The Guardian Blog

Family Wins $19M in Nursing Home Abuse Case

Martin Solomon — Wed, 13 Jan 2010 09:56:00 -0700

A nursing home in Brooklyn that neglected a 76-year-old man and caused him to get more than 20 bedsores will be required to pay nearly $19 million to the victim’s family. 76-year-old John Danzy lost nearly 100 pounds and suffered from a serious infection as a result of his bedsores after six months of staying at the Brooklyn Queens Nursing Home. It was also discovered that the nursing home had doctored records to cover up their neglect. As a result, the jury awarded $3.5 million for pain and suffering and $15 million in punitive damages for the doctored records.

Bed sores are one of the most common and most serious results of nursing home neglect. They are caused when a patient is forced to lay or sit in the same position for a long period of time. Nursing homes are required to turn or move patients on a regular basis to prevent bed sores from occurring and keep records of these movements to ensure that they are done properly. Bed sores can erode skin and cause holes in the body and lead to serious infections and even death. If you have a loved one in a nursing home, you should check for bed sores and ask to see records to ensure that bed sores are not developing.

Nursing Home Worker Pleads Guilty to Abuse

Martin Solomon — Wed, 13 Jan 2010 08:30:12 -0700

A former nursing home worker in Lufkin, TX was recently sentenced to 20 months in jail after pleading guilty to abuse of a 77-year-old nursing home patient. The victim’s husband had noticed signs of abuse, but due to his wife’s mental state, it was difficult to prove that abuse was taking place. The husband then planted a hidden camera in his wife’s room and recorded two instances of the worker abusing his wife by grabbing her arm and twisting it violently and striking her repeatedly on the arm.

This case illustrates several problems that nursing home residents and their families must deal with. Since many nursing home residents suffer from Alzheimer’s, dementia, and similar disorders, they may not be able to report abuse themselves, so family members must be vigilant in looking for signs of abuse. In addition, since this abuse happened repeatedly, after the husband had noticed it, the administrators of the nursing home may be found liable for the abuse, as they allowed it to happen on multiple occasions despite there being signs that abuse was taking place. If you believe your loved one is being abused in a nursing home, you should contact a nursing home abuse attorney to discuss your case and decide on the best course of action.

Nursing Home Worker Pleads Guilty to Abuse

Martin Solomon — Wed, 13 Jan 2010 08:30:12 -0700

Cities Often Lag in Investigating Group Home Abuse

Martin Solomon — Wed, 13 Jan 2010 08:24:54 -0700

According to a recent report in the Washington Post, Washington, D.C. is severely lagging in investigating abuse at group homes for people with developmental disabilities. The report found that the city had not filed timely reports for over 400 cases. This report illustrates the problem of group home abuse investigations throughout the country, as underfunded and overworked government agencies cannot keep up with the number of abuse cases. Additionally, these are just the cases that are reported. Many cases of group home abuse go unreported.

Here in Arizona, our government agencies face similar problems properly overseeing group homes that care for adults with developmental and physical disabilities. Therefore, if you have a friend or loved one in such a facility, it is important to be diligent in looking for signs of abuse. These signs could include depression, welts, lethargy, or other sudden and unexplained changes in mood or behavior. If you believe your loved one is being abused, you should contact an experienced group home abuse attorney to discuss your case and decide the best course of action.

Violence in Albuquerque Group Home Shows Need for Adequate Staffing, Management

Martin Solomon — Wed, 23 Dec 2009 15:43:17 -0700

An Albuquerque group home for children with hearing impairment may be shut down due to excessive calls to the police. The Albuquerque news reports that the police have been to the home "dozens of times," responding to violence and threats. Some of the teens reportedly threatened to kill staff members, broke windows and slapped their caregivers.

The operators admit the situation is not appropriate. They claim to have taken steps towards a better environment, including giving staff "additional training." This begs the question, "why wasn't the staff trained properly to begin with?" Additionally, one wonders how healthy this environment can be for the teens when the staff can't control the situation and police must be called. A group home is supposed to be a supportive environment that helps its members adapt and function in society. This level of chaos and stress would surely hinder that kind of development

This article indicates the importance of a properly trained staff and safe group home environment. If a member of your family is in a group home, be sure to make sure they caregivers manage issues constructively. And, always be aware of the signs of abuse or neglect that may be occurring.

