https://www.hrw.org/report/2018/02/05/they-want-docile/how-nursing-homes-united-states-overmedicate-people-dementia

Too many times I’m given too many pills…. [Until they wear off], I can’t even talk. I have a thick tongue when they do that. I ask them not to [give me the antipsychotic drugs]. When I say that, they threaten to remove me from the [nursing] home. They get me so I can’t think. I don’t want anything to make me change the person I am.
—Walter L., an 81-year-old man given antipsychotic drugs in a Texas nursing facility, December 2016.It used to be like a death prison here. We cut our antipsychotics in half in six months. Half our residents were on antipsychotics. Only 10 percent of our residents have a mental illness.
—A director of nursing at a facility in Kansas that succeeded in reducing its rate of antipsychotic drug use, January 2017.

In an average week, nursing facilities in the United States administer antipsychotic drugs to over 179,000 people who do not have diagnoses for which the drugs are approved. The drugs are often given without free and informed consent, which requires a decision based on a discussion of the purpose, risks, benefits, and alternatives to the medical intervention as well as the absence of pressure or coercion in making the decision. Most of these individuals—like most people in nursing homes—have Alzheimer’s disease or another form of dementia. According to US Government Accountability Office (GAO) analysis, facilities often use the drugs to control common symptoms of the disease.

While these symptoms can be distressing for the people who experience them, their families, and nursing facility staff, evidence from clinical trials of the benefits of treating these symptoms with antipsychotic drugs is weak. The US Food and Drug Administration (FDA) never approved them for this use and has warned against its use for these symptoms. Studies find that on average, antipsychotic drugs almost double the risk of death in older people with dementia. When the drugs are administered without informed consent, people are not making the choice to take such a risk.

The drugs’ sedative effect, rather than any anticipated medical benefit, too often drives the high prevalence of use in people with dementia. Antipsychotic drugs alter consciousness and can adversely affect an individual’s ability to interact with others. They can also make it easier for understaffed facilities, with direct care workers inadequately trained in dementia care, to manage the people who live there. In many facilities, inadequate staff numbers and training make it nearly impossible to take an individualized, comprehensive approach to care. Many nursing facilities have staffing levels well below what experts consider the minimum needed to provide appropriate care.

Federal regulations require individuals to be fully informed about their treatment and provide the right to refuse treatment. Some state laws require informed consent prior to the administration of antipsychotic drugs to nursing home residents. Yet nursing facilities often fail to obtain consent or even to make any effort to do so. While all medical interventions should follow from informed consent, it is particularly egregious to administer a drug posing such severe risks and little chance of benefit without it.

Such nonconsensual use and use without an appropriate medical indication are inconsistent with human rights norms. The drugs’ use as a chemical restraint—for staff convenience or to discipline or punish a resident—could constitute abuse under domestic law and cruel, inhuman, and degrading treatment under international law.

The US has domestic and international legal obligations to protect people who live in nursing facilities from the inappropriate use of antipsychotic drugs, among other violations of their rights. These obligations are particularly important as people in nursing facilities are often at heightened risk of neglect and abuse. Many individuals in nursing facilities are physically frail, have cognitive disabilities, and are isolated from their communities. Often, they are unable or not permitted to leave the facility alone. Many depend entirely on the institution’s good faith and have no realistic avenues to help or safety when that good faith is violated.

US authorities, in particular the Centers for Medicare & Medicaid Services (CMS) within the US Department of Health and Human Services, are failing in their duty to protect some of the nation’s most at-risk older people. On paper, nursing home residents have strong legal protections of their rights, but in practice, enforcement is often lacking. Although the federal government has initiated programs to reduce nursing homes’ use of antipsychotic medications and the prevalence of antipsychotic drug use has decreased in recent years, the ongoing forced and medically inappropriate use of antipsychotic drugs continues to violate the rights of vast numbers of residents of nursing facilities. The US government should use its full authority to enforce longstanding laws, including by penalizing noncompliance to a degree sufficient to act as an effective deterrent, to end this practice.

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This report documents nursing facilities’ inappropriate use of antipsychotic drugs in older people as well as the administration of the drugs without informed consent, both of which arise primarily from inadequate enforcement of existing laws and regulations. The report is based on visits by Human Rights Watch researchers to 109 nursing facilities, mostly with above-average rates of antipsychotic medication use, between October 2016 and March 2017 in California, Florida, Illinois, Kansas, New York, and Texas; 323 interviews with people living in nursing facilities, their families, nursing facility staff, long-term care and disability experts, officials, advocacy organizations, long-term care ombudsmen, and others; analysis of publicly available data; and a review of regulatory standards, government reports, and academic studies.

This report is especially relevant at this time because the US is aging rapidly. Most of the people in the nursing facilities Human Rights Watch visited are over the age of 65. Older people now account for one in seven Americans, almost 50 million people. The number of older Americans is expected to double by 2060. The number of Americans with Alzheimer’s disease, the most common form of dementia, is expected to increase from 5 million today to 15 million in 2050. The system of long-term care services and supports will have to meet the needs—and respect the rights—of this growing population in coming years.

Social Harm and Health Risks Caused by Antipsychotic Drugs Used Unnecessarily or as Chemical Restraints

The American Psychiatric Association (APA) Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia states that, after eliminating or addressing underlying medical, physical, social, or environmental factors giving rise to manifestations of distress associated with dementia, antipsychotic drugs “can be appropriate” as a means to “minimize the risk of violence, reduce patient distress, improve the patient’s quality of life, and reduce caregiver burden.” However, given the “at best small” potential benefits and the “consistent evidence that antipsychotics are associated with clinically significant adverse effects, including mortality,” it is essential that the drug treatment is only attempted when appropriate.

Nursing facility staff, individuals living in facilities, their families, long-term care advocates, and others told Human Rights Watch that the drugs are not used only as a last resort, after all factors potentially giving rise to a person’s distress have been ruled out, and after nonpharmacologic interventions have been attempted unsuccessfully. Instead, antipsychotic drugs are used sometimes almost by default for the convenience of the facility, including to control people who are difficult to manage.

One facility social worker said that one of the most common “behaviors” leading to antipsychotic drug prescriptions was someone constantly crying out, “help me, help me, help me.” An 87-year-old woman reflected that at her prior facility, which gave her antipsychotic drugs against her will, “they just wanted you to do things just the way they wanted.” A social worker who used to work in a nursing facility said the underlying issue is that “the nursing homes don’t want behaviors. They want docile.” A state surveyor said: “I see way too many people overmedicated…. [Facilities] see it as a cost-effective way to control behaviors.”

Human Rights Watch interviewed people who live in nursing homes and their family members who described the harmful cognitive, social, and emotional consequences of the medications that all too often should never have been administered in the first place: sedation, cognitive decline, fear, and frustration at not being able to communicate. Most or all antipsychotic drugs are associated with sedation and fatigue in people with dementia.

A 62-year-old woman in a nursing facility in Texas who said she was given Seroquel, a common antipsychotic drug, without her knowledge or consent said: “[It] knocks you out. It’s a powerful, powerful drug. I sleep all the time. I have to ask people what the day is.” The daughter of a 75-year-old woman in Kansas said that when the nursing facility began giving her mother an antipsychotic drug, her mother “would just sit there like this. No personality. Just a zombie…. The fight is gone.”

Nursing staff, social workers, long-term care ombudsmen, and state surveyors echoed this perception. One director of nursing said: “You actually see them decline when they’re on an antipsychotic. I think it’s sadder than watching someone with dementia decline.”

Lack of Informed Consent Prior to Antipsychotic Medication Administration

The use of antipsychotic drugs to control people without their knowledge or against their will in nonemergency situations violates international human rights. The practicalities of obtaining consent from an older person with dementia can be fraught. However, in many of the cases Human Rights Watch documented, nursing facilities made no effort to obtain meaningful, informed consent from the individual or a health proxy before administering the medications in cases where it clearly would have been possible to do so.

Our research suggests that in many other cases, facilities that purport to seek consent fail to provide sufficient information for consent to be informed; pressure individuals to give consent; or fail to have a free and informed consent procedure and documentation system in place. Under international human rights law, in the absence of free and informed consent, a nonemergency medical intervention that is not necessary to address a life-threatening condition is forced treatment.

One former nursing facility administrator explained:

The facility usually gets informed consent like this: they call you up. They say, “X, Y, and Z is happening with your mom. This is going to help her.” Black box warning (the government’s strongest warning to draw attention to serious or life-threatening risks of a prescription drug)? “It’s best just not to read that.” The risks? They gloss over them. They say, “That only happens once in a while, and we’ll look for problems.” We sell it. And, by the way, we already started them on it.

A current director of nursing admitted, “We are supposed to be doing informed consent. It’s on the agenda. But really antipsychotics are a go-to thing. ‘Give ‘em some Risperdal and Seroquel.’ We tell the family as we’re processing the order. The family is notified.” The daughter of a woman in a nursing facility described having consented to antipsychotic drugs for her mother without understanding the risks: “I had no idea, not at all, that the drugs were dangerous. I had no idea…. I’m guessing most people have no idea.”

A detailed examination of the question of legal capacity—the right to exercise one’s own rights and to make decisions on one’s own behalf—is outside the scope of this report. Because many people living in nursing facilities have dementia and other progressive conditions that affect their cognitive ability, it is a highly complex question how medical and other decisions concerning their care should be made in a rights-respecting manner. In US nursing facilities, substituted decision-making—where a family member or other third party, whether voluntarily designated in advance or not, makes decisions on an individual’s behalf—is common.

Government Obligations

In 2012, CMS created the National Partnership to Improve Dementia Care in Nursing Homes, in recognition of the unacceptably high prevalence of antipsychotic drug use. While the initiative—which set targets for the industry to reduce antipsychotic drug rates—may have contributed to the reduction of the use of antipsychotic medications over the last six years, it cannot substitute for the effective regulation of nursing homes, including by ensuring that facilities face meaningful sanctions for noncompliance with mandatory standards. Our research found that CMS is not using its full authority to address this issue. Recently, CMS is in fact moving in the opposite direction, limiting the severity of financial penalties and the regulatory standards with which facilities must comply.

CMS and the state agencies with which it contracts to enforce federal regulations are not meeting their obligation to protect people from the nonconsensual, inappropriate use of antipsychotic drugs. Human Rights Watch identified several key areas of concern:

• Failure to adequately enforce the right to be fully informed and to refuse treatment or to require free and informed consent requirement. The Nursing Home Reform Act of 1987 grants residents the right “to be fully informed in advance about care and treatment,” to participate in care planning, and to refuse treatment without penalty. If it were enforced fully, these protections would not differ substantially from the right to free and informed consent. However, without adequate enforcement, current practice falls far short of this protection.
• Lack of minimum staffing regulations. Adequate numbers of sufficiently competent staff are at the crux of nursing facility care. Yet government regulations do not set a minimum staffing requirement for nursing facilities, instead requiring that facilities determine for themselves what amounts to “sufficient” and “competent” staff for their residents. While experts put minimum adequate nursing staffing time at 4.1 to 4.8 hours per resident per day, most facilities self-reported to the government providing less than that; almost one thousand facilities self-reported providing less than three hours of staff time per day.
• Weak enforcement of federal regulations specifically banning chemical restraints and unnecessary drugs. Federal regulations prohibit chemical restraints—drugs used for the convenience of staff or to discipline residents without a medical purpose—and unnecessary drugs: a technical term meaning drugs used without adequate clinical indication, monitoring, or tapering. The regulations also provide for the right to refuse treatment. However, federal and state enforcement of these regulations is so weak that the drugs are routinely misused without significant penalty. Almost all antipsychotic drug-related deficiency citations in recent years have been determined to be at the level of causing “no actual harm,” curtailing the applicability and severity of financial sanctions.

With such vast numbers of nursing facility residents still getting antipsychotic drugs that many do not need, do not want, and that put their lives and quality of life at risk, federal and state governments need to do more to ensure that the rights of residents are adequately protected. An industry entrusted to provide care—and paid billions of public and private dollars to do so—cannot justify compounding the vulnerabilities, challenges, and loss that people often experience with dementia and institutionalization.

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Related Content

• • February 5, 2018 News Release

• US: Nursing Homes Misuse Drugs to Control Residents

Key Recommendations

Federal and state government agencies should take steps to end the inappropriate and nonconsensual use of antipsychotic medications in nursing facilities. In particular, the Centers for Medicare & Medicaid Services (CMS) and other government agencies should:

• End the inappropriate use of antipsychotic drugs in older people with dementia in nursing facilities, including many instances where they are administered without free and informed consent; used as chemical restraints; or where their use qualifies as an “unnecessary drug.” CMS and state agencies should use the regulatory and enforcement tools at their disposable to ensure that routine violations of regulations that help to safeguard individuals’ human rights cease.
• Require nursing facilities and residents’ physicians to seek free and informed consent prior to the administration of antipsychotic medications to nursing facility residents. Federal regulations providing for the right to be fully informed and to refuse treatment—as well as state laws that provide for informed consent—should be enforced more effectively. The establishment in the federal regulations of a right to informed consent may improve protection in practice by clarifying the right’s content and underscoring its significance. Congress and CMS should require that consent be documented and revisited as appropriate.
• Ensure nurse staffing numbers and training levels are adequate. CMS should establish minimum nurse staffing levels for facilities or undertake other effective measures to address understaffing, inadequate training, and high turnover rates in many nursing facilities. Implementation of the payroll-based staffing data collection system, as required by the Affordable Care Act, should be completed, particularly with regard to nursing staff who provide direct resident care.  This includes public reporting of staff-to-resident hours of care per day and turnover and retention rates in each nursing home certified by Medicare and Medicaid.
• Strengthen enforcement on particular subjects linked to the inappropriate use of antipsychotic drugs, including care planning requirements and transfer and discharge rights. CMS should improve inspection and penalty guidance and enforcement practices related to antipsychotic drugs. Surveyors should follow CMS guidance indicating that many inappropriate uses of antipsychotic drugs amount to Level 3 or 4—actual harm and immediate jeopardy—severity of violations.

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Methodology

This report focuses on the inappropriate use of antipsychotic drugs among older people, primarily with dementia, in nursing facilities across the US. Many older people who live in nursing facilities or reside there temporarily are at risk of suffering from this abuse. They rely on the government’s enforcement of federal regulations to protect their rights, including to be free from unnecessary drugs, drug treatment to which they object, and sedating drugs administered for the convenience of facility staff. Human Rights Watch found that enforcement is inadequate to deter the misuse of antipsychotic drugs.

This topic was chosen because of the paradox that misuse of the drugs has been well-documented for decades, prohibited by law, and yet persists as a pervasive, serious problem. The amount of publicly available data on nursing homes and antipsychotic drugs specifically made it feasible to conduct the research. The project was also chosen to attempt to amplify the voice and highlight the circumstances of some of the most isolated individuals: not only by living in nursing homes or having dementia, but also by being under the influence of the psychotropic medication.

The report is based on interviews with 323 people in New York, Texas, Kansas, Illinois, California, and Florida between October 2016 and March 2017. Additional interviews were conducted over the phone from September 2016 to April 2017. In addition, Human Rights Watch consulted secondary sources, conducted significant background research, and analyzed copious amounts of data.

These six states were selected for multiple reasons. California and Texas have the highest number of nursing facilities, with 1,219 and 1,212 respectively in 2014. California, Florida, Illinois, New York, and Texas have among the highest numbers of nursing facility residents of any state. Excluding facilities where less than half of the residents are over age 65, Texas and New York lead all states in terms of the number of nursing home residents taking antipsychotic drugs without an exclusionary diagnosis of schizophrenia, Huntington’s disease, or Tourette syndrome. Kansas, Texas, and Illinois have some of the highest proportions of residents on antipsychotic drugs. More detailed data on these states and their rankings nationally can be found in Appendix 3. Most of these states were also chosenbased on their strong citizen advocacy organizations working on nursing facility reform and resident rights protection and their long-term care ombudsman programs.

In the six states, Human Rights Watch interviewed 74 people between the ages of 37 and 93 who live in nursing facilities, including 15 under the age of 65. All of the individuals in nursing facilities had cognitive, psychosocial, and/or physical disabilities. Almost all of the individuals were in facilities with high rates of antipsychotic drug use; in many cases, they or someone who knows them told Human Rights Watch that they currently or previously took antipsychotic drugs. However, not all interviewees claimed to take antipsychotic drugs, and it was not possible to view the medical records of the majority of interviewees.

We interviewed 36 family members of residents, 20 long-term care ombudsmen, 18 advocates including attorneys, 10 state and federal government officials, 90 facility administrators, nursing, and social services staff, and six medical professionals such as pharmacists, psychologists, psychiatrists, and doctors. We have omitted people’s names or used pseudonyms where names or other identifying information may compromise the privacy of individuals or invite possible reprisals.

Human Rights Watch also interviewed 69 experts, including lawyers, academic researchers, professors, journalists, doctors (in addition to those interviewed associated with nursing facilities or nursing facility residents mentioned above), government officials, and advocates. Human Rights Watch sent letters to CMS, the American Health Care Association (AHCA), and LeadingAge—the government agency that oversees the nursing facility industry, the for-profit trade association, and the nonprofit trade association, respectively—with questions regarding this report’s findings. We received responses from AHCA and LeadingAge (see Appendices 6 and 7). We did not receive a response from CMS at time of writing.

Human Rights Watch visited 109 facilities. In 17 of the 109 facilities, we were not allowed to conduct research. Of the remaining 92, sometimes our entry was with explicit permission of the facility, sometimes with permission of the person we were visiting, and sometimes without permission of the facility but without objection. In some cases, we talked to staff only and not residents.

Two of the 109 facilities were in New York, 25 in Texas, 20 in Kansas, 16 in Illinois, 23 in California, and 23 in Florida. One of the 109 has since closed. All facilities were skilled nursing facilities or nursing facilities rather than assisted living facilities, and all received some combination of payment through Medicare, Medicaid, private insurance, and private pay. The US Department of Veterans Affairs operates community living centers, nursing homes, and state veterans’ homes across the country as well, as part of the Veterans Health Administration; they are regulated differently and outside the scope of this project. Facilities were selected based on publicly available data on the average percentage of residents without an exclusionary diagnosis given at least one antipsychotic medication in the last quarter.

We primarily visited facilities with a majority population over the age of 65. As of 2010, 16 percent of the nation’s nursing home population was between the ages of 31 and 64. Younger people live in nursing facilities for a variety of reasons. However, nursing homes with majorities of younger people and high rates of antipsychotic drug use tend to have greater concentrations of people with psychosocial disabilities. While the administration of antipsychotic drugs may be inappropriate despite psychiatric diagnoses for which the drugs are approved, the root of the rights violations may be distinct, and this report was limited to the demographic of older people, often with dementia.

Of the 109 facilities visited, 79 facilities (72 percent) were for-profit and corporate owned; five (5 percent) were for-profit and individually owned; five (5 percent) were for-profit and part of a partnership government hospital district; 16 facilities (15 percent) were nonprofit and corporate owned; and one facility (1 percent) was nonprofit and church related.

Researchers were refused admission or asked to leave shortly after arriving in 24 facilities. In some cases, administrators had notice of our interest in visiting and refused to meet or allow us to speak with residents who might wish to speak with us. In other cases, facilities did not have notice and requested that we return at another time.

Whenever possible, Human Rights Watch spoke directly with people who live in nursing facilities. In some cases, nursing facility administrators, directors of nursing, directors of social services, or business or admissions officers refused our request to speak with residents. Some facilities claimed that no resident was their own “responsible party” and that they thus could not consent to an interview.

Where access to residents was not blocked, Human Rights Watch sought to interview residents and staff in private so that they could speak openly without fear of potential retaliation. In some facilities, finding locations that afforded sufficient privacy was difficult. As a result, in some cases, with the interviewee’s permission, we conducted interviews in rooms where the interviewee’s roommate was asleep or watching television. In other cases, we conducted interviews in an activity room or at the end of a hallway that was out of ear shot of other people, but not fully secluded.

Human Rights Watch asked interviewees questions on a wide range of issues, including use of antipsychotic medicines; quality of care; quality of life; demographics of the facility residents; access to health care and rehabilitative services; respect for free and informed consent; autonomy; privacy; visitation; and discharge rights.

Interviews were conducted in English or Spanish. Human Rights Watch obtained the consent of each interviewee; explained the aim of the research; how information collected would be used; and informed them that they could discontinue the interview at any time and could decline to answer questions without consequence. Human Rights Watch provided no personal service or benefit and informed interviewees that their participation was voluntary and confidential.

Finding and interviewing people on antipsychotic drugs is difficult for a number of reasons. First, many are unaware because they were never informed, or are unable to recall, that they are on these medications. Facility staff sometimes do not inform the individuals concerned—or their relatives, the legal representative in some cases—that they are being given antipsychotic drugs.

