to say common infections that one would see in a nursing home, as well as the ramifications of those infections, and some of those things that those nursing homes and skilled nursing facilities can do to mitigate and minimize the onset of infections or mass infections in those facilities themselves.
Smith: So this is a topic that is something that I am really passionate about, and the reason I am is – and I know I say this every episode – having worked in a nursing home, but working in nursing homes, working in hospitals, one thing is inevitable. You get sick because you get exposed to all kinds of viruses and bacteria over and over and over again. And I can’t tell you – I don’t know if you remember “They Live,” the movie “They Live” with Rowdy Roddy Piper?
Schenk: I don’t know what you’re talking about.
Smith: And he got the glasses…
Schenk: RIP.
Smith: …Where he puts the glasses on and he can see like all the aliens. It was a 1980s movie called “They Live” with Rowdy Roddy Piper.
Schenk: The wrestler? The professional wrestler?
Smith: Yeah, the wrestler. And he finds these glasses that the aliens are using and they’ve infected certain parts of the population, and when you put these glasses on, all of a sudden you can see all of their stuff, like you can see their billboards, you can see the aliens.
Anyways, the point on that tangent was when I’m at a nursing home or hospital, I basically put those glasses on and what I see if totally different. I see a floor that’s been urinated on, that’s been defecated on. I see walls that are covered in feces and urine, and they are covered in all types of bacteria, viruses, multi-strain resistant viruses. And that’s not to say that it’s necessarily the nursing home or the hospital failing to keep the place clean.
Schenk: It’s just the fact of being a human person. So the statistic here from the Health and Human Services in an abstract report, over 1.5 million people live in 16,000 nursing homes across the United States and experience an average of 2 million infections a year. Infections have been associated with high rates of morbidity, mortality, re-hospitalization, extended hospital stays, substantial healthcare expense. Emerging infections and antibiotic-resistant organisms in an institutionalized environment where there’s substantial anti-microbial overuse and the population is older, frailer and sicker creates unique challenges create unique challenges for infection control.
Smith: Yeah. So these places, it’s like anybody who has kids, they can tell you that kids are just little Petri dishes. Nursing homes and hospitals are Petri dishes. These are really dirty places and if you don’t take away anything else from this podcast, for the love of God, please take this away. When you bring your children to a nursing home to visit grandma and grandpa, remember that. I can’t remember how many times I’d see kids playing on the floor, doing their cars all over the place and then putting their hands in their mouth. No, you need to use precaution.
But who definitely needs to use precaution and is the cause of many transferred infections are the staff. So staff training includes universal precaution training, and that is how we prevent transference of bacteria or viruses from resident to resident. So it involves proper hand washing. It involves when to use gloves. It involves what to do with certain items, for example, with bedpans. Bedpans must be cleaned. How are they cleaned? Where are they cleaned? For example, you have to think this through. You don’t just walk into a nursing home resident’s room, help them use the bedpan, then clean it out in the toilet, then clean it out in the sink, because what you’ve just done is infected the entire bathroom with any possible bacteria, one of the biggest ones being CDIF, which is a major cause of diarrhea, which can kill the elderly because of dehydration and other issues.
So there’s a certain procedure for everything in a nursing home that is meant to cut down on the transference of viruses and bacteria, including – and to me, this is completely unforgiveable, and this is definitely something you need to look for when you go to a nursing home – does anybody there have long fingernails? That is if you want long fingernails, like your fingernails should be short if you work in healthcare. If you see anybody there with fake nails or long fingernails, don’t go there. That is absolutely unacceptable. If that’s something you want to do as a human, you cannot work in healthcare, because all that does is essentially grab all that bacteria and virus, keep it under your fingernails, spread it over everywhere else and even take it home with them. It’s gross.
I tell you what my mom would make my dad and I do, because I lived at home part of the time doing this, as soon as we came home, we would have to take our scrubs off and put them in the washing machine. We weren’t allowed to go sit on the couch. We weren’t allowed to walk around the kitchen first. We weren’t allowed to do any of that. And my dad and I would spray the inside of our cars with Lysol or something.
