Literature Review

Polk County home health aide accused of sleeping on the job arrested in man’s death: ‘He was old anyway' Fox 13, Winter Haven, FL; by Fox 13 News Staff; 9/30/24 A home health aide in Polk County is being held without bond after investigators say she fell asleep, and an 86-year-old man died in her care. ... The Polk County Sheriff’s Office says the victim’s family hired around the clock care from Assisting Hands, which consisted of two 12-hour shifts during the day and night. The victim had recently been hospitalized and was diagnosed with congestive heart failure. He was also receiving services from Good Shepherd Hospice. ... After the day shift nurse left, investigators say Taylor fell asleep on the couch in the living room, which is against company policy that states she should not have been sleeping. Deputies say Taylor woke up around 1 a.m. on August 16 and heard a thump coming from the victim’s bedroom. According to PCSO, Taylor went into the bedroom and saw the victim lying on his right side, on the floor, with his head wedged in between the nightstand and the bed. She told detectives that she tried to help him back into bed but that he told her not to touch him, so she left him on the floor and did not call anyone, including 911 or her employer, which is against company policy. ... According to the Medical Examiner, had Taylor called 911 when she first found the victim, as required by her own company’s policy, the victim would not have died. The Medical Examiner ruled the victim’s cause of death positional asphyxia with a contributory cause of pre-existing health issues.

The catalyst for a 25% drop in sepsis mortality at Jefferson Health Becker's Clinical Leadership; by Erica Carbajal; 9/19/24 In the healthcare quality space, clinicians must track a plethora of metrics and measures, creating an environment where it can be easy to lose focus of ongoing priorities. To help center focus and ensure alignment of clinical priorities, Philadelphia-based Jefferson Health developed a quality and safety management system called OnPoint, which is now in place across all of its 17 hospitals. ... The platform is central to strides Jefferson Health has made in managing sepsis in recent years, ... Since 2021, the system has achieved a 25% reduction in average annual sepsis mortality, which is estimated to have saved the lives of nearly 700 patients and $30 million in costs.

Hugo man dies in house fire  [hospice patient] KXII 12 TV, Hugo, OK; by KXII Staff; 9/5/24 A fire at a home in Hugo claims the life of a former Choctaw County assistant district attorney. Officials said the fire happened Sunday afternoon. The Choctaw County Emergency Manager told News 12 that John Bounds, who was in hospice care, was unable to escape. All others in the house got out safely.Editor's note: What emergency discussions do your interdisciplinary team members have with home hospice patients and their caregivers? Regular fire safety training (and other forms of patient care safety, workplace safety, etc.) are required by OSHA and accreditation organizations. 

Elder abuse is unreported. City employees will now be trained to recognize it. San Antonio Report, TX; by Iris Dimmick; 8/21/24 City of San Antonio employees will soon be trained on how to identify and report elder abuse thanks to a collaborative effort to increase awareness of the underreported “crisis” gripping the community. City Council’s Public Safety Committee greenlit the policy Tuesday, which directs the city’s Department of Human Services and Texas Adult Protective Services (APS) to develop training curricula for staff. ... The largest share of elderly abuse cases in Bexar County is reported by medical personnel, followed by relatives, community agencies and the victims themselves. In 2022, a woman died in a local hospital after her three adult children allegedly neglected her hospice care. In 2018, a caretaker in San Antonio was charged with several felonies after police found an elderly, disabled woman was languishing in soiled clothes for months at a time.Editor's Note: What elder neglect and abuse training do you require for your hospice and palliative care interdisciplinary team members and volunteers? What incident reporting and follow-up systems do you have in place? The CMS Hospice Conditions of Participation requires the patient's comprehensive assessment to include "a thorough evaluation of the caregiver's and family's willingness and capability to care for the patient." Subpart A, § 418.3 

Proactive fall prevention: Elevating patient safety and healthcare excellenceHealthCare Business News; by Amy Hester; 7/26/24... The significance of fall prevention cannot be overstated, as it directly impacts patient outcomes and overall healthcare quality. With the patient safety solutions market growing at an expected rate of 11.2%, the importance of proactive fall prevention strategies becomes even more evident. ... In the United States, preventable medical errors, including falls, are the third leading cause of death. The impact of falls on patient health and recovery is profound, often leading to longer hospital stays, delayed recovery and increased risk of subsequent falls.Editor's Note: Proactive fall prevention is especially important for persons needing palliative or hospice care. As the person's health and mobility declines, they have to adjust to these changes mentally, emotionally, physically, and relationally. Recognizing decline can feel like defeat. Asking for help can be tough. Family members can expect the person to move more independently more than possible, leading to falls.

HIMSSCast: Improving patient safety and employee retention with best incident reporting practicesHealthcare IT News; by Andrea Fox; 7/26/24 By modernizing systems and improving leadership and culture to embrace reporting, healthcare organizations can better address the top 10 patient safety concerns for 2024, says Heidi Raines, founder and CEO of Performance Health Partners. Ultimately improving the quality of care healthcare systems deliver and preventing harm requires a degree of self-reflection. Along with digital transformation, putting an easy-to-use incident reporting system in place can help healthcare organizations address today's chief patient safety concerns, including medication errors, care delays, workplace violence and preventing patient falls, said Raines.

