GAO Finds Major Overuse of Antipsychotic Drugs by the Elderly

From the Illinois Nursing Home Abuse Blog

In late 2014 we blogged about the accusations levied against Dr. Michael J. Reinstein about his improper use of antipsychotic drugs prescribed to patients in abundance, as well as taking kickbacks from the drug maker to prescribe it, and making 140,000 or more false billing claims submitted to Medicare and Medicaid for those treatments. This activity landed him in both civil and criminal hot water, and in more recent news he pled guilty to criminal charges as well as settled civil claims with the Illinois and federal governments.

The companies accused of providing those kickbacks and receiving Medicare and Medicaid dollars from the business Reinstein generated by prescribing their antipsychotic drugs. Reinstein exemplifies a holdover of a slowly diminishing practice of using antipsychotic medications, which now is viewed more as the easy way out and a method of chemical restraint when there are other methods that could more humanely calm and care for a patient, particularly dementia and Alzheimer’s patients who have historically been the recipients of antipsychotic medications. Nursing homes historically used these especially when they kept low staffing levels and did not have the manpower to aid patients. Yet antipsychotic drugs can create a cycle of drug dependency, and can even lead to death.

Changing Tides?

While the movement to eliminate the use of antipsychotic medications has gained steam in recent years, the federal government reports that elderly Americans have been overusing psychiatric drugs such as clozapine (Dr. Reinstein’s apparent drug of choice), Abilify, and others. Such drugs are meant to calm down and sedate patients that are prone to violence or outbursts, which those suffering from dementia or psychosis may be particularly prone to exhibiting. The Government Accountability Office (GAO) has released a report stating that elderly adults who live outside of nursing homes and long-term care facilities overuse antipsychotic drugs which are prescribed to them by doctors, though residents in nursing homes also fell into such dependency and overuse, and efforts to curb over-prescription and overuse must continue there as well.

Notably, according to the report, about 86% of Medicare enrollees who suffer from dementia and live outside of nursing homes are prescribed antipsychotic medications, which is a staggering statistic. It is even more remarkable when considering that only approximately 6% of total Medicare enrollees living outside of nursing homes suffer from dementia. Thus the choice of treatment has predominantly been geared toward chemical intervention. For those in nursing homes, of the elderly dementia patients living in nursing homes for over 100 days in the year 2012, approximately a third of those patients were prescribed antipsychotic drugs (and 14% of those outside of nursing homes during 2012).

Part of the problem, according to the GAO report, is the lack of oversight by the government. Medicare and Medicaid specifically take responsibility for such oversight on behalf of the federal government, and states typically have Medicaid fraud units that look into not only financial fraud related to health care, but also investigate when issues include abuse or misuse of medications (which can result in unnecessary and excessive, and thus fraudulent, payments to providers and pharmaceuticals with federal dollars). Those agencies and offices, as well as the U.S. Department of Health and Human Services as the report notes, should be vital in promoting awareness of the dangers of antipsychotic drugs and reducing that use far more than the government has in the past.

Life Care Of Greeneville, NC Named In Wrongful Death Lawsuit

As reported in the Greenville Sun

Many more Details are available at the link

A wrongful death civil lawsuit has been filed against a Greeneville nursing home and several other defendants alleging wrongdoing in the care the facility gave an elderly dementia patient.

In the complaint, filed Dec. 2, 2014, in Greene County Circuit Court, the plaintiff, Robin Tweed Keller, of Virginia, alleges that medical battery and negligence by Life Care Center of Greeneville resulted in the suffering and eventual death of her father, Bobby Glenn Tweed, on Nov. 19, 2013, at the age of 79.

The suit identifies Keller as Tweed's only daughter and his next-of-kin -- and the person he had designated his Tennessee Healthcare Durable Power-of-Attorney in September 2009.

She is also identified as the court-appointed representative of his estate.