And this is important because infections are a leading cause of death in nursing homes, and there are several different kinds. There are diarrheal infections that can occur from CDIF. There are respiratory infections. Aspiration pneumonia is a major killer of the elderly, and what aspiration pneumonia is it’s an infection of the lungs. Pneumonia is the infection of the pulmonary system, of the lungs. So what happens with aspiration pneumonia is you inhale some foreign object into the lungs, which causes an infection. It can be gastric juices, so in other words, somebody has gastric reflux disease and they accidentally inhale some of that gastric acid into the lungs and it causes an infection. A lot of them are oropharyngeal dysphagia, which is the inability to swallow. That’s why a lot of residents will have thickened liquid, because they have trouble swallowing, and because of that, we all say, “Oh, I took something down the wrong pipe,” they actually will, and those food particles – doesn’t have to be a lot – can cause an infection. Improper dental care, which is something we have talked about before, bacteria from cavities and from dental problems can be inhaled into the lungs and can cause aspiration pneumonia.
Another common occurrence are UTIs, urinary tract infections. And these are – UTIs are almost inevitable when you have an indwelling catheter. I mean if your loved one has a Foley catheter, they’re going to get a UTI at some point. The nursing home can keep it clean, they can do whatever they want to, but you have – your bladder is sealed off typically, and it – what’s the word I’m looking for? – it’s sterile. It’s sterile in a sealed off environment. When you have an indwelling catheter, you have something from the outside world going into that sterile environment, and inevitably bacteria is going to find its way in there. What you hope doesn’t happen is they don’t end up getting urosepsis, which is even worse than an UTI, and can end up leading to their death.
So just to recap what we’re looking at so far, you’re looking at diarrheal infections, which come from CDIF among others, pneumonia, aspiration pneumonia, even simple – not that it’s simple – but even influenza, the flu can cause pneumonia, which can kill the elderly. You’ve got UTIs.
Schenk: UTIs, which I’m reading here that – and I didn’t realize it, I mean I knew they were common – UTIs are the most common infections and perhaps the most over-diagnosed infections in nursing homes. The presence of an indwelling urinary catheter increases the risk of both UTIs and bacteriura. For example, approximately 3 to 7 percent of nursing home residents with a urinary catheter will require a UTI for each day the catheter remains in place.
Smith: Yeah, that’s amazing. And look at that – what is this next one?
Schenk: By day 30 following catheter insertion, the prevalence of bacteriuria is almost 100 percent.
Smith: That’s bacteriuria. It’s urinary bacteria. It’s bacteria in the urinary tract.
Schenk: Okay. So it is estimated that 50 percent of nursing home residents with a urinary catheter will have symptomatic catheter related UTIs.
Smith: But it’s 100 percent. It is absolutely inevitable. And someone that has had loved ones with disabilities that have to cath in order to go to the bathroom, I can tell you that even in the most strict environments with people giving them round the clock attention, you’re going to get a UTI. It’s just extremely common. Be careful.
Schenk: Okay, let’s take for example, what was the normal protocol in your instance when a resident got aspiration pneumonia?
Smith: Well any time somebody gets an infection, whether it’s a UTI or aspiration pneumonia, the question then becomes – and actually, I don’t want to get off on another tangent here, but this is an interesting subject – so essentially they’re going to have to be treated by a physician, right? So their primary care doctor is notified, and then the question becomes this person has an infection – do we send them to a hospital or do we treat them in house? And that’s a very interesting question because the nursing home only gets that money from CMS while the resident is in the nursing home. So if they have to send this person to the hospital, the hospital then – the money from the federal government follows the resident. So if that person is sent to a hospital, the hospital gets money. So a lot of times, the nursing home sends residents to the hospital when they can just have a staff physician give them antibiotics or whatever they need. So that can become an issue of liability, I think, if that’s how they’re choosing them.
So anyways, in addition to the various indwelling infections, those that are in the lungs, those that get caught in the urinary tract, those that get caught in the bloodstream, infections can get caught on the outside too – lots of skin infections, lots of soft tissue infections.
