Signs of Neglect

As our population ages, the number of elder Americans in nursing homes and assisted living facilities continues to soar.  Research indicates that one-half of women and one-third of men will eventually need nursing home or assisted living care.  By the year 2020, the demand for nursing home and assisted living beds will increase by almost 250%.  Nursing homes and assisted living facilities eagerly accept the financial benefits of the "graying of America."  They must also accept responsibility when our loved ones do not receive the care, dignity, and respect they deserve.

Nursing home and assisted living neglect and abuse take a variety of forms.  Pressure ulcers, falls, malnutrition, dehydration, and medication errors are painful, but frequent, reminders that more must be done.  Fortunately, increased media scrutiny of nursing homes and assisted living facilities and their business practices has resulted in a heightened awareness of the problem. State and federal governments have also come to the aid of families by enacting laws and regulations designed to ensure that patients receive appropriate care.

Unfortunately, media attention and regulatory oversight are poor substitutes for good care. Patients and their families need to recognize the "red flags" of nursing home and assisted living neglect and abuse.  If your loved one is a patient in a nursing home or assisted living facility, look carefully for any of the following signs of neglect and abuse:

 

Wandering and Elopement

The terms “wandering” and “elopement” are often used interchangeably. However, they are different terms that apply to different events.

Wandering

“Wandering” refers to the random or repetitive movement of a patient within a nursing home or assisted living facility. The patient may wander in pursuit of a particular goal (e.g., searching for something such as an exit), or the wandering may be non-goal-directed or aimless. Wandering of any type requires the nursing home or assisted living facility to address safety issues and identify the cause of the wandering behavior. For example, aimless wandering may mean a patient is frustrated, anxious, bored, hungry, or depressed.

A patient may be prone to wander into acceptable or unacceptable areas. Wandering may occur when the patient enters an area that is physically hazardous or that contains potential safety hazards (e.g., chemicals, tools, equipment). A wandering patient may also enter the room of another resident, which can result in a patient-to-patient altercation, a fall, or contact with a hazard. Nursing homes and assisted living facilities need to plan for and provide care in a manner that ensures the safety and well-being of their wandering patients.

Elopement

Elopement occurs when a patient who lacks safety awareness leaves a nursing home or assisted living facility or a safe area within or outside a facility without the knowledge of the facility’s staff and without proper supervision. A patient who elopes is at risk of heat or cold exposure, dehydration, drowning, getting struck by a motor vehicle, and falling. Facility policies should clearly define the procedures for monitoring and managing patients at risk for elopement to ensure patients are not permitted to leave the facility or a safe area without authorization and appropriate supervision. The care plan of patients at risk for elopement should address the potential for elopement. A nursing home or assisted living facility’s disaster and emergency preparedness plan should also include a plan to locate a missing patient who has eloped.

Standards

A nursing home or assisted living facility is required to provide residents with a “safe and secure environment” using “adequate supervision and assistance devices to prevent accidents.”  Injuries and death caused by unsafe wandering and elopement are preventable. A mobile, dependent, cognitively impaired patient should never be permitted to wander or elope undetected and unsupervised. A nursing home or assisted living facility must recognize the risk of wandering or elopement and take immediate steps to ensure the patient’s safety. Staff should be educated and warned about the patient’s risk of wandering or eloping. The nursing home or assisted living facility should also use electronic alarms that will notify staff immediately when the patient leaves the facility or a safe area in or around the facility.

Wandering and Elopement Alarms

Nursing home and assisted living facility standards of practice universally require electronic wandering and elopement alarms when a facility accepts patients at risk for wandering or elopement. These types of alarms are usually placed around the patient’s wrist or ankle. When a patient wearing the alarm leaves the facility or a safe area in or around the facility, a signal from the wrist or ankle alarm sounds. Many nursing homes and assisted living facilities have electronic wandering and elopement alarms that will sound or signal at one or more nursing stations. When an alarm sounds, staff respond to prevent the patient from wandering any further or eloping. Some types of alarms automatically lock exit doors when the patient approaches. Nursing homes and assisted living facilities should ensure all alarms are properly functioning at all times by performing routine tests and by repairing and replacing alarms and their components, including batteries, on a routine schedule.