Second, the effect of the medications can make it difficult to respond to interview questions, and the drugs often make people drowsy.

Third, most people in nursing homes have dementia or other cognitive disability. Additionally, most people given antipsychotic drugs without an “exclusionary diagnosis”—schizophrenia, Huntington’s disease, or Tourette syndrome, the most clear-cut and common conditions for which antipsychotic drugs are approved—have dementia, which affects memory and the ability to express oneself understandably.

Fourth, privacy concerns make determining who is receiving the medications difficult.

Fifth, nursing facility staff often do not consider residents to be their own “responsible party”—a term of art frequently used in an overly broad manner to indicate who can exercise a person’s rights. In many cases, facility staff decided on behalf of all residents that Human Rights Watch could not interact with them, often justifying that decision by invoking the need to protect residents.

Informed consent and legal capacity—the right to exercise one’s rights and to make decisions—are critical human rights linked inextricably with the question of appropriate antipsychotic drug use. The administration of psychoactive medication may violate a person’s rights if it is not administered with informed consent. Legal capacity controls whose consent is necessary and valid. However, a comprehensive analysis of consent and legal capacity is beyond the scope of this report. The report focuses on violations of the right to informed consent in cases where it was clearly possible for the facility to seek it, either because a person lacked any severe cognitive disability or because the person had voluntarily designated a proxy to act on their behalf.

Because of significant practical challenges, the residents interviewed do not reflect the most isolated and at-risk people in nursing facilities: people who are on their own, without family or friend visiting or communicating with the facility staff, and who have significant cognitive disabilities that impair their ability to communicate or advocate on their own behalf. Compounding the aforementioned challenges in interviewing residents, for these “unbefriended” or “unrepresented” individuals, there is the additional barrier of not having any intermediary person to identify and connect Human Rights Watch researchers to the person living in the nursing facility.

It is these individuals with severe cognitive disabilities and without someone to assist their communication or decision-making whose rights to legal capacity and informed consent are at the greatest risk of violation. However, they are also the individuals whom it is hardest to access to inquire about an interview and hardest to interview. As a result, the rights violations documented in this report reflect those experienced by people in nursing homes either able to more easily communicate with Human Rights Watch researchers or those experienced by people with family or friends involved in their care.

This report does not analyze nonconsensual use of antipsychotics in nursing facilities on persons who have a diagnosis for which antipsychotics have been approved. Rather, it focuses on the use of these drugs on people with dementia. This report also does not address the process in which people are placed in nursing homes. These issues are complex and go beyond the scope of this report.

Human Rights Watch relied upon several data sets for the quantitative analysis involved in this report, including one provided by Nursing Home Compare. This website, maintained by CMS, provides facility- and state-level data based on the Minimum Data Set (MDS), a federally mandated national database of periodic, individual, clinical, comprehensive assessments of all residents in Medicare and Medicaid certified nursing homes. Nursing facilities submit electronically the MDS information. Nursing Home Compare includes other self-reported and governmental surveyor-reported data for all facilities in the country certified to receive payment from Medicare and Medicaid, which is almost all facilities nationwide.

Despite the volume of publicly available data on the use of antipsychotic drugs in nursing facilities, a number of significant challenges arose in conducting quantitative analyses. First, it is not possible to determine from a single publicly available data set the proportion of all individuals with dementia in nursing facilities without a psychiatric or neurological diagnosis for which an antipsychotic drug is clinically indicated that takes antipsychotic medication. Second, a significant amount of the data on nursing homes is self-reported by those facilities, some of which could be inaccurate and as such may influence the results of statistical tests that Human Rights Watch ran.

Nonetheless, through quantitative data analysis, Human Rights Watch was able to estimate the total numbers of people who receive antipsychotic drugs, live in nursing facilities with a majority population over the age of 65, and do not have an exclusionary diagnosis. (Age 65 is a rough cut-off point to exclude people who are younger and given antipsychotic drugs, appropriately or not, since this research was focused on older people.) We also analyzed antipsychotic drug-related deficiency citations, which are federal and state government inspectors’ findings of facilities’ noncompliance with the federal regulations that establish minimum health and safety standards for the industry. A detailed description of the methodology used can be found in Appendix 4.

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I. Background

Long-Term Care in the US

The population of the US is growing older. Between 2005 and 2015, the country’s population aged 65 and over increased by 30 percent. Older people now account for one in seven Americans: almost 50 million people, over 26 million women and over 21 million men.^[1] By 2060, the number of older Americans (age 65 and older) is expected to double to almost 100 million, or one in four Americans.^[2] The population aged 85 and over is growing particularly rapidly and is expected to triple by 2050.^[3] The US population will include so many older people in the coming decades because of the baby boom generation is aging while fertility rates continue to decline and life expectancy rates have increased.^[4]

As the older population increases, more people will experience age-related disabilities, and dementia in particular.^[5] Today, over 5 million Americans have Alzheimer’s disease or another form of dementia, involving the loss of cognitive abilities, memory, and language.^[6]By 2050, as many as 16 million Americans could have Alzheimer’s disease; currently, one person in the United States develops the condition almost every minute of every day.^[7]

With the growth in older populations and the increases in debilitating conditions such as dementia, the need for long-term care and support services will grow rapidly. Although some forms of dementia have earlier onset, the disease is associated with older age: increasing age is the “greatest known risk factor” for Alzheimer’s disease.^[8] Experts estimate that approximately 70 percent of people aged 65 and over will require long-term services and support, ranging from limited support in their own homes and communities to around-the-clock care in institutional settings.^[9]

In the US, older people receive long-term care in a variety of settings: at home, in institutional facilities, and in in-between settings like retirement communities, senior housing, assisted living facilities, and board and care homes. Skilled nursing facilities (which provides short-term rehabilitation) and nursing facilities (for long-term care) provide certified and regulated services to people with significant healthcare and assistance needs.

Of the 6 million older people receiving long-term care, about 4 million receive care from a home health agency at home.^[10] About 1.2 million people aged 65 and over lived in 15,600 nursing facilities in 2014, and almost 780,000 people lived in other residential care communities.^[11] The proportion of people living in institutional settings increases with age because care needs become more intensive.^[12]

Other institutional care settings like assisted living are non-medical and provide minimal supervision. Medicare and Medicaid do not pay for assisted living in most cases.^[13] Medicare is the primary provider of health insurance to people aged 65 and older in the United States. It includes four parts: Parts A, B, C, and D, covering hospital insurance (including the first 100, rehabilitative days in a skilled nursing facility); medical insurance (such as doctors, outpatient care, medical equipment, and preventive services); private companies’ health plans (Medicare Advantage); and prescription drugs (including long-stay nursing facility residents’ drug prescriptions), respectively.^[14]

Medicaid, which is the primary public health insurance program for people with low income in the US and is jointly administered by the federal government and the states, is the primary payer for long-term care, accounting for 51 percent of the nursing home industry’s expenditures.^[15] Consequently, to receive institutional long-term care outside of a nursing facility requires significant private resources, estimated at over US$3,000 per month.^[16]

The total cost of long-term care varies by context. In 2015, the median annual cost of living in a nursing facility was over $90,000, roughly twice the cost of having a home health aide and five times the cost of an adult day health care program (almost $18,000).^[17] Long-term care costs vary significantly by state. For example, a semi-private skilled nursing home room in the most expensive states (Alaska, Connecticut, and Massachusetts) costs almost three times as much as in the least expensive states (Texas, Missouri, and Louisiana), $143,000–$168,000 compared to $56,000–$61,000 annually. Moreover, home health aides in the most expensive states (Massachusetts, Alaska, and New Jersey) cost almost twice as much as in the least expensive states (Alabama, Louisiana, and West Virginia), $28–$31 versus $17–$19 hourly.^[18] In 2013, approximately half of Medicare beneficiaries, which include older people and younger people with disabilities, earned less than $23,500 per year.^[19]

Despite the common perception that Medicare is for older people and Medicaid is for the poor, many people in the middle class in nursing facilities depend on Medicaid. Many people who saved for assisted living or other non-nursing facility care spend down their savings rapidly. In 2012, paying privately for the median cost of a nursing home ($81,030) would cost 252 percent of the median household income ($34,381) for people aged 65 and up.^[20] One in three people turning 65 may require care from a nursing facility at some point in their life, and three-quarters of long-term nursing facility residents will be covered by Medicaid at some point.^[21]

The US Nursing Facility Industry

Seventy percent of nursing facilities in the US—about 11,000—are owned by for-profit companies, and almost 25 percent are nonprofit.^[22] About 6 percent are publicly owned, most of which (46 percent) are owned by counties, followed by hospital districts (21 percent), states (14 percent), city-county (9 percent), city (8 percent), and the federal government (1 percent).^[23] In 2014, almost three in five nursing facilities were part of a chain, meaning they were owned by an entity that owns multiple facilities.^[24] Private equity firms own about 12 percent of all nursing facilities (18 percent of for-profit ones).^[25] Ten chains own the facilities in which 14 percent of the nation’s residents live, the largest concentration.^[26]

In 2015, the nursing facility industry, assisted living, and other types of long-term care recorded annual revenues of $156.8 billion, 41 percent of which came from Medicaid and 21 percent from Medicare.^[27] Medicare and Medicaid have provided the financial foundation of the nursing facility industry since their creation.^[28]

The federal government regulates the nursing facility industry through the Nursing Home Reform Act of 1987, requiring facilities to meet certain standards to be certified and paid by Medicare and Medicaid.^[29] CMS contracts with state agencies to certify facilities and to ensure “substantial compliance” with minimum health and safety requirements.^[30]

In subsequent sections, this report describes the inappropriate use of antipsychotic drugs in older people with dementia in US nursing facilities—including use without valid medical reason; for the convenience of staff; inconsistent with federal regulatory requirements; and without informed consent. The report discusses the inadequacy of federal regulations, enforcement, and access to private remedies for harm.

This background section describing the long-term care system provides the context to understand—and highlights the salience of—facilities’ abuses and governmental shortcomings. The population is aging, and long-term care services and supports, including nursing homes, are more likely to be necessary as age-related disabilities rise. It is not only the poor who end up in nursing facilities but many people in the middle class: people who never had and never anticipated relying on Medicaid. Dementia—a risk factor for being given antipsychotic drugs in nursing homes inappropriately, until the government enforces protections against such abuse more effectively—affects people across income, gender, and race.

The industry’s reliance on Medicare and Medicaid described in this section, as well as the breakdown in the industry by ownership status, with the prevalence of chain ownership, relate to regulatory and enforcement concerns. As noted, facilities are required to comply with certain standards of care to receive certification and payment from Medicare and Medicaid: these health insurance programs are the government’s basis for regulating facilities.

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II. The Risks and Harms of Antipsychotic Medications on People with Dementia in Nursing Facilities

I would just shut off and not say anything. [It] was a very traumatic time.
—Madeline C., an 86-year-old woman at a nursing facility in Illinois describing being on antipsychotic medications, February 2017.^[31]

Antipsychotic drugs were originally developed to treat schizophrenia. The first generation—so-called “conventional” antipsychotics, such as Haldol (haloperidol)—was developed in the 1950s, and a second generation—called “atypical” antipsychotics, such as Seroquel (quetiapine)—was developed in the 1980s.^[32] The US Food and Drug Administration (FDA) has approved some of these medicines for treatment of other conditions since then, such as Tourette syndrome and bipolar disorder.^[33] The FDA has not approved antipsychotic drugs for treating symptoms of dementia.

Antipsychotic medications are one of several classes of psychotropic drugs affecting the central nervous system. Psychotropic drugs include anti-anxiety medications, anti-depressants, hypnotics, anxiolytics and sedatives like benzodiazepines (e.g., Xanax, Ativan, Valium, Klonopin), anticonvulsants, and mood stabilizers (e.g., Depakote or lithium, often used for bipolar disorder), some of which have comparable effects to antipsychotic drugs and all of which are used prevalently in nursing facilities.^[34] (CMS has expressed concern that, as the use of antipsychotic drugs in people with dementia is discouraged as inappropriate, these other classes of medications should not replace them.^[35]) Other types of psychotropic drugs, such as anti-anxiety drugs, can have similar sedating properties and cause adverse effects if used inappropriately. In revising federal regulations in 2016, CMS wrote:

Expanding the requirements for antipsychotic drugs to psychotropic drugs will expand protections for residents prescribed drugs that have an increased potential for being prescribed inappropriately or for reasons other than the resident’s benefit, such as for the purpose of a chemical restraint.^[36]

Antipsychotic medicines are widely used off-label, that is, for indications or purposes for which the FDA has not approved them. Off-label use of medication is both common and legal. However, the problem with the use of antipsychotic drug in older people with dementia is beyond the issue of legality. As the FDA states in the boxed warning manufacturers must include on conventional and atypical antipsychotic drug labels, elderly patients with “dementia-related psychosis” treated with antipsychotic drugs are at an increased risk of death.^[37] It is uncommon for the FDA to require a boxed warning regarding a never-approved use of a drug. Neither off-label use nor the use warned against in boxed warnings affects Medicare coverage of the drug.^[38]

The boxed warning on antipsychotic drugs for use in older people with dementia is based on findings that the drugs increase the risk of death in older people with dementia.^[39]

Aside from raising the risk of death, the drugs’ side effects include severe nervous system problems; neuroleptic malignant syndrome (a life-threatening reaction associated with severe muscular rigidity, fever, and altered mental status); tardive dyskinesia (characterized by stiff, jerking movements that may be permanent once they start and whose likelihood of onset increases the longer antipsychotic drugs are taken); high blood sugar and diabetes; and low blood pressure, which causes dizziness and fainting.^[41] Other side effects include increased mortality, cerebrovascular events (stroke), cardiovascular effects, blood clots, central and autonomic nervous system problems, visual disturbances, metabolic effects, extrapyramidal symptoms, fall risk and hip fracture, irreversible cognitive decompensation, and pneumonia.^[42]

In the context of nursing facilities, the most common use of these medications is in older people with dementia for the “behavioral and psychological symptoms of the disease.”^[43] A 2012 Office of Inspector General investigation found that Medicare processed 1.4 million claims for atypical antipsychotic drugs from nursing facilities in 2007. Older people with dementia accounted for 88 percent of the 1.4 million claims.^[44] Only 4.7 percent of these claims were for medications that were not used in older people with dementia and were not used for an off-label use. In other words, they were used for someone with schizophrenia or another psychiatric or neurological condition for which the drugs are approved.^[45]

The medical reason for prescribing antipsychotic drugs to people with dementia, usually as a last resort, is that dementia is often accompanied by irritability, agitation, aggression, hallucinations, delusions, wandering, disinhibition, anxiety, and depression—what some medical professionals call “behavioral and psychological symptoms of dementia.”^[46]

Some studies find that a majority of people with dementia will develop at least one of these symptoms and that individuals in nursing facilities tend to have more severe symptoms than people in other care settings.^[47] These symptoms can be distressing and dangerous to the individuals experiencing them and to those around them, including family and caregivers.^[48] Nursing facility staff that administer antipsychotic drugs to older people inappropriately but who are not administering them intentionally for staff convenience often appear to believe that the drugs are the best or only treatment option for someone seemingly in distress.

Dementia-related symptoms may result from “underlying neurochemical changes,” changes in the body’s nervous system, associated with dementia or from an external or underlying situation such as pain or personal needs.^[49] Pain is often underreported in people with dementia.^[50] Unlike schizophrenia and other psychiatric conditions, the “behaviors” of people with dementia often arise from feelings of loneliness, boredom, depression, anxiety, sun-downing (increased agitation or distress in early evening), apathy, distrust of new caregivers, hunger, dehydration, impairment of the brain’s executive function, grief, noise stress, and delirium.^[51]

In addition to unmet physical needs, symptoms may be a “response to environmental triggers,” such as being ignored unless a person screams (which inadvertently reinforces the “behavior” of screaming); alternatively, symptoms may be “consequences of a mismatch between the environment and patients’ abilities to process and act upon cues, expectations and demands.”^[52] An example of such a distressing mismatch is “resisting care” when expected to be showered if it frightens a person by association with a prior fall. In its revised guidance that intended to go into effect in November 2017, CMS states:

Behavioral or psychological expressions are occasionally related to the brain disease in dementia; however, they may also be caused or exacerbated by environmental triggers. Such expressions or indications of distress often represent a person’s attempt to communicate an unmet need, discomfort, or thoughts that they can no longer articulate.^[53]

Experts agree on the importance of attempting nonpharmacologic interventions with individuals with dementia-related symptoms; federal regulations also require such interventions unless clinically contraindicated (when the intervention should not be used due to adverse effects).^[54] These interventions follow these steps: evaluating and understanding the origin of the “behavior”; ruling out underlying physical illness, infection, or needs; addressing any underlying dementia-related or environmental issue; and re-evaluating the care plan based on its effectiveness.^[55]

Examples of nonpharmacologic interventions include:

• Reducing boredom, pain, loneliness, and similar experiences by changing a person’s activities, surroundings, opportunities, and access to relationships;
• Creating individualized sleep, hygiene, bathroom, and other daily routines that the person prefers;
• Ensuring staff are consistent and familiar to the individual;
• Physical and cognitive exercises; and
• Many types of therapy (music, aroma, reminiscence, behavioral, pet, light, etc.).^[56]

Fundamentally, many of these interventions are ways of making an institutional environment conform to an individual’s needs; it is the converse that can give rise to distress, discomfort, and disorientation. Older people and people with dementia should be included and consulted on non-pharmacologic alternatives and other matters that affect their lives and well-being. Including residents shows that their opinions and perspectives about their own care are respected and valued. Even when people with cognitive disabilities have difficulties expressing themselves verbally, they can often indicate some preferences otherwise.

Some medical experts believe and CMS endorses that if it is not possible to address underlying medical, physical, social, or environmental factors in some people, an antipsychotic drug “can minimize the risk of violence, reduce patient distress, improve the patient’s quality of life, and reduce caregiver burden.”^[57] The evidence of the effectiveness of nonpharmacologic intervention is mixed.^[58] According to the American Psychiatric Association, which issued practice guidelines on the use of antipsychotic drugs in people with dementia, the “expert consensus suggests that use of an antipsychotic medication in individuals with dementia can be appropriate.”^[59]

Yet the guidelines conclude, “in clinical trials, the benefits of antipsychotic medications are at best small.”^[60] Meanwhile, countering these meager potential benefits is the “consistent evidence that antipsychotics are associated with clinically significant adverse effects, including mortality.”^[61] The risks vary depending on the type and stage of dementia, other conditions the person has; other drugs the person takes; the dosing and duration of the antipsychotic drug; and the particular antipsychotic drug.^[62]

Similarly, CMS has warned against inappropriate use of antipsychotic drugs, given the risks that are unwarranted when the drugs do not serve a medical purpose:

It has been a common practice to use various types of psychopharmacological medications in nursing homes to try to address behavioral or psychological symptoms of dementia (BPSD) without first determining whether there is an underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental cause of the behaviors…. When antipsychotic medications are used without an adequate rationale, or for the sole purpose of limiting or controlling behavior of an unidentified cause, there is little chance that they will be effective, and they commonly cause complications.^[63]

Human Rights Watch uses the term “inappropriate” to describe use of the drug in older people with dementia that is: inconsistent with recommendations of medical experts and authorities, such as the American Psychiatric Association and FDA; inconsistent with federal regulations governing nursing homes, which overlap significantly with medical experts’ recommendations; and administered without free and informed consent except in cases of emergency. Concretely, “inappropriate use” in people with dementia often entails use that is not a last resort, use excessive in dose or duration, use without appropriate monitoring of side effects, or use not based on an informed choice about treatment options.

Massive Use of Antipsychotic Medications

It is essential that antipsychotic drugs be used cautiously in people with dementia, only where medically appropriate, and only with informed consent because of the propensity for nursing facilities to use the drugs for non-medical purposes and because of the high risk and low likelihood of benefit even when used for medical reasons. However, Human Rights Watch’s analysis of data on the prevalence of use in people without “exclusionary diagnoses” and interviews with this category of people strongly suggest that such limited use is not what occurs in practice.

Nursing facilities in the US use antipsychotic medications on a massive scale. Every week, facilities administer antipsychotic drugs to over 179,000 long-stay residents (residing in the facility for more than 100 days) who do not have an exclusionary diagnosis—of schizophrenia, Huntington’s disease, or Tourette syndrome, psychiatric and neurological diseases for which the drugs are approved—and most of whom have dementia.^[64] At the end of 2016, CMS’s official measure was that 16 percent of long-stay nursing home residents were receiving an antipsychotic medication without one of these three exclusionary diagnoses.^[65]

While the national average rate of use of antipsychotic medications among older people in nursing facilities without an appropriate diagnosis has declined in recent years, current prescription rates vary significantly across the country (see Map 1).