LA Times Reveals Unqualified Temp Nurses Working in Hospitals, Nursing Homes

Martin Solomon — Wed, 23 Dec 2009 15:30:22 -0700

When loved ones enter the hospital or assisted living centers, we expect them to receive quality care from experienced professionals. But what if your family member was actually being ignored by a recently hired nurse whose license was suspended in another state? A recent report by the LA Times detailed that exact situation, and reveals similar situations occur more than we realize.

The problem the article explores is the lack of oversight in the temporary nurse staffing industry. Staffing companies provide temp nurses to hospitals and nursing homes when demand increases or if the nursing home prefers to use temp staffing. While these companies are needed to help keep nursing homes and hospitals staffed, problems arise when neither the temp company nor the nursing home perform background checks on the temp nurse.

The Arizona Republic reported that these temp nurses have been known to steal medication, fall asleep on the job, and even fail to perform critical tests on patients. Nurses can be disciplined at other hospitals and even lose their licenses, but moving to another state lets them get hired again, putting patients at risk.

This study illustrates that seniors in nursing homes rely on quality care from the institution as well as their individual caregivers. A normally decent home could unwittingly hire a neglectful nurse who doesn't give your loved one the proper care or attention needed and deserved. When visiting family in a nursing home, it is critical to know the signs of neglect and prevent such problems from escalating to serious health concerns.

Yuma Students Reach out to Seniors in Nursing Homes for the Holidays

Martin Solomon — Wed, 23 Dec 2009 14:53:45 -0700

During the holiday season it is only natural for thoughts to drift to family and friends. Unfortunately, seniors living in nursing homes sometimes feel isolated from family who have limited time to visit or live out of state. These feelings are only intensified by the lack of activities in a nursing home setting. Thankfully, a group of college students in Yuma put together a project to reach out to seniors in nursing homes this holiday season.

The Yuma Sun reports that these NAU-Yuma students went above and beyond their assignment and actually implemented their class project. Wanting to help their community, they collaborated with local businesses to bring entertaining performances and informative workshops to local nursing homes. The workshops teach hobbies and skills seniors can use to stay connected and engaged with the community.

This student project will go a long way to help Yuma seniors stay connected and engaged. Their efforts are especially helpful in nursing homes, where seniors can feel isolated and idle. Lack of adequate staffing or materials leaves residents with little to do with their time. If you visit family in a nursing home this holiday, you may want to ask what kind activities are offered, as well as making sure their basic health and comfort needs are being met.

Department on Disability Services Overwhelmed with Reports of Group Home Abuse

Martin Solomon — Tue, 01 Dec 2009 16:12:37 -0700

The Washington Post reported Saturday that hundreds of cases of group home abuse in Washington D.C. are going uninvestigated due to a lengthy backlog of reports. This backlog was created when the Department on Disability Services reformed its oversight methods and began investigating privately run group homes, thus discovering many cases of neglect and abuse that had gone on with impunity.

The department reported a 60 percent increase in serious incidents, up to 1057 in 2009, and will be hiring additional investigators to resolve the claims. But, this inability to protect some of our most vulnerable citizens in our nation’s capital speaks to the difficulties faced by those living in group homes.

As Arizona’s budget crisis deepens, deep cuts will be made to the Arizona Department of Economic Security and Department of Health Services, negatively affecting the care and wellbeing of group home residents. With government agencies falling behind, it is now more important than ever for family members to know the signs of neglect in group homes and nursing homes. Families serve as the first and best line of defense to protect the health and happiness of their loved ones.

Nursing Home Abuse in Arizona

Martin Solomon — Thu, 29 Oct 2009 12:12:32 -0700

Arizona is one of the few states in the country that has a unique statutory definition of “abuse” of nursing home patients.

“Abuse” means:

1. Intentional infliction of physical harm.
2. Injury caused by negligent acts or omissions.
3. Sexual abuse or sexual assault.

This definition is broader than the common definition of abuse and therefore includes what would ordinarily be classified as simple negligence. This expanded definition is helpful in asserting claims for poor care given to Arizona nursing home patients.

Family Councils: Suggested Agendas

Martin Solomon — Thu, 24 Sep 2009 15:51:53 -0700

Many patients remain in the nursing home setting for the balance of their lives. Their final years can either be comfortable or tragic depending on the quality of care they receive.