In addition to safety alarms, nursing homes and assisted living facilities in Virginia should have a written “missing persons” policy and staff trained to implement that policy. The policy should identify who (e.g., staff, police, physician, family) is to be called and when.  Nursing homes and assisted living facilities should analyze all wandering and elopement incidents so that appropriate corrective action can be taken.  The facility should involve the medical director, who can help design and implement appropriate prevention measures.  Nursing homes and assisted living facilities should also ensure their buildings are properly staffed at all times to prevent unsafe wandering and elopement. Safety devices like alarms help monitor a patient’s movement, but staff must respond to alarms in a timely manner for the alarms to have any benefit. Alarms do not replace good supervision by staff. Finally, lighting and environmental hazards should be identified and corrected because wandering or eloping residents are especially vulnerable to harm from these dangers.

Patient-to-Patient Assault

Nursing homes and assisted living facilities must ensure that all reasonable steps are taken to prevent injuries inflicted by one patient on another patient. A nursing home or assisted living facility must provide adequate supervision when the risk of patient-on-patient assault exists. The potential for patient-on-patient assault increases when a patient has a history of acting aggressively with other patients or staff, including striking out, verbal outbursts, sexual improprieties, and other negative interactions.

The risk of patient-on-patient assault also increases when a patient exhibits behavior that tends to disrupt or annoy others, such as constant verbalization (e.g. crying, yelling, calling for help), making negative remarks, restlessness, repetitive behaviors, taking items that do not belong to them, going into others’ rooms, drawers, or closets, and undressing in inappropriate areas. Although these behaviors may not be aggressive in nature, they may result in a negative response from other patients and thereby result in verbal, physical, and/or emotional harm.

Nursing homes and assisted living facilities are responsible for identifying patients with a history of disruptive or inappropriate conduct or who exhibit other behaviors that make them more likely to be involved in an altercation. In that regard, a nursing home or assisted living facility must identify the factors (e.g., illness, environment, etc.) that increase the risks for individual patients of an altercation or assault. The care plan team of the nursing home or assisted living facility should review the risk assessment in the presence of the patient and the patient’s family in order to identify interventions that would prevent altercations.

Nursing homes and assisted living facilities can also prevent patient-on-patient assaults by providing sufficient staff to supervise patients, providing safe supervised areas for unrestricted movement, eliminating or reducing underlying causes of distressed behavior (e.g., boredom and pain), monitoring environmental influences (e.g., temperature, lighting, and noise levels), evaluating staffing assignments to ensure staff members are consistently responsible for the same patients (so changes in a patient’s condition and behavior can be quickly identified), and training staff consistently about how to approach a patient who is agitated, combative, verbally or physically aggressive, or anxious.

Pressure Ulcers (Bedsores)

A pressure ulcer (also known as a pressure sore, bed sore, and decubitus ulcer) is defined as an area of injury to skin and/or underlying tissue, usually over a bony prominence (e.g., heel or sacrum) caused by friction, shear, or prolonged pressure. Pressure ulcers are “staged” to describe the severity of tissue injury and destruction.

A stage I pressure ulcer is defined as intact skin with non-blanchable redness over a bony prominence. When compared to adjacent tissue, a stage I pressure ulcer may have a different skin temperature (warmth or coolness), tissue consistency (firm or soft feel), and/or sensation (pain).

A stage II pressure ulcer involves partial thickness skin loss that appears as a shiny or dry shallow open ulcer with a red pink wound bed and no slough (i.e., dead tissue that is moist, stringy, and yellow or gray) or bruising. A stage II pressure ulcer may also appear as an intact or ruptured serum-filled blister.

A stage III pressure ulcer involves full thickness tissue loss that may expose subcutaneous fat. Bone, tendon, and muscle are typically not exposed with a stage III pressure ulcer. While slough may be present with a stage III pressure ulcer, the extent of tissue loss remains visible. A stage III pressure ulcer may also involve undermining (i.e., destruction of tissue extending under the edges of the skin so that the pressure ulcer is larger at its base than at the skin surface) and tunneling (i.e., passageways of tissue destruction under the skin’s surface with an opening at the skin level from the edge of the wound).