Antipsychotic medications not only have adverse medical consequences, but also have social and emotional effects on nursing facility residents and their families. To capture these consequences of forced and inappropriate antipsychotic drug administration, Human Rights Watch interviewed people living in nursing facilities who had dementia and were currently on antipsychotic medications or had been on them previously, as well as their family members. We spoke with 74 residents and 36 family members in all six states. Residents described the trauma of losing their ability to communicate, to think, and to remain awake. Family described the pain of witnessing these losses in a loved one.

Of course, dementia itself causes significant losses, affecting cognition, communication, memory, and other functions. It is impossible without a comprehensive medical evaluation, if then, to determine the direct cause of any individual changes in residents described here. However, most or all antipsychotic drugs in people with dementia are associated with sedation and fatigue.^[66] (The type, dose, duration, drug-drug interaction, and other characteristics of antipsychotic drug treatment, as well as a person’s health condition aside from dementia, influence the effects the medications have.^[67]) Family members described cognitive and energetic improvements once antipsychotic drugs were stopped—even if the underlying dementia persisted.

Many of the following cases illustrate the psychosocial harm associated with sedation.^[68]While they are not testimonies from medical experts who could authoritatively conclude that the antipsychotic drugs caused the sedation described, these descriptions by residents and family members are representative of what antipsychotic drugs in older people with dementia often induce.^[69] Moreover, in each of the following cases (except one where the individual took the drugs until she was receiving hospice care and died), the sedative effect ceased when they stopped taking antipsychotic drugs.

Ruth D., a 62-year-old woman who said she was given Seroquel (an antipsychotic medication) without her knowledge or consent in a nursing facility in Texas said: “[It] knocks you out. It’s a powerful, powerful drug. I sleep all the time. I have to ask people what the day is.”^[70] The woman described being given the medication against her will, including in her food: “They crush it so you don’t know what you’re getting fed.” When asked to take Seroquel, she would tell nursing staff that she did not want to take it, and that she did not want to eat the food if she suspected the drug was in it. Ms. D continued to object as well as she could to being administered antipsychotic drugs until her discharge from the nursing facility the day after Human Rights Watch interviewed her.

Walter L., an 81-year-old man told Human Rights Watch that antipsychotic medicines “get me so I can’t think.”^[71] According to his wife, Anna L., who is his healthcare proxy, he was given them without his or her knowledge or consent. Mr. L told Human Rights Watch that he never again wanted to take something that made him “change the person that I am.” Ms. L. described that when her husband was on the medications he was just “staring straight ahead,” not knowing she was even there. “I leaned him up against the wall, I came back three hours later, and he had not moved,” she said.^[72] Ms. L. learned of the drug after a nurse privately alerted her. After changing facilities, the antipsychotic drug was discontinued.

Madeline C., an 87-year-old woman in a facility in Illinois, described the effect of antipsychotic medications administered in a prior nursing facility. She had been placed in a dementia unit. The woman said that when she “just about went crazy” from being in a locked unit with no activities, she “started speaking out, saying things were not right.” After that, she said, “suddenly I was very sleepy,” adding, “you feel like you’re going to die there.” She said she later learned that the facility had given her an antipsychotic drug. At the time of the interview, the woman was in a different facility that had discontinued the drug. “The fog lifted…. There’s the old Madeline again.”^[73] Being at the prior facility was “a very traumatic time.”^[74]

Alma G., the sister and power of attorney of Mariela O., an 84-year-old woman with dementia who died in 2017, said that her sister’s nursing facility gave her an antipsychotic drug to ease the burden of bathing her.[75] She said, “They give my sister medication to sedate her on the days of her shower: Monday, Wednesday, Friday—an antipsychotic. They give her so much she sleeps through the lunch hour and supper.”^[76]

Kirsten D., the daughter and power of attorney of Joan D., a 75-year-old woman in Kansas, said that when the nursing facility began giving her mother antipsychotic and other psychotropic medications, “she would be asleep when I visited. She slept a lot. They’d say she’s adjusting to the meds. I went back weeks later. She would just sit there like this.”^[77]

Joan D. said that she tried to avoid taking the antipsychotic drugs—including by hiding them in her dinner roll—because of their effect on her. “I didn’t want to take it so I didn’t. I didn’t want to feel that way.”^[78] She explained further that “I try not to take it. Sometimes I have to.”

Kirsten D. described her mother on the antipsychotic medication as “no personality. Just a zombie…. The fight is gone. It’s gone. That’s what worries me the most…. I think she’s learned to keep it contained. She was vibrant, full of life…. She’s still in there.”^[79] After significant effort to find another facility with an opening that would accept her mother, Ms. D. moved her mother to another nursing home that ceased the medication. Ms. D said that her mother became lively, talkative, friendly, and mobile again without the medication.

In New York, Dorothy R., the daughter and power of attorney of a woman in a nursing facility, told Human Rights Watch that a nurse informed her that the sudden decline in her mother’s health and cognition was due to her mother “getting older.” After an advocate’s lecture on antipsychotic drugs alerted her to the impact of antipsychotic drugs, Ms. R. requested a list of all the medications her mother was taking. She succeeded in having the facility discontinue the administration of an antipsychotic drug after discovering that the facility had put her on one without her or her mother’s knowledge or consent.^[80]

In several cases, we documented how people with dementia seemed to improve dramatically once the antipsychotic drugs were discontinued. Laura F., the daughter of a resident in California, initially saw her mother’s decline as an irreversible, progressive result of her age: “You know, she’s 90. Yesterday, she’s alert. Now she’s not. That’s what happens.”^[81] But when the nursing facility took her mother, Selina C., off Risperdal, the antipsychotic medication she had been on for over two years at that point, Ms. F. said the mother she had known returned:

Lo and behold, she can talk again. She can read again … she’s conversing … it’s not just that she can walk now … it’s her personality. She came back. She had been sleeping all the time. She was totally incoherent. She had no memory at all. She recognized no one. On the meds, she couldn’t remember if you were there while you were there…. She was drugged!^[82]

In this case, the antipsychotic medication had been initiated in a board and care home (similar to assisted living but smaller, with only six or fewer residents). Ms. F., her mother’s power of attorney, had consented to their use but had not been given full information about their side effects and risks. Upon Ms. C.’s admission to a nursing home, staff continued the antipsychotic drug. Once Ms. F. learned of its potential harm and insisted that the facility stop giving it to her mother, staff complied.

Human Rights Watch also visited some facilities that significantly reduced levels of antipsychotic drug use in the last year as a result of federal and state educational and training efforts, or due to governmental or corporate owners’ pressure. Interviews with nursing home administrators, directors of nursing, and other nursing staff provided another angle of insight into the extent to which antipsychotic drugs are used inappropriately. In many cases, staff of nursing homes that had reduced the use of antipsychotic drugs now felt very strongly that the drugs not be used inappropriately.

The director of nursing at one facility in Kansas who led an effort to reduce the rate of antipsychotic drug use in people with dementia reflected on the experience to Human Rights Watch: “It used to be like a death prison here. We cut our antipsychotics in half in six months. Half our residents were on antipsychotics. Only 10 percent of our residents have a mental illness.”^[83] She continued:

Some doctors are misinformed. When we said we wanted to reduce the antipsychotics, we had to fight with the doctor. He said: ‘You understand if I do this they’re all going to go crazy?’

But they don’t have behaviors because they need an antipsychotic. You actually see them decline when they’re on an antipsychotic. It’s just an adjustment when they’re first admitted.

There was a woman who would stand at the nurse’s station sobbing. We should have done a root cause analysis. But instead we shipped her off to psych. She was gone within a year: stiff muscles, couldn’t walk or talk. I think it’s sadder than watching someone with dementia decline.

You can reduce antipsychotics…. Residents have behaviors because their needs are not met. Not because of a lack of staff. We reduced the rate drastically and haven’t had to change staffing levels one bit. We did increase staff for activities, but not CNAs [certified nurse aides].

Taking off antipsychotics affects people differently: some are more verbal, more disruptive, louder, but not violent. Some sleep more, some sleep less. We had to educate the staff: don’t put them back on immediately. All antipsychotic prescriptions go through me. I do not allow PRN [prescription to take as needed] antipsychotics. Giving someone a Haldol one time has never been effective. It has to build up in the system.^[84]

At another facility in Kansas, a nurse told Human Rights Watch about their experience reducing use, echoing many of the same themes:

We were at 55 percent antipsychotic drug rate before. Now we’re down to only people with a diagnosis [for which the FDA has approved the medications] on the drugs. They have a better quality of life because they’re not sedated. We’re not controlling their emotions or their dementia.

At first everyone was like, ‘This is going to be awful. What do they want us to do?’ But we started with a resident with fewer behaviors and just did one or two a week. It was amazing. It’s helpful: it actually minimizes behaviors.

Before, when we slapped them with antipsychotics, they had to be in a wheelchair because they were so drugged up. But now that we’re meeting their needs, it’s easier on staff…. Their ADLs [activities of daily living] are better, their functioning.

If a resident comes in on an antipsychotic, we go over the info. We say, ‘We don’t usually use those here.’ The family usually agrees. If we start the reduction and it doesn’t work, we tell a geriatric psychiatrist to see them once a week. We have not had to change our staffing numbers. Without the antipsychotics, the residents take less time.^[85]

In Illinois, the director of nursing at a facility explained a similar course of action:

This is our biggest, biggest issue: taking people off. You have to make an attempt to reduce. If someone is taking two antipsychotics, you try to lower the dose and you try taking them off one. We attempt reductions quarterly. We have not had problems with behaviors after slow reductions…. The pharmacist sends a report monthly, giving recommendations [to reduce] every month….

We used to have a big antipsychotics problem. In 2011 more than half of the residents took them. Now everyone on an antipsychotic has a diagnosis. Usually they’re a totally different person, they’re back to life.^[86]

An administrator in California described procedures his nursing facility has put in place to reduce reliance on antipsychotic medicines:

Our psychotropic committee meets monthly. We review all the patients on psychotropics. In 2010, more than 30 percent of the residents were on antipsychotics. Now it is just over 10 percent…. If someone is admitted with an antipsychotic, we monitor them for 72 hours. We notify the doctor. We observe the behavior. [Our consultant psychiatrist] comes in to assess if it’s necessary. We gather the baseline to have a point of comparison. We look at the diagnosis. If we get someone from geri-psych, they’re often agitated in the unit. Their behavior is not consistent. We put psychotropic medication on hold. We don’t restart it. We give them a chance to adjust.^[87]

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III. Inappropriate and Non-Consensual Use of Antipsychotic Medications

The inappropriate use of antipsychotic drugs on people with dementia in nursing facilities raises two principal human rights concerns. First, antipsychotic drugs are often administered without a medical purpose—as a last resort to treat psychosis in dementia, although they have not been found to be effective to this end—and for the convenience of facility staff. Such medically unnecessary use of medication may amount to torture or ill-treatment under international law. It may also amount to a prohibited “unnecessary drug” or a chemical restraint—a form of abuse—under US law. Second, these medications are frequently administered without free and informed consent. This practice constitutes forced medication under international law.

Chemical Restraints and Unnecessary Drugs: Use of Antipsychotic Medications for Reasons Other than Medical Need

Antipsychotic drugs are frequently administered to older people with dementia without clinical indication (a valid medical reason). This practice may in some cases rise to the level of torture or cruel, inhuman and degrading treatment. As noted by the UN special rapporteur on torture and other cruel, inhuman or degrading treatment or punishment in a 2013 report: “medical treatments of an intrusive and irreversible nature, when lacking a therapeutic purpose, may constitute torture or ill-treatment when enforced or administered without the free and informed consent of the person concerned.”^[89] In June 2017, the UN special rapporteur on the right to health noted that informed consent is “a core element of the right to health, both as a freedom and an integral part of its enjoyment.”^[90]

US regulations establish that antipsychotic drugs cannot be administered to nursing facility residents without a medical need based on a comprehensive assessment.^[91] However, in some facilities, medical need is often not the primary reason antipsychotic drugs are prescribed and comprehensive assessments are not routinely conducted to determine whether a medical basis exists. CMS recognized facilities’ improper use of the drugs:

It has been a common practice to use various types of psycho-pharmacological medications in nursing homes to try to address behavioral or psychological symptoms of dementia (BPSD) without first determining whether there is an underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental cause of the behaviors.^[92]

Interviews with residents, family members, and facility staff provide numerous examples that residents are administered antipsychotic drugs without meaningful assessment of their medical necessity—an important consideration, though not one that, alone, justifies administering the medication.

A Culture of Antipsychotic Medication Use

Government reports and academic literature identify a “culture” of antipsychotic drug use as one of the potential explanations for their widespread use. In this context, the “culture” of a nursing facility, meaning the “shared values, beliefs and assumptions” of staff, “may exhibit itself as a facility-level preference for certain therapeutic modalities.”^[93] When the prescriber and individual receiving treatment interact infrequently, which is often the case in nursing homes, the general treatment approaches may take on heightened significance: without routine personal evaluations by a physician prior to medication decisions, these decisions may follow even more heavily from the existing “beliefs and assumptions” about treatment, and may be less specific to the individual and circumstances at hand.^[94] A 2015 study by the US Government Accountability Office (GAO) found that so-called setting-specific factors—such as staff leadership, training and education levels, and quantity of staff—were the principal determinants of the prevalence of antipsychotic drug use rather than patient-specific factors, such as medical conditions or behaviors.^[95] Academic studies have found that facility characteristics—not just a resident’s behavioral or neuro-psychiatric symptoms—are a strong predictor of the prevalence of psychotropic medication use.^[96] One study found that “new nursing home residents admitted to facilities with high antipsychotic drug prescribing rates were 1.4 times more likely to receive antipsychotics, even after controlling for patient-specific factors.”^[97]

In facilities with such a culture of the widespread use of these medicines, the off-label drug use is generally accepted as typical and unproblematic—even the best course of action for the resident. The GAO study found that in such facilities, nursing staff are more likely to believe the medications are truly helpful to residents, and are more likely to have lower levels of education and training around dementia and appropriate use of antipsychotic medicines. Studies have shown that low education among staff about antipsychotic use among people with dementia results in higher rates of use.^[98] The GAO report also found that insufficient staff to engage residents in activities and to provide oversight of them may “make the nursing home residents susceptible to higher antipsychotic drug use.”^[99]

In a letter to Human Rights Watch, the American Health Care Association (AHCA), the for-profit nursing home trade association, wrote:

[The] biggest challenge we have found is the mindset that clinicians, nurses and family all have that ‘behaviors’ in dementia are abnormal, resulting from dementia and that medications are an effective treatment. Difficulty in changing this belief is the greatest challenge.^[100]

To this end, the AHCA has produced a fact sheet on antipsychotic drugs and people with dementia to inform families about the dangers and ineffectiveness of their use.^[101]

Human Rights Watch obtained testimony from staff suggesting a culture in some facilities of excessive antipsychotic drug use in residents. In Texas, a facility’s admissions director seemed to believe that residents should be given the medication: “It’s a red alert if they don’t take them. We try to get them to.”^[102] A nurse at a facility elsewhere in Texas, said: “If they’re agitated or having a moment and they don’t have a prescription, we call the doctor or psychiatrist…. If we still can’t handle them, we send them to behavioral [a psychiatric hospital].”^[103]

Lena D., the daughter and power of attorney of Lucinda D., an 88-year-old woman in a California nursing facility, said she felt that the facility only attempted to silence with antipsychotic medication the symptoms that disturbed staff. To Ms. D, it was obvious that her mother had physiological conditions, such as an infection causing smell and fever, requiring medical attention instead of antipsychotic drugs to dull the expression of distress. “Every little thing, they want to put you on psych meds,” she said.^[104] Ms. D. said that her mother was screaming from pain. “She would be sitting there, slumped over, mucus everywhere. I would go over and say, ‘She’s sick.’ UTI [urinary tract infection], pneumonia, pulmonary embolism—I’d scream too,” Ms. D. said, listing a number of the infections and harms she says that her mother has endured.^[105]

In many instances, people living in nursing facility and their relatives—like most people—are inclined to defer to the recommendations of the healthcare provider unless they have a reason not to do so. As one long-time expert in Kansas put it: “The family rarely objects. They think, ‘They’re the doctor. They’re not going to hurt my mom.’”^[106] A nurse in Texas explained: “If the medication is on the psychoactive list, we need consent.^[107] We call the guardian, get verbal consent. Or not, if it’s declined. Then we’d call the doctor and start over. But we’ve never had to deal with a decline. Families want the best, and they trust the physician to do that.”^[108]

This trust can backfire in some nursing facilities. Contrary to other contexts, doctors and nurses associated with nursing facilities may favor the easier step of a prescribed medication than more time-consuming interventions. In some cases, medical and nursing staff may truly believe in the utility of the medications in situations where their use is inappropriate. Lastly, the tendency to trust doctors may be problematic in the context of nursing facilities where physicians interact with their patients very rarely even when they are prescribing antipsychotic drugs.

Antipsychotic Medication Use for the Convenience of Staff

In line with international human rights law, US law and regulation prohibit the use of antipsychotic medicines as a chemical restraint on residents—i.e., when drugs are “used for purposes of discipline or convenience, and not required to treat medical symptoms.”^[109]Interpretive guidelines of federal regulations define “convenience” as “any action taken by the facility to control a resident’s behavior or manage a resident’s behavior with a lesser amount of effort by the facility and not in the resident’s best interest.”^[110]

While most staff we interviewed were adamant that they do not use antipsychotic or other medications for their own convenience, a few admitted to exactly that. A social worker at a facility in Texas, for example, said: “You have got to get through incontinent care and the shower. We give meds before their showers…. We give them something they’re taking already. We just want to make sure it’s in their system when we’re showering them.”^[111]

While nursing staff may face real challenges providing such direct care to some people, turning to antipsychotic medications is not appropriate. As the CMS State Operations Manual explains, to comply with federal regulations, facilities must find ways to accommodate individuals’ preferences:

If the resident refuses a bath because he or she prefers a shower or a different bathing method such as in-bed bathing, prefers it at a different time of day or on a different day, does not feel well that day, is uneasy about the aide assigned to help or is worried about falling, the staff member should make the necessary adjustments realizing the resident is not refusing to be clean but refusing the bath under the circumstance provided.^[112]

Generally, as the revised CMS State Operations Manual states:

In some cases, resident with dementia may resist the manner in which care is being provided, or attempted, which can be misinterpreted as declination of care. In some cases, the resident with dementia does not understand what is happening, or may be fearful of unfamiliar staff, or may be anxious or frustrated due to inability to communicate.^[113]

It is a responsibility of facility staff to “attempt to identify the underlying cause of the ‘refusal/declination’ of care.”^[114]

Many outside observers, such as long-term care ombudsmen, academics, and state inspectors, told Human Rights Watch that antipsychotic medications were being used for the convenience of staff. A social worker at a behavioral hospital in Texas explained their perspective on nursing facilities’ use of antipsychotic medications for staff convenience, as chemical restraints:

People come in here [a hospital] for behaviors, but then we don’t see the behaviors when they’re here. Sometimes we change their meds. But they don’t usually exhibit horrible behaviors. Maybe they just need attention. But the nursing homes don’t want behaviors. They want docile. They want people with no cognitive deficits who can take care of themselves. I’ve worked in nursing homes. They’d say, ‘Send them to [the psychiatric hospital] to get medicated and let them come back.’^[115]

A state inspector with a long career in long-term care said: “I see way too many people overmedicated. The doctor signs off and the nurse fills the prescription. They see it as a cost-effective way to control behaviors.”^[116] Seventeen of 18 ombudsmen we interviewed echoed this view, including at least one from every state visited.^[117]

Madeline C., an 87-year-old woman in Illinois, reflected on her time at a prior facility, which gave her antipsychotic medications against her will, leaving her in a stupor. She said: “When I was in that other place [the prior nursing facility], they just wanted you to do things just the way they wanted.”^[118] An expert and advocate in Illinois explained: “Antipsychotics are often about the nursing staff, not the residents.” In requesting the medication from a doctor, nursing staff often say: “‘I need a restraint.’ It’s not just a figure of speech.”^[119] In other words, it’s the staff who “need” the resident to be taking it.