It is difficult for an individual family to influence the nursing home’s management to improve patient care.

The best opportunity for success in improving patient care is through the nursing home’s Family Council.

Members of the council are the families of the residents. They can set their own agendas and present the facility with their concerns which must be addressed by management.

There are care issues that are common in nursing homes. The following is an outline of several of them and how they can affect nursing home patients’ quality of life.

1. Nutrition. When there is a shortage of staff in the facility, patients who are unable to feed themselves independently, suffer.

2. Hydration. A lack of adequate fluid intake is a cause of significant problems for residents including confusion, falls, and urinary tract infections.

Residents must have water conveniently located in their room. The water container must be regularly filled. Patients must be encouraged to drink water throughout the day.

Once again, inadequate staffing is usually the underlying problem when patients are dehydrated.

3. Assistance with Activities of Daily Living. Another area of concern is the insufficient number of nursing assistants to provide patients with assistance in their activities of daily living.

These activities include: bathing, dressing, grooming, transfers to bed and chair, ambulation, toileting, and eating (as discussed above).

The Family Council through its family members can provide factual accounts of care concerns at the facility and request that the facility provide adequate staff to attend to their vulnerable patients.

If cooperation isn’t forthcoming, the Council should then request the Arizona Department of Health Services to investigate the inadequacy in the facility’s level of care.

Family Councils in Nursing Homes: Resident Protection

Martin Solomon — Thu, 17 Sep 2009 14:34:45 -0700

The adage “there is safety in numbers” is particularly true in the nursing home setting. Federal nursing home regulations provide a vehicle for enhancing patient safety, by requiring nursing homes to have “family councils”.

Family councils are made up of resident’s family members that meet regularly to discuss issues pertaining to resident care at the facility.

The nursing home must assist the council by making a “private” space available for the families to meet. In addition, a facility representative may only attend the meeting by invitation of the council, and must respond to council concerns.

If you have a loved one in a nursing home, participating in the family council is a must. If there isn’t an active council, start one!

The Nursing Home Family "Toolkit"

Martin Solomon — Tue, 08 Sep 2009 11:28:01 -0700

Placing a family member in a nursing home is painful and difficult, yet necessary when the medical and physical demands make other options unacceptable.

The nursing home environment and staff procedures may be overwhelming for the family as well as the patient. In order to function in this new environment the family must learn a new set of rules and procedures.

The Nursing Home Family “Toolkit” is a structure that families can utilize to get their bearings in an otherwise confusing situation.

The “Toolkit” is a protocol for gathering information about the facility, its caregivers, management, and the other residents and their families.

Caregivers, Management, Residents and Families

There are many caregivers in the nursing home setting. It’s important for the family to know the names, positions and shifts of all caregivers in order to understand which caregiver is responsible for the delivery of care during each shift.

To the extent possible, it is advisable for the family to meet each of the patient’s caregivers to establish a personal relationship between the family and the facility staff.

Obtaining the names of all supervisory staff and their shifts enables families to understand the chain of command.

The family should learn the name of the Director of Nursing, the Medical Director, and the Administrator and the times they are in the building.

Since there is considerable turnover in nursing homes, the information should be updated quarterly.

Finally, the name of the treating physician, the days and times he is usually in the building is also important.

Other Residents and their Families

You and your loved one are now in the new “community” with other residents and their families. There is a lot to learn and the other residents and families can be very helpful.

They will have information and opinions about the staff and administration which they can share with you. They can keep an eye on your loved one when you are not there and call potential problems to your attention.

Make sure to get the complete names of the other residents and their families, as well as their addresses and phone numbers.

Keeping a Diary

As a lawyer, I review many nursing home neglect and abuse cases. It is very helpful to visit with a family that has kept a diary of the events surrounding the care of their loved one. Details about the problems confronting the family and their efforts to obtain necessary care can go a long way in establishing nursing home accountability.

Full Disclosure in Skilled Nursing Facilities included in Health Care Reform

Martin Solomon — Tue, 25 Aug 2009 10:21:14 -0700

Contained in a joint draft bill of the House Ways and Means, Energy and Commerce, and Education committees are provisions that eliminate the secret ownership of Nursing Homes.

If these transparency provisions remain in the eventual legislation, patient advocates will score a significant victory on behalf of patients and their families.