A stage IV pressure ulcer involves full thickness tissue loss with exposed bone, muscle, and/or tendon. Slough and eschar (i.e., dead tissue that has become leathery or thick and black) may be present on some or all of the wound bed of a stage IV pressure ulcer, and undermining and tunneling are often present. A stage IV pressure ulcer may extend into muscle and supporting structures, making osteomyelitis (i.e., bone infection) possible.

A pressure ulcer is “unstageable” when it involves full thickness loss that covers the base of the wound with slough or eschar such that the true depth and, therefore, the stage of the ulcer cannot be determined.

Aside from stageable and unstageable pressure ulcers, a pressure ulcer may also involve deep tissue injury (DTI). Suspected deep tissue injury may occur with a purple or maroon area under intact skin or a blood-filled blister. The bruising indicates possible deep tissue injury. When compared to adjacent tissue, a deep tissue injury may have a different skin temperature (warmth or coolness), tissue consistency (firm, mushy, or boggy), and sensation (pain). A deep tissue injury may also involve a thin blister over a dark wound bed followed by a thin layer of eschar.

Pressure ulcer prevention in nursing homes and assisted living facilities is critical. Specifically, nursing homes and assisted living facilities must prevent new pressure ulcers from developing, prevent existing pressure ulcers from getting worse, promote healing of all pressure ulcers, and prevent healed pressure ulcers from recurring. In a nursing home, the nursing home must ensure a patient who enters the facility without pressure ulcers does not develop them unless the patient’s clinical condition demonstrates the pressure ulcers were unavoidable. The nursing home must also ensure a patient with pressure ulcers receives necessary treatment and services to promote healing, prevent infection of an existing ulcer, and prevent new pressure ulcers from developing. In an assisted living facility, the facility must provide services to prevent clinically avoidable complications, including the development and deterioration of pressure ulcers.

Pressure ulcer prevention in a nursing home or assisted living facility requires staff to identify a patient’s risk of developing pressure ulcers. The nursing home or assisted living facility must start its prevention by assessing the patient for the risk of developing pressure ulcers. Risk assessments are usually performed by using a Braden scale or Norton scale. The Braden scale is most frequently used, followed closely by the Norton scale. However, no particular standardized risk assessment or form includes all relevant risk factors (e.g., prior pressure ulcers, diabetes, vascular disease, previous pressure ulcers, etc.), so while the use of one of these scales may be necessary, a single form may not be sufficient unless all relevant risk factors are considered.

Once a patient’s risk of developing a pressure ulcer has been properly identified, the nursing home or assisted living facility must develop a care plan that minimizes the role played by each potential risk factor. Risk factors include unrelieved pressure, friction and shear, moisture, poor nutrition and hydration, and pain. With respect to avoiding unrelieved pressure, staff should turn and reposition patients in bed every two hours and more often as necessary, “float” (suspend) the heels off of the mattress or chair at all times for complete pressure relief, and ensure patients are not positioned on existing ulcers. When patients are in a chair, the patients should be repositioned and off-loaded at least once every hour.

With respect to the risk of friction and shear, the patient’s bed should be elevated at a maximum of 30 degrees unless otherwise clinically necessary, and proper transfer technique (e. g. sheet transfer) should be used during all transfers. A nursing home or assisted living facility should also use heel protectors at all times to minimize the effects of friction and shear on patients’ heels. However, heel protectors, while helpful against the effects of friction and shear, are inadequate by themselves as pressure-relieving or pressure-reducing devices. With respect to the effects of moisture, urine and feces are skin toxins that make skin more vulnerable and more prone to breakdown. As such, a nursing home or assisted living facility should require its staff to clean urine and feces from the skin of its patients as soon as possible. With respect to nutrition, poor nutrition depletes protein stores and results in less energy to meet the body’s needs. A nursing home or assisted living facility should ensure adequate nutrition and hydration at all times.

Finally, with respect to pain, pressure ulcers have been described by researchers as “a significant and increasing source of considerable human suffering.” Pressure ulcers are themselves painful. Aside from the inherent pain of a pressure ulcer, a pressure ulcer becomes more painful during a patient’s movement and activity, during routine procedures like dressing changes and wound cleansing, and when the ulcer is debrided or surgery on the ulcer is required. Since severe pressure ulcers result in more severe and persistent pain, a nursing home or assisted living facility should ensure a patient with pressure ulcers does not experience avoidable pain.