Failure to Initiate, Monitor, and Discontinue Antipsychotic Medications

US law and regulations require nursing facilities and healthcare providers to have an adequate medical basis for initiating antipsychotic medications and for continuing use. Regulations prohibit the use of any “unnecessary drugs,” defined as:

• In excessive dose, which can be determined based on a manufacturer’s label;
• For excessive duration, meaning beyond the manufacturer’s or clinical studies’ recommended period of use; and/or without evidence of additional therapeutic benefit;
• Without adequate monitoring;
• Without adequate indications for use: “the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident’s condition and therapeutic goals”;
• In the presence of adverse consequences indicating the medication should be reduced or discontinued. Adverse consequences include “unpleasant” symptoms or events, including “impairment or decline in an individual’s mental or physical condition or functional or psychosocial status.”^[120]

Federal regulations particular to psychotropic drugs mandate that any prescription for someone not already taking such medication must be “necessary to treat a specific condition as diagnosed and documented in the clinical record.”^[121] Anyone given psychotropic medications must “receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.”^[122]Gradual dose reduction must be attempted annually, except twice in the first year of use.^[123]

These regulations represent an attempt to limit and regulate the use of antipsychotic drugs in ways that would help protect the human rights of nursing home residents if facilities adhered to the regulations. One of the most recent government studies on resident assessments and care planning—the foundation for determining what antipsychotic drug use could be appropriate—found that few facilities comply with relevant regulations. The 2012 Office of Inspector General of the US Department of Health and Human Services report found that 99 percent of the records reviewed of older nursing facility residents (aged 65 and older) receiving antipsychotic drugs in 2007 failed to meet at least one federal requirement for resident assessments and care planning.^[124] Human Rights Watch’s research and a review of governmental surveyors’ narrative deficiency reports found that these procedures and limitations required for appropriate psychotropic drug use are often ignored.

Many of our interviews tend to bolster the contention that antipsychotic medications are often prescribed to nursing home residents for no valid medical reason. Some nursing staff described to Human Rights Watch the primary “behaviors” for which antipsychotic medications are frequently used. A nurse at a facility in Kansas said that “calling names, screaming, scaring people” justified antipsychotic medication.^[125]

In Texas, a social worker said that the most common “behaviors” leading to antipsychotic medication use were: “‘Son of a bitch.’ ‘Help me, help me, help me.’ It’s not having a filter.”^[126] A long-term care pharmacist in Kansas said he routinely sees medication requests without an appropriate diagnosis. “This is a sore spot,” he said. “I write letters to the nursing homes and prescribers because there’s no supporting diagnosis for an antipsychotic at all. It just says ‘Seroquel for dementia,’ or ‘Seroquel for anxiety,’ or ‘Seroquel for behavior dysfunction.’”^[127]

A 2005 study found that about one in three nursing facility residents covered by Medicare took medication in excessive doses and lacking appropriate indications.^[128] The US Department of Health and Human Services Office of Inspector General report from 2011 found that 51 percent of Medicare atypical antipsychotic drug claims—the second generation of antipsychotic drugs, commonly used for their perceived lesser side effects—for older people in nursing facilities “were either not used for medically accepted indications as supported by the [medical] compendia or not documented as having been administered to the elderly nursing home residents.”^[129] The Office of Inspector General review of 1.4 million antipsychotic drug claims for older residents found that 22 percent “were not administered in accordance with CMS standards regarding unnecessary drug use in nursing homes.”^[130]

A review of surveyors’ narrative deficiency reports provides examples of facilities’ failure to comply with requirements to monitor, taper, and discontinue antipsychotic drugs. For example, in New York, in 2016, government surveyors issued a deficiency citation for unnecessary drugs because a nursing facility prescribed a “standing dose” of an antipsychotic drug for “wandering, noncompliance, and aggressive behaviors” to a man who had no history of taking antipsychotic drugs. The dose was increased from twice a day to three times a day within one week and surveyors concluded it contributed to the man’s death within 10 days.^[131]

In Illinois, in 2015, an inspector issued a deficiency citation for unnecessary drugs for a facility’s “failing to have indications for use, assessing, identifying/monitoring targeted behaviors, clinical rationale for the medication dosage use above the recommended level, and completing a Gradual Dose Reduction (GDR)” for an antipsychotic drug.^[132] The excessive dose of an antipsychotic without an appropriate diagnosis in a person with dementia led to the person’s “being continuously somnolent” and falling repeatedly, according to the government surveyor. The individual’s records show that, in less than five months, the individual fell eight times, the last time leading to an irreparable condition and the person’s admission to hospice.

In Texas, in 2015, government surveyors issued a deficiency citation for unnecessary drugs based on a facility’s giving a woman “excessive doses” of an antipsychotic drug, not adequately monitoring her, and giving the drug without an appropriate diagnosis.^[133] As a result of the facility’s failure to comply with unnecessary drug regulatory requirements, the woman was hospitalized for septic shock. Nursing staff described the woman’s decline to government regulators: she was “alert, oriented…, could feed herself, and could carry on conversations” when she was admitted. After the excessive medication, the woman could not bear her own weight or “stay awake to eat or drink.” Staff corroborated that no nonpharmacologic interventions were attempted and no behavioral monitoring occurred.

Interviews and a review of national nursing home data also suggest that some facilities are circumventing pressure to reduce inappropriate use of antipsychotic drugs by inappropriately seeking a diagnosis from a physician of a medical condition, such as schizophrenia, for which these medicines are approved in order to not raise red flags when prescribing someone antipsychotic medication inappropriately. The onset of bipolar disorder and schizophrenia rarely occurs in people over the age of 30.^[134] Thus, experts are concerned that the uptick in schizophrenia diagnoses in older people in nursing facilities—from 6.53 percent in the fourth quarter of 2011 to 8.49 percent in the second quarter of 2017, a 30 percent increase in less than six years—is indicative of facilities adding a diagnosis to justify the use of these medicines.^[135]

In a joint statement, numerous organizations, including the American Association for Geriatric Psychiatry, American Association of Nurse Practitioners, American Geriatrics Society, American Health Care Association, American Medical Directors Association, Society for Post-Acute and Long-Term Care Medicine, American Psychiatric Association, and LeadingAge, responded to this uptick.

While there is a national need for better and more approved treatments for behavioral and psychiatric symptoms in dementia, clinicians need to be mindful of and avoid labeling patients with other diagnoses to justify the use of medications or other treatments.^[136]

In Kansas, the daughter and power of attorney of a 75-year-old woman learned that the facility had begun “giving her meds for bipolar”—a diagnosis she first received at age 74. In California, a nurse stated:

If they’re coming from an acute hospital (a hospital providing care to individuals experiencing or recovering from acute episodes of illness, injury, surgery, or trauma), they have a diagnosis. We can’t admit them otherwise. Sometimes we go around with the hospital to get us a psych diagnosis.^[137]

In Texas, a social worker at a nursing facility said: “Since you’re taking that medicine, then you get a diagnosis. That’s how you get a diagnosis. If we’re treating the symptoms, then you have the disease.”^[138]

Failure to Obtain Free and Informed Consent

I don’t take Seroquel. I take Clonidine for cholesterol, something for my heart and blood. But I don’t take Seroquel. It is nowhere in my record.
—Ruth D., a 62-year-old woman in a nursing facility in Texas, December 2016^[149]I don’t think antipsychotic drugs are presented well to the family in informed consent conversations. Because if it were, they’d all reject it. And when they [staff] don’t inform them beforehand, then the family is not having a real choice.
—A long-term care pharmacist in Kansas, January 2017^[150]

International human rights standards require that any medical intervention be provided only with free and informed consent.^[151] At its foundation, this right arises from an individual’s right to decide what is done with his or her own body.^[152] Free and informed consent—contrary to mere consent: written or oral permission, however it is obtained and whatever its basis—requires a full understanding of the purpose, risks, benefits, and alternatives to the medical intervention, and the absence of pressure or coercion in making the decision.^[153]

US federal regulations, including revised regulations that intended to go into effect on November 28, 2017, state that nursing home residents have the right to be fully informed in advance of their treatment and have the right to refuse treatment.^[154] Combining the right to be informed with the right to refuse treatment, individuals should have protection that is substantially similar and potentially equal to informed consent if enforced effectively.

Obtaining free and informed consent for medical interventions can pose significant challenges for doctors and nurses whose patients are in nursing homes. A large percentage of people who live in these institutions experience dementia or other conditions that affect their cognitive abilities. Many people in nursing facilities do not make their own decisions about their treatment.

In some cases, people are formally stripped of legal capacity, meaning the authority under law to exercise one’s rights and to make decisions for oneself, and another person acts as a surrogate decision-maker.^[155] (Under US regulations, the rights to be fully informed in advance about treatment and to refuse treatment apply only to residents that have not been formally “adjudged incompetent” and who do not have a surrogate authorized to stand in on these subjects.^[156]) More commonly, doctors either informally determine that people are not competent to make decisions about their care, or doctors and staff discuss care issue with relatives or health proxies by default, regardless of the resident’s cognitive abilities and the scope and activation of the proxy.

Proxies are legal devices to protect “prospective autonomy.”^[157] Instead of being formally adjudicated to lack capacity, many people voluntarily designate in advance, under state law, another person—termed a proxy, agent, healthcare representative, advanced directive, attorney-in-fact, legal appointee, or durable power of attorney for health care—to support them in decision-making or to act in their stead and carry out their wishes upon a certain stage of cognitive disability.^[158] However, these legal representatives are limited in scope and time. The proxy authority is activated only during the period of lost capacity and only on the specified subjects or decisions: “Any decision-making power that is not legally granted to a representative under state law is retained by the resident.”^[159]

The formal loss of legal capacity and excessive or premature use of proxies can completely exclude people from decisions that have major implications for their health. In some cases, this deprivation happens even when the person concerned does not have significant cognitive disabilities. For example, a former Kansas long-term care ombudsman said: “The nursing home sometimes goes straight to the POA [power of attorney] when the resident still has capacity. I often had to remind the nursing home that the POA is not all-encompassing.”^[160] As the revised federal regulations state: “Determinations of capacity to consent depend on the context of the issue and one determination does not necessarily apply to all decisions made by the resident.”^[161]

A small percentage of people in nursing facilities make up the most complex cases: they have a cognitive disability that compromises their ability to provide informed consent and do not have any family members or other support persons, designated or otherwise, to assist them in making medical and other decisions.^[165]

Most of the cases documented in this report do not fall into the category of highly complex ones. The nursing facility residents whose testimonies on the use of antipsychotic drugs appear in this report did not have significant cognitive disabilities. In our conversations with them, they seemed to understand their situation and to express their preferences regarding—and objections to—antipsychotic drugs. In other cases, the residents had designated a relative as their health proxy.

Yet we found that even in these cases where it clearly would have been possible for nursing facility staff and attending physicians to seek informed consent, doctors and facility staff failed to seek it from the individual or their proxy. In some cases where a health proxy was heavily involved in the individual’s care, the facility or practitioner sought consent but never provided sufficient information for consent to be informed.

In Texas, for example, Human Rights Watch interviewed a woman, Ruth D., 62, in a nursing facility who was given antipsychotic drugs without her or anyone’s consent, despite Ms. D.’s ability to give or withhold consent and objection to the medication.[166] Ms. D. was transferred to a nursing facility for rehabilitation after a minor stroke. After a month, the facility had not discussed care plans with her. Instead, she said, staff administered an antipsychotic medication, without informing her or seeking her informed consent.

Initially, Ms. D. said, she did not realize she was taking new medications. Once she realized, she refused to take them. She told Human Rights Watch: “They crush it so you don’t know what you’re getting fed. Put it in baby food. You know, [they put it in the] apple sauce.” As a result, Ms. D. said, “I don’t want to eat the food.”[167]

Ms. D. reported that the antipsychotic drug had had a major impact on her state of mind:

I do not mess with no Seroquel [an antipsychotic drug]. I don’t know what the drug does. But I know it’s dangerous. I was seeing monkeys on the wall… It knocks you out. It’s a powerful, powerful drug. I sleep all the time. I have to ask people what the day is… That Seroquel: that’s gonna kill me.[168]

Over the course of the interview with Human Rights Watch, nursing staff twice knocked, entered, and attempted to administer an antipsychotic drug in gel form to Ms. D. “Can I give you your medicine?” the aide said, “It’s your Seroquel.” Ms. D. replied, “I don’t take Seroquel. I take Clonidine for cholesterol, something for my heart and blood. But I don’t take Seroquel. It is nowhere in my record.”

With Ms. D.’s permission, the long-term care ombudsman, a registered nurse, and Human Rights Watch staff examined her medical chart at the nurse’s station. It did not contain any documentation that Ms. D had ever consented to taking Seroquel.

Throughout our interview, Ms. D. repeatedly stated her desire to leave the facility as she did not trust the staff and wanted to go home. “I will pay for the cab,” she kept saying.[169] The long-term care ombudsman helped facilitate her release from the facility the next morning.

In Illinois, Madeline C., 87, told Human Rights Watch that her nursing facility gave her antipsychotic medication without her knowledge or consent, or that of any family member or power of attorney. She said she never signed providing her informed consent. “I just did not know I was taking the medications. But I felt different.”^[170] The woman’s family could not persuade the facility to cease the medications; instead the family eventually moved her elsewhere.

Informed consent practice varies by state and facility. Consent does not have to be obtained in writing or signed by the person providing it as opposed to nursing staff, but many facilities have informed consent sheets for residents or proxies to sign.^[171]

In Texas, Dayvon G., the great-grandson and power of attorney of Nora G., said his great-grandmother’s facility had informed him they were putting her on two antipsychotic medicines. He had not objected. But the facility had failed to give him any information on the potential risks of the medications. Speaking with Human Rights Watch, he asked: “What is a black box warning? No one has mentioned it.”^[172]

Rosanne J., the wife and power of attorney of Marc J., a 79-year-old man in a Texas nursing facility, said that, although she knew the medicines had a sedative effect, she was “not real familiar with anything else, if they do anything to the mind.”^[173] In conversations with Human Rights Watch, she evinced an understanding that antipsychotic medication simply calmed her husband to the point of his appearing to be asleep.

Laura F., the daughter and power of attorney of Selina C., a 92-year-old woman in a California nursing facility, described having consented to antipsychotic drugs for her mother without understanding the risks: “I had no idea, not at all, that the drugs were dangerous. I had no idea. It’s on me because I didn’t know when I had agreed [to their prescription]. I’m guessing most people have no idea.”^[174] When her mother was later transferred to another facility, staff there continued administering the drugs without seeking informed consent from Ms. F.

In Kansas, a long-term care ombudsman gave an example of what she said was a typical situation in a care plan meeting where facility staff wanted to put a resident on Haldol:

It’s not explained to the family. I wanted them [the facility staff] to explain the side effects. They weren’t going to tell the family that. The nursing home just said, “the resident could get aggressive, could get hurt” [if they were not put on Haldol]. So, the family agreed to put them on it.^[175]

Our research suggests that in other cases, facilities that purport to seek informed consent put pressure on individuals to give consent. It is not known how common it is for facilities or doctors to use pressure to obtain consent. It is a serious abuse of the right to informed consent and of several federal regulatory requirements for those affected by the practice.

For example, Ruth D. told Human Rights Watch researchers that she feared retaliation after refusing to take the antipsychotic medication and speaking to long-term care ombudsmen about her objection to the facility’s coerced treatment. She said to the ombudsman and Human Rights Watch staff: “Once you leave I’ll be in trouble. I’m sweating.”^[176]

In Illinois, a long-time advocate said: “Informed consent is telling people risks and benefits and giving them a choice. In practice, the conversation is, ‘take it or we will discharge.’”^[177]For many residents, the threat of being evicted—involuntarily discharged—is real, even if federal regulations prohibit it in many circumstances.

Lena D., the daughter and designated health proxy of a resident in California explained: “If I object to the Risperdal, Seroquel, Haldol, they say, ‘okay, we are moving her.’”^[178] Although the facility did not follow through on that threat, it caused Ms. D significant anxiety and made it more difficult for her to refuse the medications.

In some cases, facilities appear to play on family members’ guilt to convince them to approve the medications’ use. Christina F., the daughter of a former resident in Kansas, recounted:

The nursing home called a meeting once and said he needs meds. They didn’t present alternatives. We said, “no.” My father said he trusted my judgment. The physician’s assistant told me: “You know you’re hurting him. You’re making it worse for him.”^[179]

The legitimate challenges in seeking informed consent from some nursing home residents do not excuse facilities’ failure to have an adequate standard practice of seeking informed consent. Staff from 15 nursing facilities in Texas, Kansas, California, and Florida, including administrators, directors of nursing, nurses, social workers, and social services directors, said their facilities do not seek consent generally; have no protocol for obtaining informed consent; or do not have regular discussions about these medications with residents or their relatives.^[180]

Accounts of some of the residents Human Rights Watch interviewed also demonstrated a severely inadequate understanding of the meaning of informed consent among staff at nursing facilities. Ombudsmen and nursing staff explained that many facilities do no more than notify the family after the fact, with no communication with the individual concerned. One ombudsman said: “They routinely do not tell either the resident or the family [about antipsychotic medication initiation]. Or they’ll have a meeting [after the fact] and say, ‘Well, we tried to call you.’”^[181] One facility’s director of nursing, the most senior medical professional in the building at most times and responsible for the administration of medications and interaction with prescribing physicians, admitted to Human Rights Watch:

We are supposed to be doing informed consent. It’s on the agenda. But really antipsychotics are a go-to thing. “Give ‘em some Risperdal and Seroquel.” We tell the family as we’re processing the order. The family is notified.^[182]

In Kansas, a director of nursing, admitted: “We don’t tell someone with dementia what drug we’re giving them. That would be very good practice to do that, but in practice it’s only if they ask [that we would tell them].”^[183]

A former nursing facility administrator in Kansas said:

The facility usually gets informed consent like this. They call you up. They say, “X, Y, and Z is happening with your mom. This is going to help her.” Black box warning? “It’s best just not to read that.” The risks? They gloss over them. They say, “That only happens once in a while, and we’ll look for problems.” We sell it. And, by the way, we already started them on it.^[184]

A Texas state regulator told Human Rights Watch: “There is very rarely informed consent. Nurse calls [the relatives], says resident is doing this [behavior], is highly agitated. The medication is explained as ‘he really needs it.’ They [the relatives] don’t understand.”^[185] A social worker at a facility in Kansas said: “There is no informed consent for antipsychotic drugs specifically. The only consent is to see a psychiatrist and to be treated. They can sign that consent at admission.”^[186] While social workers are not part of the medical or nursing staff, they are liaisons between the facility staff and residents’ families and thus would be familiar with these kinds of procedures.^[187]

In response to an inquiry into the facility’s informed consent procedure, one nurse at a facility in Texas told Human Rights Watch: “For informed consent, we just call to let them [the family] know. It’s verbal consent. They’ll sign it when they next come in.”^[188] At another facility in the state, the social services director explained:

The doctor writes the order. The nurse calls the responsible party and says, “The doctor made a medication change. This is what the new medication is.” The [durable power of attorney] or guardian says yes or no. That’s informed consent.^[189]

While the social services director would not be directly involved in this process, she appeared to explain it based on her personal knowledge of how it is done. In yet another facility, a director of nursing said, inexplicably: “Seroquel is not necessarily an antipsychotic drug. It could be an anti-convulsant. You don’t have to have consent if you’re not using it for psychotropics.”^[190]

One administrator in Kansas told Human Rights Watch: “I don’t know the answer, whether we have an informed consent procedure.”^[191] While facility administrators do not have to be medical professionals, they are responsible for the facility’s compliance with federal regulations, which include residents’ right to be fully informed in advance about their treatment options. They are also responsible for facilities’ compliance with state law.^[192]

A director of nursing at another facility in Kansas gave her best guess on what informed consent might entail. “How do you do informed consent? I have no idea on that. Maybe call the physician, get it prescribed, give it, call and tell the family what we did.”^[193] But, she clarified, “No, we don’t do that.”

The fact that a director of nursing would make this statement is particularly problematic because the job of seeking informed consent is often delegated, legally, nursing staff.^[194] The fact that the head of all nursing staff is unfamiliar with any procedure is a bad sign. As CMS explained in response to comments on its proposed revisions to federal regulations, although only the physician or prescribing practitioner prescribes medication, “[n]urses also bear the responsibility for the medications they administer to residents.”^[195] Staff at several facilities that have achieved significant reductions in off-label antipsychotic drug use told Human Rights Watch that they require all requests for antipsychotic drug orders to go through the director of nursing.

BACK TO TOP

IV. Inadequate Government Regulation and Enforcement

The US government has a duty to effectively regulate the nursing home industry with a view to protecting the human rights of residents. This responsibility is particularly important because nursing facilities are institutions with almost complete control over all aspects of the lives of residents. Effective regulation and oversight require not only the establishment of an appropriate regulatory framework to protect people from harm, but also effective enforcement of regulatory standards. Voluntary initiatives like the National Partnership to Improve Dementia Care in Nursing Homes are no substitute for the core CMS functions of regulation and enforcement.^[196] Our research found that CMS has failed to use the tools at its disposal to ensure adequate protection for residents’ rights.