Nursing Homes would be required to disclose ownership and organizational information, as well as their regulatory compliance and ethics programs.

Additional disclosures, involving financial expenditures for direct and indirect care, capital assets, and administrative costs will be also required to be disclosed.

Skilled nursing facilities provide vital services to our most vulnerable patients. In order to deliver quality care, facilities must allocate sufficient resources to nursing, dietary, oversight and safety services.

There is a direct correlation between dollars spent and the services provided to patients. Mandating full public disclosure of expenditures and ownership will advance owner accountability and help ensure quality patient care.

Evaluating a Nursing Home Neglect and Abuse Case

Martin Solomon — Mon, 17 Aug 2009 13:30:44 -0700

It is always difficult to tell a family that I am unable to represent them regarding the loss or severe injury of their loved one in a nursing home.

However, arriving at the right decision as to whether to accept a nursing home neglect and abuse case is the foundation of a nursing home practice.

Difficult decisions are made at the junction where emotion and intellect intersect.

Emotion is the first to weigh in when a death or life changing event is presented to me for review. It is difficult not to become incensed at the poor care given to our most vulnerable patients or to become attached to a family that has lost a loved one.

Since intellect, in the form of practical considerations, are slow to appear, caution in the decision process is well advised.

Nursing home, assisted living, and group home cases are expensive, labor intensive and emotionally draining for an attorney. They are also difficult for families because they take a long time to resolve and therefore there is delayed closure of the emotional wound.

The first consideration is whether the neglect or abuse resulted in significant injury or death.

The second consideration is whether the injury or death was the result of neglect or abuse.

Having said that, my analysis as to whether to move forward is based on a broad view of the nursing home (including both the specific facility and the parent organization).

I examine the history of the nursing home to determine whether they have had similar problems in the delivery of patient care. Have they learned from their prior mistakes or are they continuing with the same conduct?

I determine whether the harm was the result of a systemic failure such as inadequate staffing, training or oversight. These systemic failures are evidence that the facility was incapable of providing quality care.

I then determine whether the systemic failures were the result of corporate business decisions. In other words, did the nursing home corporation decide to place profits over quality patient care and did that decision lead to the injury or death?

The answer to this question will determine whether the facility’s conduct warrants an award of punitive damages. Punitive damages are assessed against a facility to punish it for outrageous conduct.

Going through these considerations in the case selection process enables me to decide whether to accept or reject a nursing home case. However, it doesn’t make it any easier to tell a family that I am unable to help them.

Use of Restraints and Seclusion by Schools on Children with Disabilities

Martin Solomon — Wed, 10 Jun 2009 10:14:39 -0700

The United States Government Accounting Office (GAO) recently completed a study of public and private schools and reported to Congress on the abuse of vulnerable children who were students at those institutions.

The GAO first testified that there were no federal laws restricting seclusion or restraints in public or private schools and that state laws were widely divergent.

Most significant was their report that found hundreds of cases of alleged abuse and death related to the use of restraints on school children during the last 20 years.

The use of restraints on vulnerable adults in the nursing home setting has been band except under very limited circumstances with physician supervision. There is no good reason to continue this dangerous practice with disabled children in the school setting.

Assisted Living Facilities: Filling Beds in Hard Economic Times

Martin Solomon — Thu, 04 Jun 2009 16:09:55 -0700

Assisted Living Facilities are private pay organizations where fees can cost $6,000 or more per month.

They are not skilled nursing facilities and are unable to provide care to residents with complex nursing or medical needs.

In order to fill empty beds, assisted living managers may stretch, in terms of promises they make to families, as to the level of care their facility is equipped or competent to provide.

It may be difficult for a family to place a loved one in a nursing home when they believe that an attractive assisted living facility is willing to accept the patient. However, it is the quality of care that is critical not the quality of the ambiance.

So beware of promises made by assisted living admission representatives and inquire of your loved one’s treating physician about the level of care necessary before making this important decision.

Drug companies may be required to disclose payments made to doctors for the "Objective" Evaluation of their drugs

Martin Solomon — Thu, 28 May 2009 15:28:12 -0700

Senators Grassley and Kohl have sponsored a bill that would require drug companies and manufacturers of medical equipment to publicly disclose payments to physicians that exceed $500 per year.