Finally, in Virginia, an assisted living facility cannot admit or retain patients with stage IV pressure ulcers. An assisted living facility in Virginia also cannot admit or retain patients with stage III pressure ulcers unless the ulcers are determined by an independent physician to be healing and, then, only if a licensed health care professional under a physician’s or other prescriber’s treatment plan performs necessary dressing changes. An assisted living facility cannot admit or retain a patient with any pressure ulcer unless the facility can provide services necessary to prevent the development of new ulcers and the deterioration of existing ulcers.

Medication Errors

Nursing homes and assisted living facilities must ensure that medication errors do not occur. Medication errors occur when the nursing home or assisted living facility prepares or administers drugs contrary to a physician’s order, the manufacturer’s specifications, or accepted professional standards. When a facility’s medication error rate (based on the number of medication errors divided by the number of times medications are administered) is 5% or greater, the facility likely suffers from systemic problems with its medication administration system.

A significant medication error is one that causes the patient to suffer or jeopardizes the patient’s health and safety. The significance of a medication error is a matter of professional judgement, but depends on the effect of the medication error on the patient’s condition, the category of the drug that was administered in error, and the frequency of the error. A medication error does not need to occur frequently or continuously to be significant. A single medication error can be significant.

Medication errors occur when drugs are administered without a doctor’s order, when the wrong dose of drugs is administered, when a drug is administered via the wrong route, when the wrong drug is given, and when the manufacturer’s specifications or accepted professional standards are not met. For example, a medication error occurs when medications are crushed despite manufacturer’s instructions and accepted professional standards that warn “do not crush.” A medication error also occurs when the nursing home or assisted living facility does not give a drug at the correct time. Medications are required to be given to a patient within 60 minutes of the scheduled time of administration to be considered timely.

Malnutrition and Weight Loss

Nursing homes and assisted living facilities must ensure their patients receive proper nutrition and maintain proper body weight and protein levels. Unplanned weight loss, peripheral edema, cachexia, and laboratory tests indicating low protein levels are signs that a patient may not be receiving proper nutrition. The amount of weight lost during one-month, three-month, and six-month intervals reveals the severity of weight loss:

        One Month, Significant = 5%, Severe = Greater than 5%
        Three Months, Significant = 7.5%, Severe = Greater than 7.5%
        Six Months, Significant = 10%, Severe =  Greater than 10%

For example, a loss of five percent of a patient’s body weight in one month is “significant,” but a loss of more than five percent in one month is “severe.” The percentage of weight loss is calculated using the following formula: (usual weight - actual weight)/(usual weight) x 100.

Malnutrition can be diagnosed clinically and with laboratory tests. Clinical signs of malnutrition include pale skin, dull eyes, swollen lips, swollen gums, swollen or dry tongue with scarlet or magenta hue, poor skin turgor, cachexia, swelling in the extremities, and muscle wasting. Laboratory tests can also detect malnutrition. For example, in a patient over 60 years of age, albumin (which reveals protein depletion) should remain between 3.4-4.8 g/dl. Plasma transferrin in a patient older than 60 years of age should remain between 180-300 g/dl. Hemoglobin in males should remain between 14-17 g/dl and in females should remain between 12-15 g/dl. Hematocrit in males should remain between 41-53 and in females between 36-46. Likewise, potassium levels should remain between 3.5-5.0 mEg/L and magnesium should remain between 1.3-2.0 mEg/L. Departures from these laboratory values may, with or without clinical symptoms, be a sign of malnutrition.

Risk factors for malnutrition and weight loss include drug therapy (i.e., cardiac, glycosides, diuretics, anti-inflammatory drugs, overuse of antacids, overuse of laxatives, overuse of psychotropic drugs, anticonvulsants, antineoplastic drugs, phenophiazines, oral hypoglycemics) that may contribute to nutritional problems, poor oral hygiene, poor eyesight, poor motor coordination, taste alterations, depression, dementia, cancer, a therapeutic or mechanically altered diet, a lack of access to culturally acceptable foods, a slow eating pace which makes food unpalatable, and poor feeding practices by staff like removing food trays before the patient has finished eating.