Inadequate Regulation

Nursing industry officials frequently claim that nursing homes are the second most regulated sector in the US after the nuclear industry.^[197] In a letter to the then-US Department of Health and Human Services Secretary Thomas Price, AHCA wrote: “We are already the most regulated profession in the country.”^[198] Following the adoption of the Nursing Home Reform Act of 1987, the federal government has established extensive regulations of the nursing facility sector and requires detailed reporting on numerous aspects of facilities’ operations. Nursing facilities’ participation in the Medicare and Medicaid programs—whose payments make up over half of the average facility’s budget—is contingent upon certification and compliance with these regulations.^[199]

Despite the depth and breadth of the regulations, which range from emergency preparedness and infection control to prevention of abuse and neglect, crucial shortcomings remain. Our research on the inappropriate use of antipsychotic medications identified the failure to ensure minimum staffing levels necessary for residents to attain their highest practicable wellbeing and the lack of explicit requirements around informed consent (or functionally equivalent legal requirements that are framed in different terms) as key gaps in existing regulations.

Failure to Set Effective Standard to Address Gross Understaffing

The right to health requires governments to ensure that health services are of adequate quality. Gross understaffing and under-training of staff may contribute to the inappropriate use of anti-psychotics. According to one state long-term care ombudsman: “Insufficient CNAs [certified nurse aides] is the crux of the antipsychotics problem.”^[200] The federal government has not taken effective steps to tackle this problem.

Instead of requiring facilities to ensure every resident has a minimum number of nursing staff hours per day or staff per number of residents, CMS imposes a more general requirement that staffing be “sufficient” and “competent,” based on the facility’s own annual assessment of residents’ acuity, diagnoses, and care plans.^[201] This self-regulation is inadequate, given the continuing prevalence of staff shortages at many facilities.

CMS has recognized the importance of staffing, saying that staff competency and numbers are “critical to quality of care and resident safety,” and that there is “no question that staffing and quality are associated.”^[202] Likewise, numerous studies have shown that adequate staffing—sufficient quantity, training, and consistency of staff—is critically important to the quality of care nursing facility residents receive and that inadequate staffing leads to substandard care.^[203] Some studies have found that staffing is the best predictor of deficiencies—findings by government inspectors of substantial non-compliance with the law—and of hospitalization rates of residents, which in turn are associated with neglect.^[204]

Interviewees with distinct vantage points on nursing home challenges—residents, ombudsmen, nursing staff, and administrators—agreed that adequate staffing was essential. In Illinois, Barbara Jo V. described her experiences with and concerns about inadequate staff in her nursing home, where she has lived for ten years: “I need help to get to the bathroom. I can’t go by myself. That’s the problem with me. There’s no nurses at night at the station. Think if we had a fire.”^[205] Joyce M., another resident of the same facility, where she has lived for five years, said: “You should never wait ten minutes when we have the call light on. I’ve waited an hour for it to be answered. They’re always short of help.”^[206] In Kansas, Marisa N., who has lived in several nursing facilities since falling in 2014, said:

I don’t think there’s enough staff. Many of the residents are two-person transfers. I tell you, it’s been very frustrating to me to sit here [in the bathroom] waiting. On weekends it has been horrendous. If they know State [inspectors] is coming, they’ll get six or seven more [staff] than usual to come in. Otherwise it’s just kitchen, waiter, two or three CNAs [certified nurse aides] on the floor, and a nurse.^[207]

One former ombudsman in Kansas said: “What distinguishes facilities most of all is their staffing. Especially with dementia, you need consistent staffing.”^[208] An ombudsman in Florida said:

I wish they could get quality staff who stay. Poor CNAs make a pittance. A nursing home might meet the minimum staffing requirement but still not meet residents’ needs. AHCA [Florida’s regulatory agency, the Agency for Health Care Administration] has okay’ed one CNA for 20 residents. Some residents need a two-person lift!^[209]

A nurse in Texas who has worked in nursing homes since 1992 said: “It’s very stressful. The hardest is when there’s not enough help. You can’t do your job the way you know you need to do it. You just do the most basic needs.”^[210] A nurse elsewhere in Texas said, “Staffing is the biggest problem across the nation. Here, we don’t have many staff on weekends. So there are no showers on Sundays. Then the workload is less.”^[211] An administrator in Texas said: “CNAs are the most important…. They’re the heart of the nursing home and nobody cares. The thinking is, ‘we’ll just get another one.’”^[212]

Various studies have found that staffing levels and staff training affect the use of antipsychotic medicines, although some did not find a robust association.^[213] Studies that examined efforts to reduce antipsychotic drug use found that staffing and staff training were associated with the success of those efforts. One study found that a full-time advanced practice registered nurse at the nursing home led to a drop from almost one in three to one in ten long-stay residents taking the drugs and “achieved no use of antipsychotic medications for residents with a diagnosis of dementia.”^[214] Another study concluded that “[n]urses working longer on the ward, with lower education, presented higher barriers to discontinuation of antipsychotics.”^[215]

Governmental studies have underscored the importance of minimum staffing standards, too.^[216] In 2001, a CMS-funded study concluded that to avoid compromising quality of care, long-stay residents should have 4.85 nursing staff hours per day, and that short-stay residents should have 4.1 hours.^[217] A subsequent report in 2004 by the Institute of Medicine, recommended following these same standards and updating minimum requirements to require at least one registered nurse on duty at all times (not just eight hours a day); staffing levels to increase based on resident numbers, consistent with the 2001 CMS report; and setting staffing levels for nurse aides, recognizing that aides “provide the majority of patient care.”^[218]

More than a decade later, staffing at many facilities still falls far short of these recommendations. A review of the data in 2017 shows that almost a thousand nursing facilities reported that they were providing less than three hours of staff time to residents per day—almost 40 percent below the recommended level.^[219] Human Rights Watch analysis found that state-level averages of total reported nurse staffing hours vary: Illinois and Texas have two of the lowest levels, at 3.80 and 3.83 hours respectively; California and Florida have two of the highest, at 4.63 and 4.59 respectively.

Moreover, CMS has stated that those numbers are likely inflated because nursing facilities tend to over-report their staffing levels.^[220] CMS expects the payroll-based staffing data collection, mandated by the Affordable Care Act, to “greatly assist us in re-evaluating” current staffing short-comings because they expect their “understanding of how facilities are staffed … to improve with the collection of payroll-based staffing data.”^[221] One study examining the mix of residents in nursing facilities found that actual staffing levels were lower than predicted, given residents’ needs.^[222]

Studies also show the importance of having sufficient registered nurses on staff.^[223] Yet federal regulations only require one registered nurse to be on duty for eight consecutive hours per day.^[224]

In 2016, CMS rejected a minimum staffing level or ratio.^[225] First, it stated that facilities are too different for a one-size-fits-all approach—contrary to the position of the 2001 report that holds that the inability to stratify staffing thresholds by case-mix “would in no way invalidate the thresholds that were identified.”^[226] Second, it argued that a minimum staffing requirement could have unintended consequences like “staffing to the minimum” or “stifling innovation,” or could “not result in the improved quality and person-centered care [sought].”^[227] Third, CMS concluded that it lacked sufficient data for “determining if and what such [staffing] ratios should be.”^[228]

Similarly, AHCA wrote to Human Rights Watch regarding its opposition to stronger staffing requirements:

We feel that requiring staffing levels or ratios does not recognize the difference in types and acuity and care needs different individuals and facilities have. A one shoe [sic] fits all approach would not be helpful to assuring high quality care. Also focusing on just staffing levels is misguided. We believe the focus should be on resident outcomes.^[229]

LeadingAge, the nonprofit nursing home trade association, reiterated this perspective in response to a letter from Human Rights Watch:

LeadingAge has not supported minimum staffing ratios because they become just that – minimum standards to which many providers focus on. We believe that staffing should be based on the needs and acuity of the residents served and the skills/competency of the staff that care for them. Of particular note, non-profit providers typically have higher staffing ratios than the for-profit nursing homes in a given geographic area.^[230]

Yet the bottom line is that the current standard has not succeeded in pushing nursing facilities to raise staffing levels to the desired levels. A new and more robust approach, which may or may not include minimum staffing levels, is needed. If CMS does not want to establish a specific minimum staffing requirement, it should introduce another approach that is more effective at getting nursing facilities and their owners to address understaffing.

However, based on information gleaned from data from some of the states that have introduced minimum staffing levels, there is no clear evidence that stronger staffing levels mandated by law has led to higher quality of care.^[231] Human Rights Watch does not take a position on the means that the government employs to ensure sufficient staff to provide the quality of care required by domestic law and human rights standards. However, the current federal regulations are not doing the job.

Inadequate Free and Informed Consent Laws and Regulation

Federal regulations governing nursing facilities certified by Medicare and Medicaid provide for the right “to be fully informed in advance about care and treatment, to be fully informed in advance of any changes in care or treatment that may affect the resident’s well-being, and (except with respect to a resident adjudged incompetent) to participate in planning care and treatment or changes in care and treatment,” as well as the right to refuse treatment.^[232]

The regulations do not require nursing facilities to obtain free and informed consent, written or otherwise, from any residents prior to administering antipsychotic or other psychotropic medications. At least half of states also do not require written, informed consent from individuals living in nursing facilities prior to the administration of antipsychotic drugs.^[233]

CMS has an obligation to protect the right of people in nursing facilities to informed consent. In practical terms, meeting that obligation should not require a significant legislative or regulatory shift if existing regulations are enforced rigorously. However, given obstacles to doing so, informed consent remains in effect a gap in the regulations.

Current guidance states that:

[Federal regulations require facilities to involve residents, families, and representatives] in discussions about potential approaches to address behaviors and about the potential risks and benefits of a psychopharmacological medication (e.g., FDA black box warnings), the proposed course of treatment, expected duration of use of the medication, use of individualized approaches, plans to evaluate the effects of the treatment, and pertinent alternatives.[234]

CMS guidance states explicitly that “[r]esidents have the right to be informed about their medical condition, care and treatment; they have the right to refuse treatment and the right to participate in the care plan process.”^[235] Individuals in nursing facilities also already have a right to “request, refuse, and/or discontinue treatment.”^[236]

Substantively, these requirements would amount to informed consent if the provisions were enforced in practice. However, it is difficult to be sure that adequate information was conveyed in an intelligible fashion and that the person receiving care had the opportunity to make an informed decision about their treatment options.

Existing nursing home regulations already require residents be present for and included as much as possible in discussions and decisions. As dementia is a progressive, degenerative disease, nursing facilities should plan ahead for future situations when a resident may increasingly struggle to make informed decisions about their care. Residents should be proactively engaged to determine their wishes regarding future care in a range of possible scenarios in case it becomes impossible for them to engage in those discussions in the future. It is essential that this planning starts at the point of admission to the facility.

In California, a treating physician may determine that an individual lacks the ability to consent to medical treatment. If there is no legal representative to make the decision on the person’s behalf, California law mandates that the person’s nursing facility convene an interdisciplinary team to make decisions.^[237] Many states have no established procedures for a nursing home to follow to make a determination for individuals in these circumstances.

For example, the two informed consent statutes in Texas relating to antipsychotic drugs and nursing home residents make no provision for individuals deemed to lack capacity without a proxy.^[238] Otherwise, the law provides that no resident may be administered a psychoactive medication without the resident’s consent unless it is an emergency or “the person authorized by law to consent on behalf of the resident has consented.”[239] The law then enumerates when the resident’s or proxy’s consent is valid, such as when it is voluntary; adequate information was provided on which the person could make the decision; the person giving consent was aware the consent could be revoked; and the consent is documented in the clinical record.^[240]

US procedural safeguards in the determination of incapacity are much stronger in the context of civil commitment and mental or intellectual disability law.^[241] It is worth exploring whether nursing facility residents’ human rights would be better protected if these protections were to apply to them as well, despite the absence of direct state intervention in their institutional placement.

Ineffective Enforcement

Regulatory standards are only as effective as their enforcement. Our research found several significant shortcomings in enforcement of federal regulations, from the underestimation of harm cited to the inadequate deterrent effect of financial sanctions assessed. Despite widespread failure by nursing facilities to comply fully with regulations put in place to protect people living in these institutions, CMS is not using its full authority to force them to improve their performance.

In November 2017, CMS reduced enforcement requirements further, including placing a moratorium on the issuance of financial sanctions for noncompliance with Obama-era regulatory requirements.[242] Previously, industry groups had critiqued even the government’s inadequate enforcement efforts. For example, LeadingAge, the nonprofit trade association, wrote to Human Rights Watch saying:

We [believe] that the current Survey and Certification system is NOT driving quality and excellence, but is one that is focused entirely on enforcement, that it is inconsistent, that it is punitive in nature and creates a defensive environment—not one that supports innovation and excellence.^[243]

In a letter to then-US Department of Health and Human Services Secretary Thomas Price, AHCA pointed out that “a punitive approach by survey teams across the country has threatened to shut down even the best operators in our profession.”^[244] As the following analysis demonstrates, it is not accurate that typical penalties are at all onerous.

The trade associations do not argue that the government assesses sanctions when noncompliance has not in fact occurred. Instead, their view is that progress toward compliance with non-negotiable, federal, legal requirements (“we have so dramatically improved quality”) merits being “rewarded for our efforts.”^[245]

Moreover, most facilities are part of a chain, where the owner has at least two and sometimes hundreds of nursing facilities.^[246] But the government does not sufficiently collect and analyze nursing facility data based on ownership or conduct standard enforcement taking ownership into account.^[247] The facility is the only “locus of accountability” in the current enforcement system: a notable shortcoming because in many cases, fundamental decisions—about management, operations, revenue allocation, compliance with state and federal quality of care standards, staffing levels, and government reporting—are not made by the administrators of individual facilities but by upper level managers in the corporate structure that owns them.^[248] The main enforcement process authorized by law discussed in the following sections—assessing financial, licensing, and other penalties for failure to substantially comply with regulatory requirements—is exclusively focused on individual facilities.^[249]

CMS is the main agency to regulate nursing facilities. However, other government agencies have overarching enforcement authority across sectors, such as the US Department of Justice (DOJ).^[250] In 2016, the DOJ created Elder Justice Task Forces to penalize nursing facilities for grossly substandard care.^[251]

Underestimation of Severity of Harm Caused by Inappropriate Use of Antipsychotic Drugs

Federal regulations provide for regular inspections of all licensed nursing facilities. CMS contracts with state agencies to conduct enforcement of federal and state laws and regulations.^[252] Every 15 months at most, state surveyors conduct unannounced inspections to evaluate facilities’ compliance with health and safety regulations.^[253] Surveyors use a detailed protocol—the State Operations Manual produced by CMS, which includes detailed investigative protocols on particular subjects—to conduct surveys and determine the scope and severity of a deficiency.^[254] Deficiencies are determinations of noncompliance with more than 150 federal regulatory quality of care, quality of life, safety, fire, and other standards, from freedom from abuse, neglect, and exploitation to the physical environment, emergency preparedness, infection control, food services, and more.^[255]

Surveyors identify and substantiate any deficiencies, and then determine the scope and severity of harm. Inspectors determine whether the deficiency is isolated, part of a pattern, or widespread and its consequence: the potential for or actual occurrence of minimal harm, actual harm, or immediate jeopardy (likelihood or occurrence of “serious injury, harm, impairment, or death to a resident”).[256] Table 1 shows the scope/severity grid that surveyors use.

Table 1. Severity and Scope Grid for Deficiencies

Guidance to surveyors has made clear that an immediate jeopardy citation may be appropriate without any actual harm having yet occurred, that serious harm can result from neglect, and that psychological harm is just as serious as physical harm.^[257] Triggers for immediate jeopardy citations include adverse medication consequences and use of chemical restraints without adequate monitoring.^[258] Human Rights Watch analysis found that 12 percent of facilities were cited for at least one immediate jeopardy citation between 2014 and 2016; 40 percent of facilities were cited for at least one “actual harm” level deficiency. Every facility was cited for at least one deficiency of some severity level.

CMS guidance for surveyors suggests that many cases of inappropriate use of antipsychotic medications should be tagged as Level 3 or 4 severity. For example, the manual defines a Level 3 deficiency as “clinical compromise, decline, or the resident’s inability to maintain and/or reach his/her highest practicable well-being.”^[259] It cites, among others, the following example:

Facility failure to implement a GDR [gradual dose reduction] that was not contraindicated in a resident receiving prolonged, continuous antipsychotic therapy resulting in functional decline, somnolence, lethargy, tremors, increased falling, or impaired ambulation.^[260]

Level 4 deficiencies are defined as regulatory noncompliance that:

[H]as allowed, caused, or resulted in, or is likely to allow, cause, or result in serious injury, harm, impairment, or death to a resident; and requires immediate correction, as the facility either created the situation or allowed the situation to continue by failing to implement preventative or corrective measures.^[261]

The guidance includes the following examples related to antipsychotic drugs: “Failure to recognize that continuation of an antipsychotic…, has caused significant changes in the resident’s behavior;” “continuation of the antipsychotic without indication resulted in significant psychosocial harm;” and “failure to re-evaluate continuation of an antipsychotic originally prescribed for acute delirium which resulted in significant side effects from the medication.”

Yet Human Rights Watch’s data analysis suggests that deficiencies related to antipsychotic drugs are almost exclusively assessed as “no actual harm.” Our review of more than 7,000 deficiency reports related to antipsychotic drugs between January 1, 2014, and June 30, 2017, found that 97 percent of these deficiencies were tagged as Level 2 (D, E, and F categories), or “no actual harm.” Only 93 deficiencies (1 percent) were tagged as Level 3 (G and H) and 63 deficiencies (less than 1 percent) as Level 4 (J, K, and L). See Table 2 for the distribution of assessed scope and severity. A detailed description of the data analysis performed can be found in Appendix 4.

Table 2. Scope and Severity of Drug-Related Deficiency Citations with Antipsychotic Drug-Related Key Terms[262]

A study by the Center for Medicare Advocacy, a national nonprofit, nonpartisan law organization focused on protecting older people’s and people with disabilities’ fair access to Medicare and quality health care, and Dean Lerner Consulting, an attorney consultant with expertise in the long-term care industry, of all deficiency citations for unnecessary drugs (f-tag 329) in 2010 and 2011 from seven states (Georgia, Illinois, Massachusetts, Oregon, Pennsylvania, and Texas) reached a similar conclusion. Of 602 citations, 292 concerned antipsychotic drugs. Almost all—95 percent—were cited at the “no actual harm” level.^[263]Examples of what surveyors considered to be “no actual harm” included: a person falling 20 times; becoming more agitated with the drugs; being given more than the “daily recommended dosage;” being prescribed antipsychotic drugs without appropriate evaluation; declining to the point of needing total care; requiring hospitalization for undiagnosed underlying infections; and “spending all her time in bed.”^[264]

This apparently systematic underestimation of the severity of harm caused by inappropriate uses of antipsychotic drugs (among other drugs and medical interventions) not only appears to point to woefully inadequate enforcement and protection of nursing home residents’ rights, but also leads to inappropriately light penalties. Without a finding of more severe harm, financial penalties are minimal, optional, or do not attach.^[265] A concerted effort from CMS to address this problem is urgently required.

The revised CMS State Operations Manual, which was meant to go into effect on November 28, 2017, before a moratorium on enforcement of significant portions of it was established on November 24, 2017, may go some way toward addressing this routine underestimation of the harm of deficiencies related to antipsychotic drugs if it were enforced.[266] The manual states explicitly that Level 1 deficiencies—for no harm with potential for minimal harm—“does not apply for this regulatory requirement [regarding psychotropic drugs] because the failure of the facility to provide appropriate care and services to manage the resident’s medication regimen to avoid unnecessary medications and minimize negative outcome places residents at risk for more than minimal harm.”^[267]

It also provides as an example of a Level 4 deficiency:

Failure to recognize that use of an antipsychotic medication, originally prescribed for agitation, has caused significant changes in the resident’s quality of life. The resident no longer participates in activities that they previously enjoyed, has difficulty concentrating and carrying on conversations, and spends most of the day isolated in his or her room, sleeping in a recliner or in bed. Use of the antipsychotic medication without an adequate clinical indication, GDR attempts, and non-pharmacological approaches resulted in psychosocial harm.^[268]

Weak Deterrent Effect of Citations and Penalties in a Remedial Enforcement System

Until they get a tag that bites them, nothing will change. In this industry, there is a real cost-benefit analysis. If the fine will be $100,000, then they’ll hire the three nurse aides who will cost them about the same amount.
—Long-term care consultant in Kansas, January 2017^[269]

Appropriate financial sanctions and other penalties for violations of regulatory standards are a critical element of a robust enforcement mechanism. Penalties should be commensurate to the seriousness and nature of the infraction and should seek to bring about enduring changes in practice. While the framework for a meaningful enforcement system exists, our research found that CMS and its state counterparts often impose penalties for serious infractions that are so low, automatically reduced, or negotiable that they do not generate meaningful pressure to address the root causes of violations.^[270]

The scope and severity of harm determines the range of potential fines or civil money penalties. Consequences for facilities’ noncompliance with the law fall into three categories. The first category of lightest penalties includes: directed plan of correction; state monitoring; and directed in-service training.^[271] In other words, facilities suffer no financial sanction. The only consequence for noncompliance for the lowest scope and severity deficiencies is making a plan to correct the problem.

