The Detroit Free Press three-part investigative series on nursing home abuse and neglect continued last week with a look at the failure of many suspicious nursing home deaths to be fully and properly investigated. Not all nursing home deaths must be reported to a medical lab for further analysis on causes. Instead, most are not officially reported at all. The investigation into care at facilities in the state revealed that only a rarely are nursing home deaths investigated with an autopsy.
Nursing home law in the state requires a full medical examination when there are “violent, unexpected, or medically attended deaths.” In these cases the nursing home employees are supposed to call the examiner right away and not move the body unless instructed to do so. However, the independent investigation found that facility administrators failed to meet that standard, and some suspicious deaths were not reported for medical review as the law requires. The oversights are not rare. This one investigation alone found at least thirty three cases over only a three year period where clear nursing home care violations were made just before the death of a residents. The violations were a combination of omissions, staffing shortages, and other mistakes. In at least eight of those cases there was never any medical review of the death. No one was called, for example, when an 82-year old man fell, slammed his head (cracking his skull), and died from bleeding on the brain.
The head of the state’s medical examiner’s association explained that in the end it is up to the nursing home officials to decide whether or not an examiner is called. The medical examiners themselves have little ability to investigate or even become aware of suspicious deaths on their own. Of course, this presents a bit of a conflict when it comes to holding facilities accountable for their nursing home neglect. There are clear incentives for not reporting suspicious deaths caused (at least in part) by quality of care lapses.
This policy is distinct from that in other states which require all deaths to be reported to a medical examiner. The examiner often does not decide to perform an autopsy, but it at least ensures that the official is made aware of the death and can act depending on the circumstances. Illinois currently does not require all nursing home deaths to be reported to the coroner, though a pilot project where all deaths were reported was conducted several years ago. The pilot project consisted of ten counties and in that time at least eight suspicious deaths were found that otherwise would have been swept under the rug. Those deaths were potentially caused by Illinois nursing home neglect or abuse.
The Free Press story highlighted another proposal which would require medical examiners to set up panels to investigate these deaths. The panels would bring in pathologists, coroners, and others to routinely review these cases. The goal would be for no deaths caused by neglect to go unnoticed. That added scrutiny would likely force homes to slowly enact needed safeguards and improve the overall care provided to residents.
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