In order for a nursing home or assisted living facility to ensure a patient receives proper nutrition, the nursing home or assisted living facility must first assess the patient’s risk factors for becoming malnourished, plan and provide care to minimize the effects of these risk factors, and implement and document compliance with the nutrition care plan. For example, a nursing home or assisted living facility must monitor the amount of food consumed at each meal and at snack times and ensure all snacks and nutritional supplements are provided and consumed as appropriate. The amounts of all meals, snacks, and nutritional supplements, as well as any refusals by the patient to eat, should be carefully documented in the records of the nursing home or assisted living facility. Even if the patient becomes malnourished, sustains significant or severe weight loss, or does not eat, the nursing home or assisted living facility must consider changes to its plan of care (e.g., by providing the patient with alternative forms of nutrition like total parenteral nutrition (TPN), partial parenteral nutrition (PPN), or a feeding tube) to guard against worsening malnutrition.

Falls

A fall occurs when a patient unintentionally comes to rest on the ground, floor, or a lower level, including when the patient is found on the floor. A fall also occurs when a patient loses his or her balance and does not fall, but would have fallen if staff had not have intervened to stop the fall. A fall occurs whether or not injury results from the fall.

A nursing home or assisted living facility has the responsibility to ensure the safest environment possible for its patient. Specifically, a nursing home or assisted living facility must provide an environment free from accidents and hazards over which the nursing home or assisted living facility has control.  A nursing home or assisted living facility must provide proper supervision and assistive devices to prevent falls and other avoidable accidents.

An assistive device refers to equipment or other devices used by the patient to promote, supplement, or enhance the patient’s function and safety. Assistive devices include handrails, grab bars, canes, standard and rolling walkers, manually operated wheelchairs, powered wheelchairs, portable total body lifts, sit-to-stand lifts, transfer belts, gait belts, and mechanical lifts, including Hoyer lifts and Vanderlifts. Properly fitted and maintained assistive devices help prevent falls and other accidents.

Devices and other equipment like personal fall alarms can help monitor a patient’s activities, but they do not eliminate the need for adequate supervision. Adequate supervision must be based on the individual patient’s needs and the hazards of the patient’s environment. Therefore, adequate supervision may vary from patient to patient.

Assistive devices can cause falls and other accidents when those devices are not fitted or maintained properly. The risks of falls and other accidents increases when assistive devices and equipment are defective, not used properly or according to the manufacturer’s specifications, when the devices are disabled or removed for staff convenience, when devices do not meet the patient’s needs, or when no devices are provided. For example, the risk of a fall or other accident is increased when assistive devices are placed too far from the patient. Understaffing, unsafe transfer techniques, improper supervision, and improper training also increase the risk of falls and other accidents.

In order to prevent falls and other accidents, the nursing home or assisted living facility must identify environmental hazards and assess the patient’s risks, implement a care plan that includes adequate supervision and other measures based on the patient’s needs, monitor the effectiveness of the care plan, and, if the plan is not working, change the plan. In order to enhance supervision, a nursing home or assisted living facility may need to provide safe supervised areas for unrestricted movement, eliminate or reduce boredom, monitor environmental factors such as temperature, lighting, and noise levels, evaluate staff assignments to ensure qualified staff is provided to each patient, and evaluate staffing levels to ensure adequate supervision that meets the patient’s needs.

Dehydration

A nursing home or assisting living facility must ensure each patient is provided with fluids sufficient to stay hydrated. Dehydration occurs when the excess of fluid output over fluid intake results in clinical harm.

The amount of fluid each patient needs depends on the patient’s medical condition. Generally, a patient requires 30 ccs of fluid per kilogram (1 kg = 2.2 lbs.) of body weight, although fluid needs may increase or decrease as the patient’s medical condition changes. Patients with renal or cardiac problems may require less fluid in order to prevent fluid excess or overload, which itself can cause medical problems.

A patient is at greater risk of becoming dehydrated when the patient suffers from confusion, fluid loss and increased fluid needs (e.g., from diarrhea, fever, or uncontrolled diabetes), renal dialysis that results in fluid restriction, functional problems that make it difficult to communicate fluid needs, reach fluids, or drink fluids (e.g., aphasia), and dementia that causes the patient to forget to drink or refuses fluids.