In discussing the need for this legislation, Senator Grassley reported that drug companies are paying fees and expenses to physicians who are supposed to be objectively reviewing the effectiveness of medications.

Grassley explained that a physician had recently been paid in excess of a half a million dollars in fees and expenses by a major drug company during the time the physician was the lead physician on a study evaluating the company’s new drug.

Treating physicians must be able to rely on independent studies to make medical decisions regarding treatment. Even the suggestion of impropriety can have serious treatment implications. We hope Congress will implement this legislation in this new era of recapturing public trust.

When a Loved One Dies in a Nursing Home: Searching for the Truth

Martin Solomon — Fri, 22 May 2009 09:42:01 -0700

When a loved one dies while receiving care in a nursing home, the family is entitled to know whether the death could have been avoided by good nursing care.

According to an article in the New York Times, after a death occurs at a nursing facility, it is not uncommon for the family to mistrust what they have been told by the facility as to the cause of the death.

In my experience, this is particularly true of deaths occurring at nursing homes where the history of care has been questionable.

It may not be helpful to rely on the nursing home treating physician for answers, as many of the treating physicians in nursing homes are also the facility’s medical director.

Even a death certificate stating the cause of death may be suspect as the physician signing the certificate may have only limited information as to the circumstances surrounding the death.

What is a family to do?

The answer may be an autopsy, either performed by the county medical examiner or by a private pathologist.

The county medical examiner will usually only perform an autopsy if the circumstances surrounding the death calls into question whether the death was by natural means.

To have a private autopsy performed in Arizona can cost between $3,500 - $4,500. However, it may be the only way to determine the cause of death and give the family closure they deserve.

The Nursing Home Medical Director: Accountability

Martin Solomon — Wed, 13 May 2009 14:08:57 -0700

A nursing home is a nursing institution that is managed by an Administrator, who is not a medical professional.

The highest level of medical management in the nursing home is the Medical Director.

It is also common for the Medical Director to be the primary treating physician for his own patients in the facility.

Under Federal Regulation, the nursing home Medical Director is responsible for “the coordination of medical care in the facility.” This means that the Medical Director is responsible for assuring that the nursing staff is providing appropriate care to its patients.

In addition, the Medical Director is a member of the clinical care oversight committee which is charged with addressing all facility deficiencies as identified by the state’s Department of Health Services.

The role of the Medical Director requires an investment of time for the analysis of the facility’s operations and should not be taken lightly by any physician. The Medical Director must become familiar with the system of healthcare delivery within the facility and assure that it functions properly.

With this responsibility comes accountability which means liability, should the Medical Director fail to perform as required.

Families Can Monitor the Quality of Nursing Home Care

Martin Solomon — Fri, 08 May 2009 10:06:58 -0700

Can I do anything to improve the care my loved one is receiving at the nursing home?

This is a common question. Today I would like to discuss what I believe is a reasonable methodology to assist families in playing a positive role in the care of their nursing home patient.

Family participating in their loved ones care is becoming more important every year. However, there is little information available to inform and educate families as to how they can successfully advocate for their loved one. The following is an introduction to Family Advocacy 101.

Inadequate Communication in the Nursing Home
One of the major impediments to good care in the nursing home is inadequate communication among health care providers (nursing assistants, nurses, physicians, and nursing home management).

The nursing staff is responsible for continually assessing patients for changes in condition and for the accuracy and completeness of charting the patients’ condition. Facility understaffing places many hurdles in the path of staff-to-staff communication.

It is not the family’s job to facilitate staff communication in the nursing home. However, a family that is knowledgeable enough to understand the weakness in the nursing home’s system of communication is able to provide a communication bridge between the patient and the nursing home staff.

The family can thus make a significant contribution to the patient’s well being by facilitating awareness and understanding of the patient’s condition.

The Nursing Home Chart
The “chart” is a collection of records, first created when the patient is admitted to the nursing home and supplemented throughout the patient’s stay.

The purpose of the chart is to enable any healthcare provider to obtain a history and current status of the patient.

Understanding the Chart
This is not as difficult as you may think. Families with the patient’s permission may examine the patient’s chart.

There are certain documents in the chart that are key to evaluating care. We’ll briefly discuss each and also how it can be utilized by the family.

Hospital Transfer Records
The patient is usually accompanied to the nursing home with Hospital Transfer Records. These are records which explain the patient’s condition upon discharge from the hospital. The records also include a list of the medications the patient is taking, and any physician orders for continued medication and care.