The second category of penalties includes: denial of payment for all Medicare and/or Medicaid residents; denial of payment for all new admissions; and the lower range of civil money penalties (CMPs), financial sanctions.^[272] These penalties, if imposed, may generate financial pressure that incentivizes facilities to take seriously the problem and correct it in a lasting way.

The third category of heaviest penalties includes: termination of the provider agreement; temporary management; and the upper range of CMPs.^[273] This category of remedies may include transfer of residents or transfer of residents and closure of facility, at states’ or CMS’ discretion.^[274] Historically, government studies of CMS and state level enforcement have found that lower levels of all types of penalties are used much more frequently than higher levels.^[275]

Human Rights Watch quantitative analysis of fines assessed in all states between 2014 and 2016 found that 80 percent were less than $10,000 and 20 percent between $10,000 and $100,000. As of July 2017, a citation that is “no actual harm” with potential for more than minimal harm that is widespread can garner a fine of $405 per day or a per instance fine of $5,000.^[276] “Actual harm” citations (Levels G, H, and I, depending on scope) can garner a fine between $505 and $2,055 per day and between $10,000 and $15,000 per instance, depending on scope. “Immediate jeopardy” level citations (Levels J, K, and L, depending on scope) can garner a fine between $6,394 and $10,494 per day or between $10,000 and $20,000 per instance, depending on scope. Only the highest level deficiency is now eligible for the top civil money penalties.^[277]

Until July 2017, when CMS revised its Civil Money Penalty Tool through sub-regulatory guidance that had no public notice and comment period, CMS Regional Offices were in most cases instructed to impose a per day (that the noncompliance persisted) penalty.^[278]Generally, per day penalties are more significant.^[279] The Bipartisan Budget Act of 2015 amended the Federal Civil Penalties Inflation Adjustment Act of 1990 to allow the civil money penalty amounts set in 1987 to be adjusted for inflation for the first time.^[280]

AHCA pushed for such reductions in March 2017.

Any violation in the SNF [skilled nursing facility] setting, no matter how small, is treated as a violation of the requirements of participation in Medicare and Medicaid and puts the SNF on a termination track from these programs. These violations can also result in large Civil Monetary Penalties (CMPs)…. The use of CMP’s is out of control…. We have seen a dramatic increase in CMPs being retroactively issued and used as a punishment.^[281]

The sub-regulatory guidance appears to respond to some of AHCA’s specific requests.

Analysis of data on deficiencies related to antipsychotic drugs and rates of use of these medicines by nursing facilities, however, suggests that the issuance of deficiency citations without financial sanctions attached—the current situation given routine practice of assessing antipsychotic drug-related deficiencies as Level 2, with corresponding lighter penalties—has little impact on the off-label use of these medications, raising concerns about the deterrent effect of current enforcement.

To assess the impact of antipsychotic drug-related deficiency citations, we compared rates of antipsychotic drug use in people without an exclusionary diagnosis for the 4,221 unique facilities that received a cumulative 5,880 antipsychotic related deficiencies.^[282] In the year following an antipsychotic drug-related deficiency citation, facilities reduced their antipsychotic drug use rate in people without an exclusionary diagnosis by 1.5 percentage points (see Table 3).

Table 3. Change in Antipsychotic Drug Use in People without an Exclusionary Diagnosis in the Year Following an Antipsychotic Drug-Related Citation

EXPAND

Graph 1. Antipsychotic Related Citations Have Minimal Effect on Antipsychotic Use Rates

However, there was no statistically significant difference in the rate of change in antipsychotic drug use between facilities that received an antipsychotic deficiency citation and those that did not.[283] Facilities reduced their antipsychotic drug use by 1.57 percentage points on average in the year following a citation, but those same facilities were already reducing their rates by 1.60 percentage points during periods where they were not cited, and facilities that were not cited at all were reducing their rates by 1.29 percentage points. Between 2014 and the first quarter of 2016, the average reduction in antipsychotic use rates was only 0.031 percentage points greater in facilities that received an antipsychotic related citation compared with those that were not cited. For detail on the statistical analysis performed, see Appendix 4.

Binding Arbitration Agreements

In many contexts, individuals use civil tort lawsuits to secure accountability and redress for abuses the law does not otherwise prevent or punish. Approximately half of the country’s nursing facilities ask residents (or their proxies) to sign binding arbitration agreements upon admission; some make it a condition of admission.^[288] Under these contract clauses, disputes between the facility and resident must be resolved outside of the court system. In other words, the resident “waiv[es] his or her right to judicial relief for any potential cause of action covered by the agreement.”^[289] Instead, disputes that may arise are resolved through arbitration proceedings. As is true in many other contexts, these agreements raise concerns about whether arbitration offers a fair and impartial hearing and a realistic chance at remedy.

In 2016, CMS banned the use of pre-dispute arbitration clauses, describing them as “fundamentally unfair” because “it is almost impossible for residents or their decision-makers to give fully informed and voluntary consent to arbitration before a dispute has arisen.”^[290] Instead of limiting avenues for relief in cases of violations “residents should have a right to access the court system if a dispute with a facility arises.”^[291]

CMS noted that “there is significant evidence that pre-dispute arbitration agreements have a deleterious impact on the quality of care for Medicare and Medicaid patients” in nursing facilities.^[292] It also emphasized that while arbitration proceedings are widespread in the healthcare industry, the “significant differential in bargaining power” between residents and nursing facilities—the former depends on the latter for almost all their needs—make it “unconscionable” for such facilities to demand, as a condition of admission, that residents sign a pre-dispute agreement for binding arbitration.

In June 2017, CMS did a complete about-face, issuing a new proposed rule that not only would eliminate provisions prohibiting pre-dispute arbitration, but also would allow facilities to deny admission to a resident who refuses to sign the arbitration agreement.^[293]

In justifying its reversal, CMS stated that the binding contracts are “advantageous to both providers and beneficiaries because they allow for the expeditious resolution of claims without the costs and expense of litigation,” adding that “this proposal is consistent with our approach to eliminating unnecessary burden on providers, and supports the resident’s right to make informed choices about important aspects of his or her healthcare.”^[294]

Proposed federal tort reform legislation could pose additional obstacles to obtaining a remedy for harm. At time of writing, the House of Representatives had passed and the Senate had received H.R. 1215, the Protecting Access to Care Act of 2017, which would impose a three-year statute of limitations for individuals to sue nursing homes for harm, a $250,000 cap on damages, and a limit on attorney contingency fees.^[295]

These measures would likely not only reduce the compensation an individual might receive for serious harm or wrongful death, but also deter lawyers from taking the cases in the first place. Other proposals would limit class action lawsuits and the number of years after a harm occurs that a plaintiff could sue, whatever occurred—abuse, neglect, sexual assault—by a number of providers of medical care, including nursing facilities.^[296]

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V. International Human Rights and US Law

Key Obligations Arising from International Human Rights Law

Torture and Other Cruel, Inhuman, and Degrading Treatment

The Convention on the Rights of People with Disabilities (CRPD), which the US has signed but not ratified, requires governments to “take all effective legislative, administrative, judicial or other measures to prevent persons with disabilities, on an equal basis with others, from being subjected to torture or cruel, inhuman or degrading treatment or punishment.”^[297] The US is not legally bound by the CRPD, but the Convention does represent an important authority on the measures the government should take to protect and improve respect for the rights of people with disabilities.^[298]

In 2013, Juan Mendez, then the UN special rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, warned of the danger of human rights violations in the healthcare setting where the perception persists that “certain practices in health-care may be defended by the authorities on grounds of administrative efficiency, behaviour modification or medical necessity.”^[299]

Mendez also noted that “medical treatments of an intrusive and irreversible nature, when lacking a therapeutic purpose, may constitute torture or ill-treatment when enforced or administered without the free and informed consent of the person concerned.” He also emphasized that an act may constitute ill-treatment, even if it is “intended to benefit the ‘patient’” and may “exist alongside ostensibly therapeutic aims.”

Mendez stated that this rights violation is particularly likely to occur when the “treatments are performed on patients from marginalized groups, such as persons with disabilities, notwithstanding claims of good intentions or medical necessity.”^[300] The use of a “prolonged restraint” may constitute torture and ill-treatment; when used against people with mental disabilities, “even a short period of time may constitute torture and ill-treatment.”^[301]

The Right to Health and Informed Consent

The highest attainable standard of physical and mental health is a fundamental human right enshrined in numerous international human rights instruments, including the Universal Declaration of Human Rights, the International Covenant on Economic, Social, and Cultural Rights, and the CRPD. The special rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health has expressed that informed consent “is a core element of the right to health, both as a freedom and an integral safeguard to its enjoyment.”^[302]

In the words of the special rapporteur on the right to health:

Informed consent is not mere acceptance of a medical intervention, but a voluntary and sufficiently informed decision, protecting the right of the patient to be involved in medical decision-making, and assigning associated duties and obligations to health-care providers. Its ethical and legal normative justifications stem from its promotion of patient autonomy, self-determination, bodily integrity and well-being.^[303]

Informed consent is fundamental to “respecting an individual’s autonomy, self-determination and human dignity.”^[304]

The special rapporteur on the right to health called on States to:

[R]adically reduce medical coercion…, [and] not to permit substitute decision-makers to provide consent on behalf of persons with disabilities on decisions that concern their physical or mental integrity; instead, support should be provided at all times for them to make decisions, including in emergency and crisis situations.^[305]

However, the special rapporteur acknowledged that such change “is a challenging process that will take time” and emphasized the importance of taking intermediary steps:

1. Mainstream alternatives to coercion in policy with a view to legal reform;
2. Develop a well-stocked basket of non-coercive alternatives in practice;
3. Develop a road map to radically reduce coercive medical practices, with a view to their elimination, with the participation of diverse stakeholders, including rights holders;
4. Establish an exchange of good practices between and within countries;
5. Scale up research investment and quantitative and qualitative data collection to monitor progress towards these goals.^[306]

Key Domestic Legal Protections

US federal and state laws protect against abuse and neglect in skilled nursing facilities, primarily through the Nursing Home Reform Act of 1987 and associated regulations.^[307]Some of these protections on the quality of care and quality of life a person is entitled to receive while living in a nursing facility are listed explicitly as “resident rights.”^[308] Many enumerated rights pertain to antipsychotic medications, discussed below; they also provide for the context of broader care planning based on every individual’s goals and preferences.

These latter rights include: the facility’s promotion of residents’ dignity; the provision of activities to meet individual needs; the provision of medically-related social services; resident assessments as the foundation for all care comprehensive care planning that involves the resident; professional quality services; availability of psychosocial services; sufficient nursing staff; care supervised by a physician; pharmacist reviews of drug regimens; effective administration of facilities; competence of nursing staff; and facilities’ supervision by a medical director.^[309]

Other federal and state laws address the protection of people’s rights when living in a nursing facility. Federal laws include the Americans with Disabilities Act, since anyone eligible to live in a nursing facility meets the definition of having a disability, and the Civil Rights of Institutionalized Persons Act, though only for the minority of individuals living in publicly-owned nursing facilities.^[310] State laws concerning nursing facilities’ regulation and residents’ rights generally emulate the federal law while setting out distinct provisions on some issues that nonetheless comply with federal minimum standards.

Freedom from Chemical Restraints, a Form of Abuse, and Unnecessary Drugs

Federal and state laws protect individuals in nursing facilities from chemical restraints and other forms of abuse. US regulations also prohibit the use of any unnecessary drugs, including antipsychotic drugs, in nursing facilities even if they do not amount to chemical restraints.^[311]

Regulations particular to psychotropic drugs mandate that any prescription for someone not already taking such medication must be “necessary to treat a specific condition as diagnosed and documented in the clinical record”; and anyone given psychotropic medications must “receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.”^[312] For antipsychotic drugs, gradual dose reduction must be attempted twice in the first year of administration and annually thereafter.^[313]

Informed Consent and Right to Refuse Treatment

The Nursing Home Reform Act does not provide for express, written informed consent. However, it provides for the right to be fully informed of one’s health status; the right to participate in treatment planning; the “right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers”; and the right to refuse treatment.^[314]

Most state laws do not expressly require written informed consent prior to the administration of antipsychotic drugs to individuals in nursing facilities.^[315] However, some state laws do, and in all states, this right should be protected by a combination of nursing home laws and state civil tort statutes. Texas, California, and Illinois are examples of states that require informed consent explicitly, although without a private right of action as a basis to sue if this right is violated. The Texas Health & Safety Code provides for the right to “refuse to consent to the prescription of psychoactive medications;” sets out the requirements for informed consent, including its voluntary and revocable nature and the information that must be provided, and its documentation; and establishes the limited circumstances where it is not required.^[316]

California’s Patients’ Rights article states: “Patients shall have the right … to consent to or to refuse any treatment or procedure,” including to receive all relevant information for making the decision.^[317] For psychotherapeutic drugs specifically, the informed consent discussion must include the reason for the treatment, nature of the intervention including the duration, likely benefit with and without treatment, side effects and risks, reasonable alternatives, and the patient’s right to accept, refuse, and revoke consent.^[318]

Illinois’s Nursing Home Reform Law provides that psychotropic medication, including antipsychotic drugs, “shall not be prescribed without the informed consent of the resident, the resident’s guardian, or other authorized representative.”[319] Informed consent requires a discussion between the individual concerned or his or her representative and the physician, pharmacist, or nurse regarding the “possible risks and benefits of a recommended medication,” documented in a standard fashion.^[320]

New York and Florida are examples of states with laws that expressly mimic the federal law. New York’s statute provides that individuals in nursing facilities have the right to “be fully informed of his or her medical condition and proposed treatment…, and to refuse medication and treatment after being fully informed of and understanding the consequences of such actions.”^[321]

Florida’s statute provides for nursing home residents’ right to “be adequately informed of his or her medical condition and proposed treatment,” the right to “be fully informed in advance of any nonemergency changes in care or treatment,” and the right to “participate in the planning of all medical treatment, including the right to refuse medication and treatment.”^[322]

Kansas is an example of a state that does not require informed consent. Its administrative regulations for all adult care homes, including nursing facilities, provide for the right to “refuse treatment” only.^[323] Kansas and states like it are bound by federal requirements.

Americans with Disabilities Act

Based on the admission criteria for skilled nursing facilities and nursing facilities, almost all nursing facility residents are protected by the Americans with Disabilities Act (ADA) of 1990.^[324] The ADA defines disability as: “a physical or mental impairment that substantially limits one or more major life activities” or “a record of such an impairment.”[325] A disability under this law could also be merely “being regarded as having such an impairment … whether or not the impairment limits or is perceived to limit a major life activity,” so long as the impairment is not “transitory” (lasting six months maximum) or “minor.”^[326]

The US Attorney General has jurisdiction to enforce the ADA: to prosecute the violation of the rights of people with disabilities articulated under it. However, it does not have exclusive jurisdiction; private individuals may sue as well. Anyone who has been “subjected to discrimination on the basis of disability … may institute a civil action for preventive relief, including an application for a permanent or temporary injunction, restraining order, or other order.”^[327] The ADA has not been employed frequently to protect the rights of older people in nursing facilities. However, it is a relevant legal protection for people with dementia.

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Recommendations

To the Centers for Medicare & Medicaid Services

• Strengthen enforcement of existing regulatory requirements in conjunction with contracted state agencies to end all inappropriate use of antipsychotic medication in nursing facilities, including when the medication would be an “unnecessary drug;” when it would amount to a chemical restraint; when it would be inconsistent with other regulatory requirements; and when it is not based on free and informed consent (or functionally equivalent legal requirements that are framed in different terms).

To the United States Congress

• Reintroduce and pass S. 3604, “Improving Dementia Care Treatment for Older Adults Act of 2012,” to amend Title XVIII and Title XIX of the Social Security Act to require standardized protocol for obtaining written, free, and informed consent from an older person with dementia prior to prescribing an antipsychotic drug or from the person’s representative as appropriate.
• Reintroduce and pass H.R. 952, “Put a Registered Nurse in the Nursing Home Act of 2015,” to amend Title XVIII and Title XIX of the Social Security Act to require nursing facilities to use the services of at least one registered professional nurse 24 hours a day, seven days a week, to provide assessment, surveillance, and direct care to residents.

Until the inappropriate use of antipsychotic medications in older people with dementia in nursing facilities ceases completely, the following entities should take interim steps to contribute to the drastic and immediate reduction in inappropriate, sometimes coercive, and irreversibly harmful, uses of the medications:

To the Federal Government

To the Centers for Medicare & Medicaid Services

For Free and Informed Consent:

• To the greatest extent of its authority, require free and informed consent from the individual whose care is concerned, including with support as needed in the decision, or their appointed representative, as long as this representative is chosen freely and is tasked with reflecting the individual’s will and preferences.
• Develop and implement models of supported decision-making that enable people living in nursing facilities to make their own decisions about treatment and care.
• Strengthen enforcement of existing regulatory requirements related to informed consent, appropriate medication administration, and care planning regulatory provisions, including the rights to refuse treatment; to be involved in care planning; to be free from unnecessary drugs; to be free from chemical restraints, and to receive necessary care to achieve the highest practicable wellbeing.

For Adequate Minimum Staffing:

• Revise the final rule for Requirements for Long-Term Care Facilities for Participation in the Medicare and Medicaid Programs to require a 24/7 registered nurse presence, and to establish stronger minimum nurse staffing levels or ratios or other stronger and more enforceable minimum requirements to provide care compliant with the law.
• Publish payroll-based staffing data, as required by the Affordable Care Act, without delay and audit the Payroll-Based Journal submission system.
• Consider automatic penalties to facilities that do not meet minimum quantitative and qualitative staffing requirements, such as imposing a temporary ban on the entrance of new residents until staffing numbers are in compliance with the law.

For Enforcement Efforts Specific to Antipsychotic Medications:

• Strengthen enforcement of existing requirements around unnecessary drugs, chemical restraints, and all other relevant resident rights.
• Amend deficiency categorization guidance for antipsychotic medication-related deficiencies. Inappropriate uses of antipsychotic medications should automatically be considered a Level 3 or 4 severity level unless there is a basis to lower it.
• Amend the Psychosocial Outcome Severity Guide and Investigative Protocol to take into account the particular risks of antipsychotic medications in people with dementia. The Investigative Protocol should provide concrete examples of the occasions when the inappropriate use of antipsychotic drugs would not amount to a Level 3 or 4 severity level.
• Create a discrete f-tag, the identifier for each health or safety issue within the federal regulations for which facilities may be cited for noncompliance, for inappropriate uses of antipsychotic medications. Currently, the deficiency citations for chemical restraints, unnecessary drugs, right to refuse treatment, and other relevant citations do not distinguish between any types of treatment or drugs.
• Consider creating a new survey protocol for any facility with a high antipsychotic medication rate that takes into account potential problems of lack of medical necessity and lack of free and informed choice in accepting the medication.

For General Enforcement to Protect Residents’ Rights and Wellbeing:

• Ensure greater compliance with reporting abuse and neglect allegations. Per US Department of Health and Human Services Office of Inspector General recommendations, improve mechanisms to reduce underreporting of abuse and neglect.
• Retract the July 7, 2017, sub-regulatory guidance to state survey agency directors revising the Civil Money Penalty Tool, which reduces potential dollar amounts of penalties assessed for many instances of substantial noncompliance, and the November 24, 2017, 18-month moratorium on enforcement of critical regulatory requirements.
• Collect, analyze, make publicly available, and conduct enforcement based on ownership-level data to the greatest degree of its authority. Disseminate ownership-level data for oversight and enforcement purposes among federal and state governmental agencies.