Dehydration can be diagnosed clinically and with laboratory tests. Clinical signs of dehydration include dry skin, dry mucous membranes, cracked lips, poor skin turgor, thirst, and fever. Laboratory tests that show elevated hemoglobin, hematocrit, potassium, chloride, sodium, albumin, transferrin, blood urea nitrogen (BUN), or urine specific gravity also help diagnose dehydration.

In order for a nursing home or assisted living facility to provide proper fluids to maintain the patient’s hydration and prevent dehydration, the facility must first assess the patient’s risk factors for becoming dehydrated, plan and provide care to minimize the effects of these risk factors (e.g. keeping fluids next to the patient at all times, assisting or cuing the patient to drink), implement and document compliance with the care plan, and evaluate the effectiveness of the care plan. If, despite implementation of the care plan, the patient still becomes dehydrated, the nursing home or assisted living facility must change the plan of care (e.g. provide the patient with alternative forms of fluid intake or hydration like popsicles, Jello or other gelatin products) to guard against worsening dehydration.

Burns, Fires, and Chemical Hazards

A nursing home or assisted living facility must protect its patients from harm caused by environmental hazards like chemicals, cleaning supplies, hot water temperatures, and electrical devices.

Hazardous Substances

Substances which are toxic or caustic pose obvious safety hazards. Other solids, liquids, gases, mists, dusts, fumes, and vapors can, in sufficient amounts or sufficient concentration, harm patients of a nursing home or assisted living facility through inhalation, absorption, or ingestion. Substances in the patient’s own room or vicinity can pose a hazard. Hazardous substances include chemicals used by staff in the course of their duties (e.g. housekeeping chemicals and cleaning agents) and chemicals or other substances brought into the nursing home or assisted living facility by staff, other patients, or visitors. Drugs and therapeutic agents, and even plants and other “natural” substances found in the patient’s environment or outdoors, can be hazardous.

A Material Safety Data Sheet (MSDS) is available for many hazardous substances. The Occupational Safety and Health Administration (OSHA) requires employers to have a MSDS available for all hazardous substances used by staff when performing their duties. MSDSs are available online for many chemicals and non-toxic materials and should be reviewed carefully to determine if a particular material is toxic and poses a hazard. Poison control centers are another source of information for potential hazards, including non-chemical hazards such as plants. Toxicological profiles for a limited number of hazardous materials are also available online through the Agency for Toxic Substances and Disease Registry.

Burns from Hot Liquids

The temperature of water in a nursing home or assisted living facility can also present a safety hazard. Water can reach hazardous temperatures in hand sinks, showers, and tubs and may cause burns from scalding. Burns related to hot water and liquids can also occur with spills. Many patients in a nursing home or assisted living facility have conditions that may put them at increased risk for burns caused by scalding, including decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate.

The degree of injury from burns or scalding caused by hot water or other liquids depends on the temperature of the liquid, the amount of skin exposed, and the duration of exposure. The severity of burns and skin damage is based on the degree of the burn:

First-degree burns involve the top layer of skin (e.g. minor sunburn). These burns may be red and painful to the touch, and the skin will show mild swelling.

Second-degree burns involve the first two layers of skin. These burns involve deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of skin.

Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue. These burns involve loss of skin layers, pain, and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black.

Electrical Devices

Electrical devices, whether or not they are plugged into an electric outlet, can be hazardous to patients of a nursing home or assisted living facility when the electrical devices are improperly used or maintained. For example, electrical cords can become a tripping hazard. Halogen lamps or heat lamps can cause burns or fires if not properly installed and if not used at a safe distance from combustibles. The Life Safety Code prohibits the use of portable electrical space heaters in patient care areas, including patient rooms.

Extension cords should not be used to take the place of adequate electrical wiring in a nursing home or assisted living facility. If extension cords are used, the cords should be properly secured and should not be placed overhead, under carpets or rugs, or anywhere that can cause trips, falls, or overheating. Extension cords should be connected to only one device to prevent overloading, and they should be made of materials that will not fray or cut easily. Electrical cords, including extension cords, should also be properly grounded.