Schenk: So older nursing home residents are particularly predisposed to skin and soft tissue infections due to several physiological changes that occur with age, including atrophy of epidermis and dermis – remember the skin is an organ – reduced resistance to external insulin that promote wound. The skin can serve as a portal of entry for pathogens. Acute bacterial infections in nursing homes include cellulitis and necrotizing fasciitis.
Smith: Necrotizing fasciitis, that’s the scary one – that’s flesh-eating bacteria, and that’s always a problem. And that’s really the reason that it’s silly and stupid for nursing home staff to ever fail in their diligence of universal precautions, because they’re putting themselves at risk.
Schenk: When you say universal precautions, what do you mean?
Smith: It’s the standard by which you prevent infections. So it’s washing your hands before and after touching a resident. It’s using gloves while touching a resident for the most part – not all the time, but for the most part, you should be. It’s the very simple things you do. So it’s not at the level of the CDC treating somebody with Ebola and the precautions they have to take. These are just general universal precautions. Wash your hands. Wear gloves – that kind of thing. And sometimes you’ve got to remember that all of these things take time. Washing your hands well takes time.
Schenk: You’ve got to sing “Happy Birthday” twice. That’s what I taught my nephews. Sing “Happy Birthday” to yourself twice – that’s how long it should take you to properly wash your hands.
Smith: Yeah. But what ends up happening is any time staff can cut corners because they’re understaffed and they’re behind and they’re trying to get things done, they’re going to do. It is not uncommon for staff to take care of a resident to get them to the bathroom to remove a soiled diaper and then move onto the next resident without washing their hands. That happens and that is a bad source, that is a major source of bad infections, just going from these residents to residents, which is also one that you have to remember when you take your family, again, and I want to stress this because this is something that resident families need to really take to heart – when you go visit your loved one in the nursing home, bring Lysol and hand sanitizer and leave it in the car, so that when your kids get out, you sanitize their little hands, you spray their feet and pants down with Lysol. Remember that you’re walking into an area where infections are rampant.
Schenk: That’s right.
Smith: And I don’t want people to think that I’m so dramatic – you’re walking into Michael Crichton’s “Hot Zone.”
Schenk: What?
Smith: It was this book about this spread of this horrible bacteria.
Schenk: Oh.
Smith: I think they made it into a movie called “Outbreak” with Dustin Hoffman. Anyways, I don’t want you to think you’re walking into that. Be smart. Understand that this is a place where residents routinely void themselves in the hallways, in the rooms, in the cafeterias. I mean these places are dirty. They’re constantly cleaning them but bacteria are rampant there just in the same way that you want to get sick, go watch a couple of kindergarteners for a couple of hours.
Schenk: That’s right.
Smith: Anyways, it’s a huge problem in nursing homes because resident to resident contact and staff to resident to resident contact that doesn’t include the use of universal precautions, so you know, wear gloves, make sure you wrap it up.
Schenk: Is there anything else you want to say about that?
Smith: No.
Schenk: Moving to the next topic – here we have a case, a recently filed case out of Eden, which I guess is near Philadelphia, Pennsylvania. Martha Young, acting as the administrator of the estate of Nellie Howard filed suit earlier this year in Delaware County Court of Common Pleas against Manor Care Health Services at Mercy Fitzgerald. The suit says that Howard, who is now passed, was in need of 24-hour care due to having difficulty walking, a history of falls, dementia, muscle weakness, instable balance among other maladies, and ultimately she fell in February, sustaining a fall so severe that it required her to be transferred to the emergency department at Mercy Fitzgerald Hospital. And she passed a little bit after that, and now the family is suing based on the fact that the nursing home was negligent in failing to take the adequate precautions for this particular resident to prevent her from falling and injuring herself. It looks like there are certain claims of negligence, negligence per se and wrongful death. Not a lot of facts in this case.
Smith: Not a lot of facts in this article.
Schenk: Not a lot of facts in this article is what I mean. It does highlight the component of all cases, which is causation – did this nursing home fail to do certain precautions to prevent this particular resident from falling, which is their obligation under the law?
