Annals of Long Term Care

Introduction
A recent General Accounting Office report notes that inadequate care or physical harm continues to affect one in five nursing home (NH) patients annually,¹ an unacceptably high figure. More than 20% of residents who have been in long-term care facilities for two or more years will develop at least one pressure ulcer.² In one study in patients with pain unassociated with cancer, 25% of NH patients received no analgesic medication at all.¹ Inadequate NH care results in patients suffering pain, loss of function, decreased quality of life, and a higher risk of premature death.

The following case scenario illustrates the risks that older adults confront in the healthcare system.

Case Presentation: Mrs. W

Mrs. W was 86 years of age, living independently in her one-story home following the death of her husband two years earlier, when on September 1 she tripped on a rug and fell. In the Emergency Room (ER), a hip fracture was diagnosed, and she was admitted for surgery. Her medical history included hypertension, type 2 diabetes, osteoarthritis, dementia, and a partial hearing deficit, for which she wore hearing aids. Medications on admission, brought by her daughter, included: glipizide 5 mg daily, lisinopril 5 mg daily, sertraline 25 mg daily, and aspirin.

Over the past year, Mrs. W, previously independent and caring for her home and all of her personal needs, began to have difficulty with short-term memory. Recently, her daughter brought her to their family physician. He diagnosed Mrs. W with “mild dementia and depression,” and at that time sertraline was prescribed.

Mrs. W underwent an uncomplicated open reduction internal fixation the following day after her fall. Pain management was provided via patient-controlled analgesia (PCA). Forty-eight hours after surgery, Mrs. W became agitated, calling out for her mother. Haloperidol was ordered, but by the next day she became lethargic, and it was discontinued. Fortunately, the orthopedic resident, recognizing the degree of memory impairment present, discontinued the morphine PCA pump, ordering morphine to be given as needed by nursing.

Five days after surgery on September 7, still lethargic but “stable,” Mrs. W was transferred to a NH and rehabilitation center. Discharge medications included all of those on admission, with the addition of oxycodone and acetaminophen for pain. The admission nursing assessment documented that Mrs. W was “bed-bound and in discomfort,” “deconditioned,” “pleasantly confused,” “depressed,” and “incapable of making medical decisions.” Physical assessment by the admitting nurse revealed that there was no evidence for skin breakdown and that a Foley catheter was in place. The Mini-Mental State Examination score was 22, with deficits in orientation, recognition, and recall. Physical therapy documented that Mrs. W required a two-person assist from bed to chair, and that the resulting motion caused considerable pain. The Fall Risk Assessment placed Mrs. W at risk for falling. The Braden Scale was scored incorrectly. No points were given for altered nutrition, limited sensory perception (a typical finding in dementia), and potential for skin breakdown due to friction and shear. A formal skin prevention program was thus not initiated. The Minimum Data Set (MDS) triggered Resident Assessment Protocols (RAPs) for falls, altered cognition, pain, and depression. A falls prevention program and pain assessment sheet were initiated.

Over the next several weeks, Mrs. W made little progress with the physical therapy program. At the therapist’s request, the attending physician increased the dosage of sertraline to 50 mg daily. Mrs. W continued to experience intermittent confusion. There were many days when she could not recognize her daughter, who visited frequently. Mrs.