The Admission Record
When a patient is admitted into a nursing home an Admission Record is completed by the admitting nurse. The Hospital Transfer Records are reviewed and incorporated into the admission records for the consideration of the nursing home admitting physician.

The admitting nurse must review the hospital transfer records, examine the patient, obtain information from the patient, and educate the patient’s family regarding the patient’s needs and abilities.

The Family re: Admission Process
The family should read the patient’s Hospital Transfer Records and the Admission Records in order to make sure that they accurately reflect the patient’s condition at the time of admission to the nursing home.

Advising the nursing staff about any discrepancies or omissions will facilitate an accurate understanding of the patient. It also ensures that the staff and admitting physician will be in a better position to address all of the patient’s needs.

Treatment / Medication Administration Records
The Treatment Record documents all the treatments that the patient’s physician has ordered for the patient. There is a place on the Treatment Record for the nursing staff to document when each treatment is provided.

The Medication Administration Record documents all the medications that were ordered for the patient and there is a place for the nurses to document when each medication is administered.

The timely performance of treatments and administration of medication is important to the welfare of the patient. Failure to provide either may result in patient debility or death.

The Family: Treatments and Medication
The family should examine the treatments ordered for the patient and the medication to be administered and verify that the patient is receiving the treatments and medications as were ordered.

Pay particular attention to any new treatments and medications and tell the nursing staff and the physician if there are any changes in the patient’s condition once the new treatments and medications have been given.

A change in treatment or medication can sometimes have a negative consequence and therefore patients should be closely monitored when new therapies are implemented or new medications are administered.

Vital Signs and Weight Records
The nursing assistants commonly record the patient’s vital signs (temperature, blood pressure, pulse, and respiration) and weights. Weights are usually taken monthly unless ordered otherwise.

Any unusual readings must be retaken to allow for the possibility of error and timely reported to the patient’s physician in the event it is determined that the reading was accurate.

An elevated temperature may be a sign of infection or dehydration and must be addressed with the patient’s physician immediately.

Any unplanned weight loss must also be addressed immediately with the patient’s physician and the dietitian. In addition, a patient who has lost weight should be placed on a weekly weight plan.

It is not uncommon for recording the vitals and weights to be neglected by nursing when they are understaffed and overworked.

The Family: Vitals and Weights
Once again, the family can play an important role in assuring that the patient’s vitals and weights are regularly recorded by the staff.

By examining the vitals and weight records weekly and reporting any failures of entry to the nurse in charge and the patient’s physician, the family can help avert potential problems.

Nursing Assistant Flow Sheets
Nursing assistants provide much of the hands on care in the nursing home. They document certain elements of the care that they provide on Nursing Assistants Flow Sheets.

One of the more important aspects of their charting responsibility is to document the percentage of meals and fluids consumed by the patient.

The flow sheet forms have columns for the days of the week and cross-columns for breakfast, lunch, dinner and snacks. Each box for a particular date and meal should be filled in with the accurate meal and fluid percentages that the patient consumes.

In a busy nursing home, that lacks an adequate number of nursing assistants, it is not unusual for Flow Sheet charting to be incomplete. Unfortunately, it is also not unusual for the meals percentages documented to be fabricated, especially at times when the facility is short staffed and the percentages are recorded at a later date.

The Family: Flow Sheets
As stated before, any unplanned weight loss in an elderly patient is a serous condition and must be addressed as quickly as possible.

The family should examine the patient’s Nursing Assistant Flow Sheet weekly and report any blank boxes to the Director of Nurses.

The family should also examine the percentages of meals consumed in light of the patient’s physical condition.

For example, when a patient has unintentionally lost weight and the Nurse Assistant Flow Sheet indicates that the patient has been eating 100% of his meals, the family should be suspicious. The weight loss may be the consequence of a medical condition or may be a situation where the nursing assistants are fabricating the meal percentages that the patient has eaten.

Becoming aware of this conflict between the weight loss and the meal percentages enables the family to call this matter to the attention of the Director of Nursing and the patient’s physician.

Families place their trust in the nursing home to provide quality care. Although the nursing home staff should be an advocate for the patient, this rarely occurs because the facility is understaffed and the staff is overworked just trying to provide basic services to all the patients.