Smith: Well I’m with you. I think what we meant to say is I think the causation might be there. I think the question is the breach.
Schenk: That’s what I mean, the liability…
Smith: Yeah, I know. The liability is did they breach a standard of care? Because again, you can make sure that a resident never falls, but you’re going to be taking away massive amounts of liberty. The more protective you are of a resident, which you have to be at some times, the less and less liberty that they have. So if somebody is at risk of falling, if it’s severe enough, they may not be allowed to walk around by themselves. If the physicians order and they follow the guidelines of restraint, they may even be restrained.
Schenk: That’s right. So is it Benjamin Franklin?
Smith: “Those who would give up liberty for the sake of security deserve neither.”
Schenk: That’s pretty impressive. You’re a Founding Fathers buff, I bet.
Smith: Well I am, but I think that is especially – not to get off on a political subject – but that’s become more and more important as of late. Anyways, for nursing home residents…
Schenk: It’s a continuum. I mean they’re obviously – as you said, you can do all types of things to prevent the injuries from occurring, but what kind of life, what kind of existence is that?
Smith: And it’s difficult. And it’s a big deal to restrain a resident. And understand, I’m not talking about some “One Flew Over The Cuckoo’s Nest,” where hands are tied up kind of restraint. The most typical restraint that I would see is one that would go around the waist. It was a soft restraint. It didn’t hurt, but it would prevent – it was enough that this 98-year old woman who weighed 98 pounds couldn’t get out of a wheelchair.
Schenk: And there’s also a lot of times chemical sedation, the type of prescription medication to sedate…
Smith: Anti-psychotics like Haloperidol or things like that, those are even more frowned upon than physical restraints. Physical restraints can be used, but then again, it’s a really hard – it’s a hard thing to swallow because you’re tying this person to a chair and telling them, “You can’t get up.” So first and foremost, you need to have a physician sign off on it. But in this case, I mean with this history of gait dysfunction, which is ambulatory issues, she can’t walk, rheumatoid arthritis…
Schenk: There should have been a host of things done to prevent this fall.
Smith: Yeah. So she should have been suspect number one for a fall and it just depends on what they did.
Schenk: And like I said, the article does not give the content that we need to make an armchair decision of yea or nay on the ultimate verdict. Will, moving to the next subject, Will has referenced three movies I think so far in this podcast, two movies.
Smith: Have I?
Schenk: Yeah, you referenced whatever Rowdy Roddy Piper movie.
Smith: “They Live.”
Schenk: “They Live,” and then some Michael Crichton?
Smith: “Outbreak” by Dustin Hoffman.
Schenk: Did Michael Crichton do a movie that George Clooney was in? Wasn’t that like “Syriana?” Was that Michael Crichton?
Smith: Michael Crichton did “Jurassic Park.”
Schenk: Yeah, you’re right.
Smith: He was a doctor-author that did “Coma” – well that could have been Robin Cooke…
Schenk: The guy who married Mike Tyson?
Smith: No. No. But he did “Jurassic Park.” He did “Outbreak.” He did “Congo.” He was an author that I really liked when he was a kid.
Schenk: Apparently you really liked them.
Smith: And I don’t know who does it, but with Rowdy Piper, you’ve got to watch it. You really do.
Schenk: Apparently.
Smith: I can’t believe you haven’t seen it.
Schenk: I didn’t know he was in movies other than “No Hold Barred.”
Smith: No, he’s been in a couple. He actually did a really good job, you know?
Schenk: Okay. Well I don’t even know how to segue from that to tell you that we’ve reached the conclusion of this episode, so I’m just going to leave it at that. This does in fact conclude this episode of the Nursing Home Abuse Podcast. This podcast can be downloaded on Stitcher or iTunes or watched in its entirety on our YouTube or on our website, which is NursingHomeAbusePodcast.com, that is NursingHomeAbusePodcast.com. We are extremely happy that you’ve made it this far into the podcast, those of you still watching or listening, and we appreciate it and until next time.
Smith: Until next time.
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