Defendants named in the lawsuit are:

• Life Care Center of Greeneville, 725 Crum St.;
• Life Care Centers of America Inc., based in Cleveland, Tenn., the parent company of Life Care Center of Greeneville and more than 100 other similar centers in the nation;
• Wayne E. Tasker & Associates Inc., of Morristown, doing business as Green Tasker & Associates Inc., and Tasker Green & Associates Inc., a firm which Keller believes provides services to Life Care Centers in connection with the mental health of patients;
• Dr. William C. Diebold, a medical doctor and board-certified psychiatrist with Takoma Regional Hospital's Center for Outpatient Behavioral Health and Senior Care, who, the lawsuit states, treated Tweed at one point during the last months of his life;
• Stephen L. Haile, an advanced-practice registered nurse who the plaintiff believes to be an officer or employee of the Tasker firm; and
• Dr. Kenneth Nickle, a physician with Summit Medical Group, who, the lawsuit states, served as medical director of Life Care Center of Greeneville during the last three months of Tweed's life and, in that capacity, treated Tweed for two-and-a-half to three months.

Also cited as a defendant is an unnamed female who, the complaint states, was employed at Life Care Center of Greeneville. The lawsuit alleges that she was involved in the care and treatment of Tweed and administered certain "atypical anti-psychotic drugs" without obtaining the legally-required informed consent from Keller.

The Greeneville Sun has made attempts to seek comment from each defendant listed in the complaint. Each defendant contacted has declined comment on the pending case at this time.

WHAT LAWSUIT CLAIMS

The suit alleges that, for a few days in August 2013 at Takoma Regional Hospital and then continuing until mid-October 2013 at Life Care Center of Greeneville, Tweed was administered powerful drugs that were inappropriate for his medical condition: dementia and Alzheimer's disease (but not mental illness).

The drugs mentioned in the lawsuit -- Seroquel, Geodon and Depakote -- are described in the suit as "extremely powerful psychotropic medications" classified as "atypical anti-psychotic drugs."

Seroquel and Geodon, the suit alleges, "and other atypical anti-psychotic drugs" have been shown to increase death in elderly patients who are suffering from dementia.

Because of that increased risk of death, the U.S. Food and Drug Administration (FDA) has required the manufacturers of Seroquel and Geodon to include "black box" warnings about the danger of using those drugs with elderly patients who are suffering from dementia, the suit alleges.

The suit describes Depakote as "an anti-epileptic drug, which is used to treat a variety of epilepsy seizure types as well as acute manic symptoms in patients with bipolar disorder."

But, the suit continues, "It has not been approved by the FDA for use with Alzheimer's disease or dementia."

Many more Details are available at the link

State rips nursing home - Violations at East Peoria facility lead to a $100,000 fine

The hell of a mental health facility combined with a nursing home. An investigative report by the Chicago Tribune

A troubled East Peoria nursing home and state health officials are gearing for battle after authorities fined the home $100,000 -- one of the largest such fines ever -- for neglect and faulty care of mentally ill and elderly patients.

In a report obtained by the Tribune, state health officials detailed violations at East Peoria Gardens Healthcare Center that are unusual in scope and severity, according to state officials and watchdog groups.

After a police raid in April, the state report provides additional evidence to support claims that mentally ill patients were sometimes out of control and tormented elderly residents, a pattern that developed after the facility began accelerating the admission of younger, more volatile psychiatric patients in August.

In the 1990s, the state relaxed rules on nursing homes, allowing psychiatric and geriatric patients to live side by side. After a disturbing series of incidents involving abuse of the older patients, including dozens of injuries and deaths reported to the state, new rules were created in 2000 governing the way those two patient populations are monitored.

But among nearly 4,500 detailed investigation reports compiled each year, officials say the situation at East Peoria this spring was one of the worst they have seen.

The Illinois Department of Public Health cited the facility for poor or no staff training, ignoring numerous falls of patients, failing to check patients for criminal backgrounds and providing no appropriate service to mentally ill residents, according to the report dated June 26, which was made in response to two dozen separate complaints.

"The facility failed to provide services necessary to avoid physical harm, mental anguish or mental illness," the report reads.

A police dragnet at the home in April led to the arrests of three patients and two employees on outstanding criminal warrants.

East Peoria Gardens plans to contest the fines and charges at a state hearing, a date for which has yet to be determined.