Rosewood nursing home staff demands experience pay, free coverage Times Union, Rensselaer, NY; by Jim Franco; 7/11/24 A group of Rosewood Rehabilitation and Nursing Center workers, represented by a national health care union, is demanding a new contract with higher wages for more experienced workers and a union-provided health insurance plan that would be fully paid by their employers. ... The workers, members of 1199SEIU United Healthcare Workers East, say a contract with the experience pay and no-cost health care coverage would help address staff shortages at the facility. The union, which has an office in East Greenbush, cites federal Department of Health and Human Services data showing total nursing staff turnover at the facility is 61.8 percent, higher than the national average of 52 percent and the New York average of 44.7 percent.Editor's Note: The reasons identified for this staff strike are consistent with other nursing/healthcare strikes across the nation: pay, benefits, staff shortages. Additionally, this facility's nursing staff turnover of 61.8 percent likely impacts--negatively--patient safety, another key factor for recent nursing strikes.

Harn Art Museum encourages woman with Alzheimer’s to move again ABC TV WCJB-20; Gainesville, FL; by Kayla Lewis; 6/28/24 Pat Mclaurin’s Alzheimer’s has progressed since her daughter, Diana Dodds took her on a bucket list trip in 2022. ... “So my mom would never use a walker or a cane. She would be more likely to try to hit me with it then use it, so she’s fiercely independent, yet she knows right now she cannot really walk without falling,” Dodds shared. “She’s always grabbing for walls just in the house.” ... Pat used to walk 3-5 miles a day, but in January slowed down. They decided to test out their own walker on a trip to the Harn Museum of Art in Gainesville, but her mom didn’t like it. However, the museum offers walkers and Pat loved them. Diana tells her it’s like a shopping cart. “Four wheels, it has higher bars, it had brakes on it. It felt more like a shopping cart because of the seat,” Dodds shared. Diana described the walker they gave her mother to Haven Hospice officials who then brought her mom a walker just like it a couple days later. “It’s inspiring because I’ve seen her push through every step trying to keep moving, and I want her to be able to keep moving,” said Dodds. 

Hospice of Marion County trains first responders to care for dementia patients Hospice News; by Jim Parker; 6/18/24 Florida-based Hospice of Marion County, an affiliate of Empath Health, is training first responders in its community on how to treat dementia patients. For several years, the nonprofit hospice has been educating family caregivers and others in their community about the experiences of dementia patients and how to better interact with them. More recently, Hospice of Marion County [Ocala, Florida] has been expanding that training to include local law enforcement and fire departments, as well as medical students and staff at assisted living facilities, among others. The training uses a series of tools to simulate symptoms of dementia, related to visual, tactile, auditory senses, their ability to process information and perform certain tasks. The education helps first responders address the unique challenges associated with caring for dementia patients, according to Dr. Mery Lossada, chief medical officer of Hospice of Marion County.Editor's Note: Bravo, Hospice of Marion County!

NIH: Hot weather safety for older adults OSHA: Heat - Working in outdoor and indoor heat environmentsOSHA - Occupational Safety and Health Administration; retrieved from their website 6/18/24 

Daughter stole $25K using [dying] father's credit, debit cardsLatrobe Bulletin, Latrobe, PA; by Joseph Bell; 6/6/24 A Vandergrift woman is facing multiple felony charges after she racked up over $25,000 in credit and debit card debt using her father’s accounts. According to court records, 44-year-old Kimberly Sue Shaw of Hancock Avenue is accused of using three of her father’s credit and debit cards for unauthorized purchases, in addition to transferring a sum of money from one of his bank accounts to another while he was hospitalized and later under hospice care. The defendant’s father, Dennis Lee Barger of Washington Township, died May 2.Editor's Note: Often, we think of elder abuse as being physical harm. However, it includes much more, and your interdisciplinary team members must be trained to signs, assessments, interventions, and safety (for the patient and self). Definitions are available on the CDC's "About Abuse of Older Persons" webpage. These definitions include physical abuse, sexual abuse, emotional or psychological abuse, neglect, and financial abuse.

St. Vincent Hospital nurses and the MNA file fifth in series of complaints with state and federal agencies about dangerous patient care conditions that continue to compromise the care and safety of patients admitted to the Worcester-based facility Massachusetts Nurses Association (MNA); 5/29/24 As patient care conditions continue to deteriorate at St. Vincent Hospital, the registered nurses and the Massachusetts Nurses Association (MNA) have filed yet another round of complaints to state and federal agencies seeking immediate intervention to protect patients and staff, a situation so dire the complaints include a direct appeal to the Department of Public Health to assign onsite inspectors on a daily basis to ensure hospital administration is providing the resources needed to ensure the safety of all concerned. In fact, the nurses report that DPH has recently been at the hospital investigating yet another serious patient safety incident. Editor's Note: As reported in numerous articles in our newsletter, patient safety and workplace violence/safety issues continue to be key causes for healthcare professional resignations, unionizations, and strikes (ie., nurses and/or physicians). It's time to review your organization's patient safety and workplace violence Policies and Procedures, staff and volunteer trainings, caregiver resources to ensure patient safety in the home, topics like "Abuse and Neglect," and your community's data on workplace safety concerns and community response resources.