To the US Department of Justice

For Enforcement Efforts Specific to Antipsychotic Medications, and for General Enforcement to Protect Residents’ Rights and Wellbeing:

• Increase investigation and enforcement of nursing facilities, nursing facility chains, pharmaceutical companies, and individual pharmacists and providers under the Americans with Disabilities Act; Civil Rights of Institutionalized Persons Act; False Claims Act; and Food, Drug, and Cosmetic Act, among other legal bases of authority.
• Increase attention to inappropriate and nonconsensual uses of antipsychotic drugs within the Elder Justice Initiative efforts to combat the delivery of grossly substandard care.
• Expand efforts of the Elder Justice Task Forces beyond the first 10 regions to improve cooperation among more states’ US attorneys’ offices, state Medicaid fraud control units, state and local prosecutors’ offices, the US Department of Health and Human Services, state adult protective services agencies, state long-term care ombudsman programs, and law enforcement to protect the rights of all individuals in nursing facilities.

To State Governments

To State Legislatures

For Free and Informed Consent:

• Pass legislation to require written, free, and informed consent prior to the administration of antipsychotic medications to individuals in state-licensed nursing facilities, ensuring that the violation of this right is actionable under state law by providing a private right of action and that individuals in need of support for decision-making are afforded it.
• Expand supported decision-making measures and amend relevant statutes to require that supported decision-making processes and supports be available and used as appropriate for people who need support to exercise their right to free and informed consent.
• Take steps to minimize and ultimately reduce to zero the number of individuals in nursing facilities who are deprived of their legal capacity, formally or informally, requiring outreach where appropriate to those who know the individual and can assist, formally or informally, with decision-making.
• Pass legislation to ensure that an individual’s treating physician is not the same person authorized to make a capacity determination and determine subsequent treatment.

For Adequate Minimum Staffing:

• Pass legislation establishing stronger minimum nurse staffing levels and qualifications. Alternatively, pursue other measures to ensure staffing is adequate to provide all residents with necessary care to achieve their highest practicable wellbeing.

For Enforcement Specific to Antipsychotic Medications:

• Eliminate statutory provisions that curtail enforcement for lower level citations.
• Pass legislation to require nursing facilities to adopt, implement, and enforce a policy requiring any employee providing direct care to an individual with Alzheimer’s disease or other forms of dementia to complete a training on providing care to meet their needs.

For General Enforcement to Protect Residents’ Rights and Wellbeing:

• Pass legislation to require more significant state civil money penalties and fines instead of adhering to the federal minimum ranges, with a focus on abuse and neglect.

To State Attorneys General Offices, State Departments on Aging, Disability, Elder Affairs, and Public Health, and Other State Agencies

For Free and Informed Consent:

• Provide resources to assist nursing facilities to connect residents with supported decision-making resources, and require nursing facilities to post this information inside facilities, as it does with long-term care ombudsman services posters.
• Take measures to maximize the use of advanced directives, living wills, and, as appropriate, proxies or surrogates.
• Conduct public service message campaigns to ensure that individuals know that they have the right to informed consent, including with regard to the administration of antipsychotic drugs and other nonemergency medical interventions.

For Enforcement Specific to Antipsychotic Medications

• Keep track of facilities and chains using antipsychotic drugs at higher than average rates or struggling to reduce their rate of use to provide additional oversight, or take other appropriate action to protect the rights of residents at heightened risk of nonconsensual and inappropriate uses of antipsychotic drugs.

For General Enforcement to Protect Residents’ Rights and Wellbeing:

• Require Medicaid fraud control units to investigate and prosecute abuse, including the use of chemical restraints, and neglect in nursing facilities.

To State Long-Term Care Ombudsman Programs

For Enforcement Specific to Antipsychotic Medications:

• Ensure that in facilities with significant percentages of residents receiving antipsychotic drugs without an exclusionary diagnosis and in facilities where individuals appear at risk of being given antipsychotic drugs without their consent or as chemical restraints, volunteer and staff ombudsmen provide general information to all residents, families, and staff regarding the right to be fully informed about treatment; the right to refuse treatment; and the right to informed consent in states that provide for it. Consider disseminating publicity information produced by CMS, advocacy organizations, AHCA, and others on antipsychotic drugs in people with dementia.

For General Enforcement to Protect Residents’ Rights and Wellbeing:

• Fulfill obligation under Older Americans Act to “analyze, comment on, and monitor the development and implementation” of all local, state, and federal law, regulation, policy and actions pertaining to residents’ rights; recommend appropriate changes; facilitate public comment; and “provide leadership to statewide systems advocacy efforts … on behalf of long-term care facility residents.”
• Ensure regional, staff, and volunteer ombudsmen understand that their mandate and responsibility under the Older Americans Act is not to mediate disputes between residents and nursing facilities but to “represent the interests of residents before governmental agencies” and ensure residents’ access to “administrative, legal, and other remedies to protect the health, safety, welfare, and rights of residents.”

BACK TO TOP

Acknowledgments

This report was researched and written by Hannah Flamm, New York University School of Law Fellow at Human Rights Watch’s Health and Human Rights Division. Megan McLemore, senior researcher in the Health and Human Rights Division; Bethany Brown, researcher in the Health and Human Rights Division; and Diederik Lohman, director of the Health and Human Rights Division provided additional research support. Brian Root, quantitative analyst in the Program Office, provided quantitative data analysis. Josh Lyons, satellite imagery analyst in the Program Division, provided geospatial analysis.

The report was edited by Diederik Lohman; Chris Albin-Lackey, senior legal advisor; and Babatunde Olugboji, deputy program director. The report was reviewed by Emina Cerimovic, researcher in the Disability Rights Division; Arvind Ganesan, director of the Business and Human Rights Division; and Allison Parker, co-director of the United States Program.

Matthew Parsons, associate in the Health and Human Rights Division, provided production assistance and support. Layout and production were done by Rebecca Rom-Frank, photo and publications coordinator; Jose Martinez, senior coordinator; and Fitzroy Hepkins, production manager. Erinma Kalu, Grace Neumann, Delphine Spitaels, Courtney Tran, Romsin Zaya, and Jing Zhao, interns and fellows in the Health and Human Rights Division, provided research support.

This report would not have been possible without the generosity, courage, honesty, and incisiveness of so many people living in nursing facilities, their families and advocates, as well as facility staff. We are grateful to the many advocates, medical professionals, and scholars who greatly enriched the quality and depth of our research, analysis, and reporting. Thank you to Sarah Burger, senior adviser to the Hartford Institute for Geriatric Nursing; Tony Chicotel, senior attorney at California Advocates for Nursing Home Reform; Martha Deaver, president of Arkansas Advocates for Nursing Home Residents; Patty Ducayet, National Association of State Long-Term Care Ombudsman Programs and State Long-Term Care Ombudsman of Texas; Toby Edelman, senior attorney at the Center for Medicare Advocacy; Dr. Jonathan Evans, former president of the American Medical Directors Association; Amanda Fredriksen, associate state director of advocacy for the AARP Texas State Office; Charlene Harrington, professor emeritus at the University of California San Francisco; Jeff Kelly Lowenstein, investigative journalist, author, and professor at Columbia University’s Graduate School of Journalism; Karen Love, executive director of the Dementia Action Alliance; Mitzi McFatrich, executive director of Kansas Advocates for Better Care; Wendy Meltzer, executive director of Illinois Citizens for Better Care; Richard Mollot, executive director of the Long-Term Care Community Coalition; Sam Roe and David Jackson, investigative reporters of the Chicago Tribune; Penny Shaw, member of the board of Massachusetts Advocates for Nursing Home Reform; Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care; Margie Sullivan, executive director of Texas Advocates for Senior Care; Janet Wells, consultant for California Advocates for Nursing Home Reform; and many others including those not identified by name to protect confidentiality.

https://chicago.suntimes.com/news/convicted-judge-still-a-judge-one-week-later-but-effort-to-remove-her-afoot/

One picture says it all.

Our new administration.

As many of you are aware, in 2016 sometime, the FBI took down the email that received civil rights complaints.

However, I just received the URL of a Facebook Page for the FBI DOJ where you can make posts and provide links to crimes committed against you.

Check this out and report your court corruption here:

https://www.seattletimes.com/nation-world/bill-to-update-guardianship-laws-cleared-senate-panel/

FRANKFORT, Ky. (AP) — A bill aimed at easing the state’s growing burden as guardian of vulnerable elderly and disabled people moved a step closer to clearing the legislature Wednesday.

The measure, which seeks to ease the strain by ensuring that more relatives take on guardianship roles, won unanimous approval from the Senate Health and Welfare Committee, without any changes.

The bill goes next to the full Senate. The House approved it by a vote of 79-3 early this month.

It comes as the state struggles with growing caseloads of people who become wards of the state. The state is currently guardian for 4,448 wards, said Tim Feeley, deputy secretary of the Cabinet for Health and Family Services.

“We have a system where our guardianship program continues to grow and grow and grow, and we can’t keep up with it,” he told the committee.

State guardians are juggling caseloads of 65 to 70 wards apiece, about three times more than that recommended by national guidelines, Feeley said.

Under the current system, when families are fighting over who will serve as a relative’s guardian, judges sometimes resolve the matter by appointing the state as guardian, the bill’s supporters said.

Under the bill, judges would have to determine that “exceptional circumstances” exist to appoint the state as guardian.

The bill “makes the family have to work it out,” said main sponsor Republican Rep. Daniel Elliott of Danville.

Unlike some neighboring states, Kentucky has no cap on the number of wards in its public guardianship program, and Feeley spoke against imposing such limits.

“I don’t think a cap is the right idea, because there’s always one more case that we need,” he said.

Much of the discussion in committee focused on another provision, which would allow jury trials to be waived in guardianship matters when all participants consent to a judge deciding the case.

FIRST AMENDMENT

Law allowing actors to censor publication of their ages violates First Amendment, judge rules

BY DEBRA CASSENS WEISS

POSTED FEBRUARY 21, 2018, 11:55 AM CST

IMDb logo/Twitter.

A federal judge in San Francisco has overturned a California law that gives actors the power to remove information about their age from online profiles on the IMDb website.

U.S. District Judge Vince Chhabria ruled that the law is a direct restriction on truthful speech that violates the First Amendment, report the Recorder, BuzzFeed News, Courthouse News Service, the Hollywood Reporter and the Associated Press.

The law was intended to combat age discrimination in the movie industry, according to California and the Screen Actors Guild-American Federation of Television and Radio Artists. But that argument, if successful, “would enable states to forbid publication of virtually any fact,” Chhabria said in Tuesday’s opinion.

“That a third party could misuse truthful information is almost never sufficient to justify suppression of that information,” Chhabria wrote.

The actual problem the state is trying to solve, Chhabria said, is sex discrimination. The problem, he said, is “the movie industry’s insistence on objectifying women, overvaluing their looks while devaluing everything else,” he wrote.

The law requires online entertainment employment service providers, such as IMDb, to remove age-related information from an online profile at the request of a paid subscriber, even if the information was supplied by another source.

From Joanne:

And Ken, I want you to note that the ARDC continues to toss out valid complaints against attorneys, while viciously prosecuting attorneys like you, myself and Amu who publish entirely truthful information about embarassing cases, judges and attorneys.

We have entered a new era of truth and justice and the ARDC is operating in the old energy of lies, deception and injustice, which is no longer successful and will not survive.

The new generation is coming in and demanding truth and justice.  Within 10 years, all of these young people who are disgusted with the perfidy of the older generation will be admitted to the bar, and if the ARDC wants to see what is coming in and they think you, I and Mr. Amu are nothing but oodles of trouble, just wait.

Many young people I talk to (age 15 to 29) are thoroughly disgusted with the legal system, the medical system, the political system, etc. and they won’t stand for this nonsense.  If you will recall, it became quickly known throughout the world that kids who walked early, talked early, began reading without a teacher or school, seem to “know” math, science, physics and were called “indigos” and “crystals” and gave their bad teachers sh** all the time, are now becoming adults and they continue to not like what they see in this world and they were put here to change it.  The old bad energy cannot hide from them.

They want all the older generation covering up the lies, perfidy and deception to be hogtied to a rail, tarred and feathered and run out of town.

It’s coming.  I talk to a lot of young people in their 20’s.  They are far more militant about truth, justice, kindness, compassion for the elderly and young than you or I.

The old bad energy is going to die off soon and all I can say is “good riddance”.

Joanne

On January 8, 2018, Daniel Houlihan faxed a perfctly valid complaint regarding corruption in the Cook County Court System to the JIB and all the authorities from presiding judge Timothy Evans, the states attorneys, the FBI and the White House.  It is shown below:

 

Daniel T HoulihanDaniel T Houlihanphone: 847 990 0947410 Western #409DesPlaines, IL 60018
email dannyhoops60@yahoo.com
Illinois Judicial Inquiry Board100 W. Randolph St, Suite 14-500Chicago, IL 60601phone: 312 824 5554Fax no. 312 814 5519
January 4, 2018
VIA HAND DELIVERY
ATTN: COMPLAINT INTAKE

 

RE: Judge Lynn O’Malley, Cook County Case No. 2012 P 2221 Estate of Patrick Houlihan, Deceased
Dear Madam/Sir;
I would like to file a complaint against the above judge.  Not only did she break a land trust and give property directly to my sister without putting it into the estate as she should have, but she engaged in docket tampering, changed court dates on me, denied my right to my hearing on removing my sister as Administrator of my father’s estate (Patrick Houlihan), she denied all my objections to the Administrator’s Final Accounting, and then closed the Estate. On October 13, 2016, opposing counsel attorney Blocher set a date of December 13, 2016 for hearing on Son Daniel Houlihan’s (“Son Daniel”), pleadings, namely, his Objections to the Third Accounting and to the closing of the Estate.  The court, however, docketed the date for Dec. 14, 2016 at 2 pm.  I was unaware of the discrepancy in docketing of dates, until the day before the hearing when a witness called me and said that he was not going to come because the computer docket showed a date different than the date in the Order of Dec. 13, 2016. (Exhibit B, hereto). On Dec. 13, 2016, I showed up in court prior to noon and talked to the clerk about the discrepancy. The clerk told me she had been made aware of the discrepancy, and that she had corrected the error “4 hours earlier.”  It is not known at this time whether the clerk changed the docket of her own accord, or whether she was told to do so by Judge O’Malley.I then told the clerk that I would appear on Dec. 14, 2016 at 2 pm as the computer properly showed the date for the hearing and ask for a continuance.  I filed and served on that date Motion for a Continuance to be heard on Dec. 14, 2016, because at the time of writing of that pleading, the computer showed a court date set for Dec. 14, 2016 and not Dec. 13, 2016.  At the same time, I explained to the clerk that he had been told many times before by the judge, that if a matter was not on the computer docket, for whatever reason, it could not be heard and the docket can never be changed.  That would be improper. On Dec. 13, 2016, after the docket had been changed that day, Opposing counsel Blocher entered the attached Exhibit A, which Judge O’Malley vacated because the date of Dec. 13, 2016 never appeared on the computer docket until Dec. 13, 2016 in the morning according to the clerk. According, the Order is improper and must be vacated, and the Hearing on the Objections to the Third Accounting must be rescheduled and witnesses subpoenaed for a new trial date. In addition, there were some questionable bank records regarding numerous checks which Judge O’Malley would not give me time to investigatea) David Blocher – no fee petition, no notice, Judge O’Malley just finds fees are reasonable in summary order.  Attorneys fees. $19,776.70 check no. 5025 dated 7/12/16b) Attorney Tom Paris, attorneys fees, no fee petition. No notice.  Objections filed and ignored.  $3,000.00, check #5142 on 6/22/15c) Attorney Tom Paris, attorneys fees, no court order, no fee petition. $5,000.00 check #5049 dated 4/4/2014d) son Brian Soraghan,$3,000.00  check 5026 dated 8/9/16, no court order for this disbursement (Brain Soraghan is not an heir, he is a grandchild and all grandchildren were specifically disinherited in Patrick Houlihan’s will.  Brian Soraghan is the Executrix’s son)e) checks to Kathleen Bucholz (wife): check no. 5121 for $4,624.00Check no. 212 for $4,624.00Check no. 213 for $4,624.00–from a Trust Account held only in the name of Patrick HoulihanThese checks were never approved by the probate court, were never put on the accounting and the disbursements were never explained.  They were objected to but Judge O’Malley ignored the objections.F) payment to Executrix of $15,000.  No petition, no notice, objection filed there is not detailed statement of Exeuctrix’s work but Judge O’Malley approves these in a summary order. Prior to the Estate being closed I asked for 60 days to reset the hearing date and denied my request to hear my petition to remove the Administrator.  I asked for a Petition for Letters of Office so that I could properly prepare accountings and distribute the assets of the Estate.In addition, I objected to the payment of any Attorneys Fees to Opposing Counsel Blocher  inasmuch as there was a Petition filed for Waste and Mismanagement by the Executrix, and if Breach of Fiduciary Duty is found, then Deborah Soraghan should have paid those fees.  In addition, Deborah Soraghan asked for $15,000 in Executor Fees, but filed no detailed time records of the dates, times and amounts of hours spent has been filed by her.  The Judge approved this payment regardless of my protestations..In support of my complaint against this Judge:
Exhibit A – Order of Oct. 13, 2016 setting hearing date for Dec. 13, 2016Exhibit B – Until Dec. 13, 2016 when docket was changed by Judge/Clerk, the court’s docket showed a hearing date of Dec. 14, 2016 which was an errorExhibit C – Computer printout of Court Docket showing hearing date of Dec. 13, 2016.It should also be noted for the record, that none of this was my fault.  I had prepared witnesses and exhibits for trial, I had been told by the judge a case could not be called unless it was on the docket, and yet when I appeared at noon on Dec. 13, 2016, no one apologized for the error, all that happened was the docket was changed, and all my hard work came for naught.Exhibit D – Objections to Final AccountingExhibit E – Motion for a Continuance
I believe that this Judge is corrupt and should have been removed from my case, and all her rulings should be overturned. Very Truly Yours,
Daniel T. Houlihancc: 1 ) FBI via email2) Lisa Madigan Illinois Atty General fax 312 814 38063) US Attorney General Jeff Sessions, via USPS mail4) Kim Foxx, States Atty fax 312 603 47085)  Illinois Office of Inspector General Cook County Fax 312 603 97446)  Chicago Police, 1st Dist. Commander Robert Klich Fax 312 745 36497)  Timothy Evans, Presiding Judge Cook County Court System fax 312 603 53668) Office of Inspector General State of Illinois fax 312 814-8444

A set of Exhibits were attached detailing all aspects of the crimes committed (stealing of estate assets, docket tampering, spoliation of evidence, denial of due process)

https://drive.google.com/open?id=1czURaIv5wUjTxJpUkB8C8y56Tzh9Hti6

Now below are the response letters he received wherein all of these authorities admitted they will do nothing about the crimes which have occurred against him:

https://drive.google.com/open?id=1OQagQdQDZvN0aK1_aKful1SnqY2vPh7f

The real question is why are these elected people being paid for doing nothing where some $300,000 is missing from an estate.

Same for the case of Sykes ($3 million missing and unaccounted for and never investigated and Mary Sykes eventually murdered in probate guardianship), Jay Brouckmeersch (murdered in probate and never investigated after complaints filed), Irwanna Lahoody ($600k missing from a joint account and never investigated).

The pattern is absolutely ridiculous.

Who in their right mind would pay these people a dime for looking the other way when crimes are being committed, and that means MAJOR crimes, not petty thefts.

Washington State May Make It Easier to Sterilize People With Disabilities

In 1936, Ann Cooper Hewitt filed a lawsuit against her mother — and with good reason. At the age of 20, her mother Ann had sterilized her against her will. Having succeeded in classifying her as having an intellectual disability, Ann’s mother was legally allowed to authorize the operation over Ann’s objections. Her mother’s lawyer responded by claiming that Ann’s sterilization had been “for society’s sake” due to the girl’s “erotic tendencies.”

Even in the age of the eugenics movement, where tens of thousands were involuntarily sterilized by state governments who sought to breed “better” human beings by removing disability from the gene pool, the Hewitt case attracted nationwide attention. Could a diagnosis of disability allow parents to control their child’s reproductive future against his or her will?

Ann believed it could not, summarizing her fate matter-of-factly. “I had no dolls when I was little, and I’ll have no children when I’m old,” she said. “That’s all there is to it.”

We’ve come a long way since the age of the eugenics movement, particularly when it comes to matters of reproductive choice and bodily autonomy. And yet, state laws still allow people with disabilities to be sterilized without their consent. Today the state of Washington is considering a proposal that the ACLU believes could expand the use of sterilization for individuals under guardianship.  Guardianship is a surprisingly common legal arrangement where a third-party is authorized to make virtually all decisions for a person with a disability.

Currently, state law fortunately prohibits guardians from authorizing sterilization without court approval — but the state judicial system is currently considering a proposal to create a form to more clearly articulate how guardians can request permission for this procedure. While the proposal is designed to clarify existing law, advocates with disabilities and the ACLU believe that creating this form will streamline the process and increase the number of guardians requesting the sterilization of those under their power.