"Not only are we now operating in compliance, we categorically deny each and every charge -- including the fine -- presented by the state," said Meyer Magence, attorney for the home. "We are going to fight every one of them."

Authorities say the facility, which has about 100 residents, has improved procedures and conditions since the April raid.

The 50-page report paints a picture of a period in which communication was poor, mental patients did not receive proper medical and psychiatric care, and elderly patients were left to deteriorate.

"The breadth of the violations is extraordinary," said Wendy Meltzer, executive director of the watchdog monitor Illinois Citizens for Better Care. "It's really unusual to see this many violations affecting so many people. It's not something you see, fortunately, often."

Among the allegations in the report:

• Staff failed to try to revive a heart patient who fell and injured his head because they believed he was a hospice patient. He died soon after.
  
  
• Staff failed to properly diagnosis and monitor a 54-year-old patient who developed gangrene in his left toe.
  
  
• A 72-year-old mentally ill resident choked and died after eating a doughnut. A speech therapist had warned against giving the man difficult to swallow food but staff said they knew of no such order.
  
  
• An 81-year-old woman at the facility fell 10 times without staff putting in place precautions and a prevention plan. She died of complications from a fall.
  
  
• The facility did not have any treatment programs in place for 11 of 51 residents identified as "seriously mentally ill." With limited proper supervision in place, the safety of elderly residents was threatened when some psychiatric patients became agitated.
  
  
• The facility added more than 40 mentally ill patients from August 2006 to January and had no effective administration or adequately trained staff in place for the change.
  
  
• Seven patients were admitted with criminal records. The facility was unable to produce records showing it had notified the state as required.
  
  
• The facility failed to do background checks on 15 of the 19 residents with criminal records.

Magence declined to respond to the charges individually but called them "inaccurate."

State officials are not the only ones threatening the nursing home.

Medicaid and Medicare withheld five days of reimbursements for 66 eligible patients who were at the home in April, according to federal and state officials. Magence said he plans to contest that action.

A relative of Betty Saal, the 81-year-old woman who died after falling, is suing the facility.

The Tazewell County coroner also said he plans to soon convene an inquest into Saal's death to decide whether to file homicide charges.

"We don't know if she was pushed or fell down," said Coroner Dennis Conover. "We do know this was a nursing home gone wrong and that neglect led to her death."

The state also cites neglect in the case of 72-year-old Donald Utech, who died in April after eating breakfast. According to a preliminary autopsy, Utech died of choking. A Peoria County coroner's inquest concluded last week that the death was accidental.

But there is still conflicting testimony in Utech's case; home staffers say no food was in the man's mouth, while paramedics said food was trapped in his airway. The coroner's finding does not address the issue of neglect, according to Peoria County Coroner Johnna Ingersoll, who has jurisdiction because Utech was taken to a hospital in her county.

Officials from the Department of Public Health have called three other deaths in the last two years suspicious, but Magence said the facility bears no responsibility in any deaths.

"Absolutely none," he said.

Last month's $100,000 citation and report mark the second time the facility has faced stiff fines and sanctions.

In 2005, the facility was fined $20,000 by the state and faced weekly monitoring after two residents died following choking incidents.

The facility is again being monitored, this time twice a week, state officials said.

"The question is why was this allowed to go on for months unchecked?" asked Steven Levin, a Chicago personal injury attorney representing Saal's relative in a civil suit.

State Fines New York Psych Clinic $16.5 Million in Medicaid Inquiry

From the NY Times, another psychiatrist gets caught handing out inappropriate drugs and treatments for the sake of profits. This is also another example of psychiatric abuse of the elderly.

Some patients at a Queens substance abuse clinic who had only minor alcohol problems were given intensive treatments, four or five days a week, for up to two years, with Medicaid picking up the bill, investigators said. Other patients needed more serious psychiatric care but were instead kept in unnecessary treatments for chemical dependency, again at taxpayer expense.

The clinic, Community Related Services Inc., which investigators said specialized in treating elderly patients from the former Soviet bloc, was fined $16.5 million for overbilling the Medicaid system, Gov. George E. Pataki’s office said yesterday.