Power strips and surge protectors also should not be used as substitutes for adequate electrical outlets in a nursing home or assisted living facility. Power strips and surge protectors can be used for a computer, monitor, and printer, but they should not be used for medical devices in patient care areas, including patient rooms. Power strips and surge protectors require internal ground faults and over-current protection devices, preventing cords from becoming tripping hazards. Only power strips or surge protectors adequate for the number and types of electrical devices should be used. An overload circuit can cause overheating and fire. As such, ground fault circuit interruption (GFCIs) may be required in locations near water faucets and other water sources to prevent staff and patients from getting electrocuted.

Electric blankets and heating pads must also be used properly to avoid burns and other thermal injuries. Electric blankets and heating pads should not be tucked in or squeezed because constriction can cause wires inside these blankets and pads to break. A patient also should not go to sleep with an electric blanket or heating pad turned on. Manufacturer’s instructions for use should be followed closely because burns and fires from heating pads have caused injuries and death. Most deaths are attributable to heating pads that started fires, but most injuries involve burns that result from prolonged use or even inappropriate temperature settings on electric blankets and heating pads. Prolonged use of a heating pad on one area of the body can cause a severe burn, even when the heating pad is at a low temperature setting.

Fires

Fires are often caused by the failure of a nursing home or assisted living facility to supervise a patient who smokes. The risk of fires and burns is increased when a patient has difficulty holding or lighting a cigarette, needs staff help, but does not receive assistance.

Restraints, Bedrail, Entrapment & Asphyxiation

A physical restraint is defined as any manual method, physical or mechanical device, material, or equipment attached or adjacent to a patient’s body that the patient cannot remove easily and that restricts freedom of movement or normal access to one’s body. If such a device is used for staff convenience or for any reason other than to address a patient’s medical or safety needs, the device is a restraint. While often used for patient safety, some physical restraints create their own risk of injury or death.

Physical restraints can cause entrapment and asphyxiation in a nursing home or assisted living facility. Patients with restraints can be harmed when they attempt to remove the restraints, walk while restrained, or when they have been provided by the nursing home or assisted living facility with an unnecessary or improperly fitted device. The dangers of physical restraints were highlighted in 1992 when the Food and Drug Administration (FDA) issued a Safety Alert entitled “Potential Hazards with Restraint Devices.”

Bedrails (also referred to as side rails, bed side rails, and safety rails) are generally used to help patients with transfer and positioning. Bedrails, including full length rails, half rails, and quarter rails, are positioned in various locations on the bed. Like physical restraints generally, bedrails may cause entrapment and strangulation. Entrapment occurs when a patient is caught between the mattress and bedrail or in the bedrail itself. Entrapment can also be caused by defective or improperly latched bedrails, spaces within bedrails themselves, spaces between bedrails and the bed frame, and spaces between bedrails and the head or foot of the bed. Technical issues, such as the proper size of the mattress, the fit and integrity of bedrails, and other design elements (e.g. wide spaces between bars in the bedrails) affect the risk of entrapment. These hazards were explained in the FDA’s 1995 Safety Alert entitled “Entrapment Hazards with Hospital Bed Side Rails.”

Patients at greatest risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc. that may cause them to move about the bed or try to exit from the bed. The risk of entrapment is also affected by toileting delay, positioning errors, and other care deficiencies.

A specialty air-filled mattress or a therapeutic air-filled bed can also cause an entrapment risk. The high compressibility of an air-filled mattress compared to a regular conventional mattress requires the nursing home or assisted living facility to take special precautions for patients who are at risk of becoming entrapped. An air-filled mattress compresses under the patient. When the patient is positioned on the side of the mattress, the space between the mattress and bedrail expands, which makes it easier for the patient to slide off of the mattress or against the bedrail. When the patient becomes caught between the mattress and bedrail, the mattress can re-expand and press the patient’s chest, neck, head, and limbs against the rail, resulting in a loss of blood flow that may result in amputation, fracture, or strangulation and asphyxiation. A nursing home or assisted living facility must take special precautions to reduce the risk of entrapment by following manufacturer equipment alerts and carefully supervising patients with bedrails.