A Third Of Nursing Home Patients Harmed By Their Treatment

hide captionFailures in ordinary care are causing widespread harm that's sometimes serious, inspectors say.

On the last day of his life, Charles Caldwell was surrounded by seven members of his family. But no one thought he was dying. He was in a Dallas area nursing home, recuperating from surgery to insert a feeding tube. Caldwell had Parkinson's disease. He'd "lost his ability to swallow," explains Caldwell's son-in-law, Bill Putnam.

hide captionCharles Caldwell died in a nursing home in 2008, his family says, after a nurse there mistakenly forced medicine from his feeding tube into his lungs.

Things began to go wrong, Putnam says, when a licensed practical nurse gave Caldwell some medication through his feeding tube. The medicine wouldn't stay down. So, as Putnam describes it, the nurse came back with the medication in three large syringes and forced the liquid into Caldwell's stomach.

Within a few minutes, he was choking. "This medication is traveling up his esophagus and then into his lungs," says Putnam, "and he can't expel it like you and I could. So, within minutes, Dad's thrashing his arms and legs for his last breath. He has no pulse. His eyes are fixed. He's not breathing."

Putnam says that the family could do nothing but watch Caldwell drown.

The case is similar to the many reviewed in a national report on nursing homes. The report was released this week by the Office of the Inspector General of the U.S. Department of Health and Human Services. In a large sampling of Medicare patients discharged from hospitals to skilled nursing facilities in one year, roughly a third of the patients were harmed by their treatment in the nursing homes, the study found. And most of that harm could have been prevented.

Though Caldwell died in 2008 before the HHS review team began its study in 2011 the investigators say his case fits with the misjudgements and ignorance they found over and over again in their analysis.

"We were surprised at the seriousness of many cases," says Ruth Ann Dorrill, a deputy regional Inspector General in the Department of Health and Human Services. That's the office that conducted the study.

Dorrill says that a lot of the problems they observed were failures in ordinary, everyday care. "Lack of monitoring and paying attention was definitely a factor "along with "what clinicians would call substandard medical care." She sites the example of a patient already on 15 different medications not that rare among nursing home patients who was then given an additional anticoagulant, such as an aspirin, or something similar. "And then they would have a bleed," Dorrill says "a fatal bleed."

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A Third Of Nursing Home Patients Harmed By Their Treatment