It was the largest fine levied by the state’s new Medicaid inspector general’s office, created last year to combat rampant abuse in the joint federal-state health care program for the poor.

The state also froze $30 million in payments to the clinic, on Queens Boulevard in Rego Park, and began proceedings to revoke its license.

The inspector general and the state’s Office of Alcoholism and Substance Abuse Services cited the clinic for what they said were 45 regulatory violations, like improper patient assessments and poor record-keeping, and issued 25 findings of “serious Medicaid fraud, waste and abuse.”

The clinic can request an administrative review or challenge the fine in court, said Henry Zwack, executive deputy commissioner of the alcoholism and substance abuse office.

State records say the clinic, a profit-making entity, is owned and operated by Dr. Yelena Mamedova-Braz, a psychiatrist, and Maya Gurevich. Phone calls were placed to both owners yesterday, but they could not be reached for comment.

The clinic was founded in 1998 in an area of Queens that has a large number of immigrants from the former Soviet Union. According to Mr. Zwack, the clinic treated about 600 people a day, most of them elderly women from Uzbekistan.

Investigators found that patients had visited the clinic an average of 152 times a year, compared with an average of 34 visits a year for other chemical-dependency centers regulated by the state. The state also determined that patients at the Queens clinic tended to stay in treatment an average of 20 months, compared with 3.7 months at other clinics.

The agency also cited the clinic for paying its counselors based on the number of sessions they had with patients, creating an incentive for counselors to overbill. This system contributed to the high volume of services for patients who seemingly had minor or negligible histories of alcohol and drug abuse, investigators wrote.

Mr. Zwack said that investigators had found some people who needed mental health services but were getting alcohol treatment instead, or no services at all. For some patients, he said, the clinic acted more as a “senior day care center, a place for people to come together, speak the same language and interact.” He also said that English courses offered by the clinic had been billed as treatment.

The clinic billed Medicaid an average of $11 million a year.

“What this company was sucking out of Medicaid could have provided care for 2,400 more patients who really needed it,” Mr. Zwack said.

According to the report by the substance abuse agency, the clinic made an interest-free loan of $3.52 million in 2004 to another company that Dr. Mamedova-Braz and Ms. Gurevich owned, Advanced Community Services Inc., after the owners became aware of an investigation by the office of the state’s attorney general, Eliot Spitzer. When asked about the loan, Ms. Gurevich told investigators that it was made to ensure that they had money in case the clinic’s money was seized, the report said.

Mr. Zwack said that Dr. Mamedova-Braz was in the process of trying to get licensing for another mental health clinic. But if the Queens Boulevard clinic loses its license, Mr. Zwack said, she and Ms. Gurevich could be permanently barred from the Medicaid system.

Investigators found other problems as well, including what they said was poor record-keeping and what they described as the unethical treatment of patients. According to an agency report, Russian-born counselors referred to themselves as “real Russians” and made disparaging comments about the ethnic backgrounds of their patients.

In justifying extensive treatment programs, the clinic’s director-owner, Dr. Mamedova-Braz, told investigators that her patients had limitations due to intermarriage. “These marriages, according to Dr. Braz, produce generation after generation of mentally disabled individuals who lack the capacity to function successfully and independently,” investigators wrote.

Mr. Zwack said, “It’s just not the kind of description any of us would expect a doctor to have.”

Billing irregularities were initially discovered by the state attorney general’s Medicaid Fraud Control Unit, Mr. Zwack said. A spokesman for the attorney general, Darren Dopp, declined to comment on whether the clinic was still under investigation.

The governor created the inspector general’s position and appointed Kimberly O’Connor, a former prosecutor in Schenectady County, to fill it last year after articles in The New York Times detailed widespread abuse and poor oversight in the state’s $45-billion-a-year Medicaid program.

This year, at the governor’s urging, the Legislature set aside money for 81 positions to monitor Medicaid fraud. But in a report in June, auditors with the federal Department of Health and Human Services said that Mr. Pataki’s changes, while laudable, were not sufficient to make up for years of staff cuts and lax enforcement.