Ivanova Smith, a new mother with a developmental disability, has written beautifully in the ACLU of Washington’s blog about how people with disabilities can become loving, responsible parents, if they so choose. People with disabilities should not be denied this choice. Given the unfortunate history of involuntary sterilization of people with disabilities across the country, states must take extra caution to avoid imposing sterilization against those who, for whatever reason, do not freely choose it. It is vital that we leave behind the days in which people with disabilities lacked reproductive choice.

Whether it comes from parents, the court system, or anyone else, sterilization should never be imposed on a person without their consent.

For those who do choose it for themselves, sterilization can be an appropriate medical procedure. But the presence of guardianship seriously complicates the issue. Guardianship entails loss of legal adulthood, meaning that an individual lacks capacity in the eyes of the law to make their own decisions or express their own will and preference on how they should be treated. Measures to make it easier for guardians to permanently sterilize people with disabilities should be viewed as suspect. The Hewitt case is only one example in a long line of disagreements over who gets to make choices about medical procedures applied to people with intellectual disabilities.

Such decisions are often treated as family choices rather than questions of individual autonomy, which should require an expression of preference on the part of the person receiving the procedure. Some guardians cite fears of sexual assault in choosing to sterilize people with disabilities — yet sterilization in no way prevents the sexual assault of people with developmental disabilities, an all too common occurrence. Instead, it can merely hide evidence of it. As such, there are credible concerns that guardians may seek sterilization as a means of lessening the complications emerging from abuse, rather than taking the measures necessary to stop it. The state of Washington should decline to streamline the process for guardian-imposed sterilization. The state can ensure that individuals who require decision-making support have a clear process by which they — rather than their guardian — can request such a procedure (if it is truly their choice to do so). Guardianship, with its total loss of decision-making authority by the individual, is not the appropriate mechanism for this. Instead, the state should consider joining Texas, Delaware, and jurisdictions around the world in implementing supported decision-making, a new legal arrangement that allows people with disabilities to choose trusted advisors to help them with their choices without surrendering final decision-making authority.

Control over one’s own body is one of the most fundamental civil liberties. Everyone deserves the right to have the final say about what happens to their own body. People with disabilities are no different.

Full Article & Source:
Washington State May Make It Easier to Sterilize People With Disabilities

http://4closurefraud.org/2018/02/09/fl-3rd-dca-reverses-ruling-that-found-hsbc-forged-mortgage-documents/

MIAMI COURT WIPES RULING THAT FOUND HSBC FORGED MORTGAGE DOCUMENTS

A state judicial panel remanded the case to the trial court to enter a final judgment of foreclosure.

A Florida appellate court vindicated HSBC Bank USA N.A., reversing a Miami-Dade Circuit judge who’d found the lender forged mortgage documents to prosecute a real estate foreclosure.

Citing seven points in its analysis of the trial court’s findings, the Third District Court of Appeal Wednesday ruled in favor of New York-based HSBC, and remanded the case to Miami-Dade Circuit Judge Beatrice Butchko to enter a final judgment of foreclosure.

“This is a very disappointing decision, which ignores most of Judge Butchko’s groundbreaking ruling,” said Bruce Jacobs, the Miami foreclosure defense attorney who won at trial.

Butchko in April 2016 dismissed HSBC’s foreclosure suit against homeowners Joseph and Margaret Buset. In response to an accusation of forgery against Ocwen Loan Servicing LLC, she sided with borrowers who accused the loan servicing company of faking a mortgage assignment for HSBC.

“Judge Butchko found Ocwen and HSBC relied on false testimony, false evidence, violated the court’s discovery order and then lied about their violation of that order,” the defense attorney from Jacobs Keeley said. “Judge Butchko found the documents were untrustworthy. She found Ocwen’s loan boarding process was a legal fiction.”

Jacobs of Jacobs Keeley in Miami argued at trial that to prove the plaintiff had legal standing to sue, the financial services firm forged documents in 2012 to show the transfer of the debt about seven years earlier from one lender to another.

“They’re creating fake evidence of transactions that didn’t really happen,” Jacobs told the Daily Business Review after Butchko found the mortgage assignments “never legally occurred.”

The judge found the lender pursued the case with “unclean hands” and lacked competent evidence to support its lawsuit. She also granted the homeowners’ request to force the financial institutions to show why she shouldn’t punish them for committing a fraud on the court.

But the defense victory fizzled on appeal.

Rest here…
(behind paywall)

~

4closureFraud.org

For those of you involved in corrupt guardianship cases (Sykes, Lahoody, Rector, etc.), the courtroom player will often include the police as part of the scheme to steal in probate court and murder the elderly victim in the process.

Here is one officer who got caught.

https://www.ktnv.com/news/las-vegas-police-officer-april-parks-others-indicted-in-guardianship-case

Decorated police officer scams the elderly:

A Las Vegas Metropolitan Police Department lieutenant was jailed Wednesday, Valentine’s Day, caught up in a sweeping indictment involving elder exploitation. Contact 13 Darcy Spears continues her years-long expose on guardianship abuse with this heart- breaking case.

He was supposed to serve and protect but instead he’s accused of felony crimes for using Clark County’s guardianship system to steal from the estate of a vulnerable couple. And this police officer is directly connected to others first exposed in our ongoing investigation of guardianship corruption. 

Lieutenant James Thomas Melton is a decorated police veteran. As a sergeant, Melton received a group Medal of Valor and Purple Heart in 2009 for being wounded during a domestic violence call where a baby was pulled away from gunfire.

He was also a homicide detective and Metro’s SWAT commander, making about $300,000 a year including benefits.

But Valentine’s Day, a fall from grace as Melton was indicted by a grand jury and charged with stealing the life savings, over $700,000 from an 87-year-old widow suffering from dementia.

Court records claim Melton deceived the court after the victim died, representing that she was still alive so he could be named beneficiary on various accounts.

And Melton didn’t act alone. The indictment shows he hired private guardian April Parks. Parks is already in jail facing over 200 felony counts after our investigation revealed she was double-billing and exploiting clients. 

Parks, her attorney Noel Palmer Simpson and former office manager Mark Simmons all face additional charges of exploitation for working with Melton.

According to the indictment, Melton is also accused of stealing the victim’s Ford Explorer and taking $2,187.50  from her Disabled American Veterans Charitable Service Trust.

http://360daily.net/did-family-court-judge-commit-perjury-by-failing-to-disclose-2-5-million-of-loans-in-default/

with the internet now, there are no more secrets for public officials, and investigative reports find a gold mine of informatio on corruption:

You have a wonderful life. You’re running a business, have money in the bank and get to visit with all your friends and family whenever you like. Then one day you wake up to find someone shoving a pill down your throat in some lowdown nursing home situated in a dangerous part of the city. Without your permission, they’re liquidating your business and making all of your money disappear. You do whatever you can to try to get out of this nightmare, but discover the people who did this to you are simply too powerful. Think it can’t happen to you? Think again.

This is the true story of a newly licensed nursing facility administrator (LNFA) and the people she meets. The stories they tell her are both hard to believe and impossible to ignore. She begins investigating and the more layers she peels away, the worse it gets. Eventually, this leads to catastrophic consequences for three special people under her care. Can she repair the damage and stop the madness before it’s too late? Or are the forces against her too powerful?
A Breach of Trust exposes the weakest link in the freedoms we all hold dear. Cross the wrong line, say the wrong thing, and at any moment you too could be stripped naked and taken captive. It is for these three special friends and all the future victims that Susan Hodges offers this advice: whatever you do, don’t cross these people because soon, you might discover your life belongs to them now!

I have not read this book, but it has been rated 5 stars on 18 reviews.

Here is a dramatic trailer for the book.  The actress does a great job.

EB sent me this article on how Michigan is changing laws so that Realtors cannot open Decedents Estates quick and sell homes on the cheap causing heirs to take huge losses on the sale of homes owned by their deceased loved ones.

But note in the news stories, the Michigan officials admit they received a stream of stories over just how many years?

And how does giving notice and changing a waiting period to sell homes from 42 days to 63 days really help anyone when you know probate is a fixed game and a fixed sale and profits are only accessible to cronies of the wealthy and powerful.

I vote this a red herring, but watch for yourself.

7 Action News Investigation prompts probate law change, protects heirs

https://www.wxyz.com/news/local-news/investigations/7-action-news-investigation-prompts-probate-law-change-protects-heirs

A 7 Action News investigation has now changed the law in Michigan.  On Tuesday, Governor Rick Snyder signed the legislation that will increase protections in the law for heirs after a loved one dies.

Since November 2016, 7 Investigator Heather Catallo has been exposing several loopholes in the law that allowed real estate brokers and Attorney General-appointed lawyers called Public Administrators to open probate estates after a loved one dies. Catallo’s relentless reporting showed that Macomb County real estate broker Ralph Roberts and his company, Probate Asset Recovery, used that power from the courts to sell the homes and take thousands of dollars from the probate estates.

After the 7 Investigators exposed this, Attorney General Bill Schuette shut the practice down, and Schuette supported the changes to the law.

“Actions that came to light last year made it clear that now is the time to make changes to the public administration system,” said Schuette in a statement Tuesday. “What has happened in the system is unacceptable and these changes to an almost 40-year-old law will help ensure this never happens again. By creating a clear, current and direct path for public administrators to follow in the probate process we can better protect Michigan citizens and weed out any bad actors.”

Oakland County Sheriff’s detectives are also now conducting a criminal investigation into these practices.

In May 2017, Oakland County Treasurer Andy Meisner and Oakland County Clerk Lisa Brown brought together a bi-partisan group of lawmakers to close the loopholes.  Two bills sponsored by Rep. Jim Ellison (D-Royal Oak) and Rep. Jim Runestad (R-Highland Twp.) were signed into law Tuesday.

“We had the constant drum beat of stories that just got worse and worse that you chronicled, and I think that is major factor in why the legislature felt like ‘hey you know what, we need to deal with this one and we need to deal with it quickly,’” Meisner told Catallo.

Meisner is pleased the bills passed, especially since several probate judges and lawyers opposed the changes to the law.

“We reached out to the probate bench and to the bar, and solicited their input about it,” said Meisner. “Despite our reaching out, they didn’t connect with us, they didn’t provide any feedback – and then they submitted a letter before the committee hearing opposing the legislation… It reflects poorly on the probate bar and the judges that they came out against the legislation, and I hope in the future when they’re confronted with this sort of obvious wrong doing that they take the stand of the people.”

Here are more details from Public Act 13 of 2018:

-Heirs will now have 63 days instead of 42 days to open a probate estate, before a Public Administrator can open the estate;

-A formal hearing is now required for a Public Administrator to be appointed;

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http://www.chicagotribune.com/news/local/breaking/ct-met-judge-mortgage-fraud-trial-20180205-story.html

What attorneys can bill for (per billing rules at most large law firms):What attorneys can bill for (per billing rules at most large law firms):
Preparing pleadings 1 hour or $200 per page (attorneys should keep drafts day by day), depending on complexity.  Set a reasonable rate in advance with the attorney.
Put your attorney on a budget of expenditures per month or per task.
Legal Research:  Billing ok for:  Esoteric legal research .5 hrs to read a case, as long as cases are not unusually long .Attorneys should not bill for easy stuff they should already know like how to do an appeal brief, how to prepare a deed, how to prepare court forms, etc. Attorneys should save their list of cases they read if the client asks.
Reading or reviewing an email or pleading. Attorneys should only bill for actually writing a letter, motion or appeal brief and then it should only be 1/2 hour per page for routine motions (extension of time, motions to withdraw, etc.).  Disputing a will or trust will be more or for more complex pleadings.
Attorneys should not bill to write up an email and then call you to tell you the same stuff.  However, if you talk to an attorney, the attorney CAN bill you for confirming what was said during the conversation in a letter or email, and should make it clear in writing any important legal advice as to what to do or not to do.
No charges for secretarial time, organizing a file, making labels for a file, making a pleadings book, etc.  That should be built into overhead.  Overhead is not billable.
Travel time should not be charged, but waiting in court can be charged.  An attorney should try to have 2 or 3 motions calls per am or pm and then charge the client a proportionate share.  Say the attorney has 3 calls and starts at 9 am and leaves at 1 pm.  That’s 4 hours of work.  If s/he had 3 court calls, then each client can be billed 1.25.
Have an agreement on what, if anything, can be billed for travel time.  Argue that an attorney should not charge for travel time from a suburban building to a downtown court.
Duplicate bills.  Two bills for reviewing the same email, same correspondence by different attorneys or paralegals.
Reviewing correspondence that is not necessary to your case.  Reviewing case law not essential to your case or which is common to their field of law they should know updates on
Filing unnecessary pleadings to the case.  (Like updating a record on appeal over and over when documents are not clearly needed. These can be added as an exhibit)
If in doubt get a second opinion on your bills.
Late filed appearances should be a no no.  If your attorney takes a chunk of money (typically $3,000 to $10,000) to file an appearance, they should file their appearance right way.  If not, ask for the money back and hire another attorney.  Once you pay an attorney you should not have to dread opening up your mail to find another nasty, scathing letter from opposing counsel containing another bunch of ridiculous threats (such as taking your first born) that you don’t understand.  That’s your attorney’s job to take the stress off of you.
A pox on attorneys who take $5,000 and then don’t file an appearance for weeks on end and then at the last minute before a hearing.
A double pox on attorneys who take $5,000, don’t file an appearance for weeks, and then withdraw the day before a hearing and then you don’t even have money to hire another attorney for the hearing while they take their sweet time to return your money, or they dispute returning it with silly excuses.
A triple pox on attorneys at the disciplinary boards who you file complaints with, which are wholly ignored because they cover up for lying, cheating, scheming, dishonest attorneys that take your money and do nothing.
Other online articles on attorney billing
http://www.mylawcoach.com/my_weblog/2008/03/what-attorneys.html
https://www.timesolv.com/cant-attorneys-bill/

http://www.abodia.com/t/law/files/Challenge-to-Jurisdiction.htm

Challenge to Jurisdiction

Federal Rules of Civil Procedure, Rule 60. Relief from Judgment or Order below

“Once jurisdiction is challenged, the court cannot proceed when it clearly appears that the court lacks jurisdiction, the court has no authority to reach merits, but, rather, should dismiss the action.” Melo v. US, 505 F2d 1026.

A judgment rendered by a court without personal jurisdiction over the defendant is void. It is a nullity. [A judgment shown to be void for lack of personal service on the defendant is a nullity.] Sramek v. Sramek, 17 Kan. App. 2d 573, 576-77, 840 P.2d 553 (1992), rev. denied 252 Kan. 1093 (1993).

“Court must prove on the record, all jurisdiction facts related to the jurisdiction asserted.” Latana v. Hopper, 102 F. 2d 188; Chicago v. New York, 37 F Supp. 150.

“The law provides that once State and Federal Jurisdiction has been challenged, it must be proven.” Main v. Thiboutot, 100 S. Ct. 2502 (1980).

“Jurisdiction can be challenged at any time.” and “Jurisdiction, once challenged, cannot be assumed and must be decided.” Basso v. Utah Power & Light Co., 495 F 2d 906, 910.

“Defense of lack of jurisdiction over the subject matter may be raised at any time, even on appeal.” Hill Top Developers v. Holiday Pines Service Corp., 478 So. 2d. 368 (Fla 2nd DCA 1985)

“Once challenged, jurisdiction cannot be assumed, it must be proved to exist.” Stuck v. Medical Examiners, 94 Ca 2d 751. 211 P2d 389.

“There is no discretion to ignore that lack of jurisdiction.” Joyce v. US, 474 F2d 215.

“The burden shifts to the court to prove jurisdiction.” Rosemond v. Lambert, 469 F2d 416.

“A universal principle as old as the law is that a proceedings of a court without jurisdiction are a nullity and its judgment therein without effect either on person or property.” Norwood v. Renfield, 34 C 329; Ex parte Giambonini, 49 P. 732.

“Jurisdiction is fundamental and a judgment rendered by a court that does not have jurisdiction to hear is void ab initio.” In Re Application of Wyatt, 300 P. 132; Re Cavitt, 118 P2d 846.

“Thus, where a judicial tribunal has no jurisdiction of the subject matter on which it assumes to act, its proceedings are absolutely void in the fullest sense of the term.” Dillon v. Dillon, 187 P 27.

“A court has no jurisdiction to determine its own jurisdiction, for a basic issue in any case before a tribunal is its power to act, and a court must have the authority to decide that question in the first instance.” Rescue Army v. Municipal Court of Los Angeles, 171 P2d 8; 331 US 549, 91 L. ed. 1666, 67 S.Ct. 1409.

“A departure by a court from those recognized and established requirements of law, however close apparent adherence to mere form in method of procedure, which has the effect ofdepriving one of a constitutional right, is an excess of jurisdiction.” Wuest v. Wuest, 127 P2d 934, 937.

“Where a court failed to observe safeguards, it amounts to denial of due process of law, court is deprived of juris.” Merritt v. Hunter, C.A. Kansas 170 F2d 739.

“The fact that the petitioner was released on a promise to appear before a magistrate for an arraignment, that fact is circumstance to be considered in determining whether in first instance there was a probable cause for the arrest.” Monroe v. Papa, DC, Ill. 1963, 221 F Supp 685.

Read US v. Lopez and Hagans v. Levine both void because of lack of jurisdiction. In Lopez the circuit court called it right, and in Hagans it had to go to the Supreme court before it was called right, in both cases, void.

Challenge jurisdiction and motion to dismiss, right off the bat. If you read the Supreme Court cases you will find that jurisdiction can be challenged at any time and in the case of Lopez it was a jury trial which was declared void for want of jurisdiction. If it [jurisdiction] doesn’t exist, it can not justify conviction or judgment. …without which power (jurisdiction) the state CANNOT be said to be “sovereign.” At best, to proceed would be in “excess” of jurisdiction which is as well fatal to the State’s/ USA ‘s cause. Broom v. Douglas, 75 Ala 268, 57 So 860 the same being jurisdictional facts FATAL to the government’s cause ( e.g. see In re FNB, 152 F 64).

– – – –

       Federal Rules of Civil Procedure, Rule 60. Relief from Judgment or Order

>(b) Mistakes; Inadvertence; Excusable Neglect; Newly Discovered Evidence; Fraud, etc. On motion and upon such terms as are just, the court may relieve a party or a party’s legal representative from a final judgment, order, or proceeding for the following reasons: (1) mistake, inadvertence, surprise, or excusable neglect; (2) newly discovered evidence which by due diligence could not have been discovered in time to move for a new trial under Rule 59(b); (3) fraud (whether heretofore denominated intrinsic or extrinsic), misrepresentation, or other misconduct of an adverse party; (4) the judgment is void; (5) the judgment has been satisfied, released, or discharged, or a prior judgment upon which it is based has been reversed or otherwise vacated, or it is no longer equitable that the judgment should have prospective application; or (6) any other reason justifying relief from the operation of the judgment. The motion shall be made within a reasonable time, and for reasons (1), (2), and (3) not more than one year after the judgment, order, or proceeding was entered or taken. A motion under this subdivision (b) does not affect the finality of a judgment or suspend its operation. This rule does not limit the power of a court to entertain an independent action to relieve a party from a judgment, order, or proceeding, or to grant relief to a defendant not actually personally notified as provided in Title 28, U.S.C., Sec. 1655, or to set aside a judgment for fraud upon the court.

Writs of coram nobis, coram vobis, audita querela, and bills of review and bills in the nature of a bill or review, are abolished, and the procedure for obtaining any relief from a judgment shall be by motion as prescribed in these rules or by an independent action.

– – – – –

This rule does not limit the power of a court to entertain an independent action to relieve a party from a judgment, order, or proceeding, or to grant relief to a defendant not actually personally notified as provided in Title 28, U.S.C., § 1655, or to set aside a judgment for fraud upon the court. Writs of coram nobis, coram vobis, audita querela, and bills of review and bills in the nature of a bill of review, are abolished, and the procedure for obtaining any relief from a judgment shall be by motion as prescribed in these rules or by an independent action. Where necessary parties in government have actual notice of suit, suffer no prejudice from technical defect in service, and there is justifiable excuse for failure to serve properly, courts should not construe rule 4 of these rules governing service so rigidly, or construe this rule governing relief from orders so narrowly, as to prevent relief from dismissal, especially where dismissal signals demise of all or some of plaintiff’s claims. Jordan v. U.S., C.A.D.C. 1982, 694 F.2d 833, 224 U.S.App.D.C. 267.   A liberal construction of this rule is particularly appropriate where equitable considerations are involved. Johnson Waste Materials v. Marshall, C.A.5 (Tex) 1980, 611 F.2d 593. This rule authorizing a court on motion to relieve a party or a legal representative from a final judgment or order for any reason justifying relief is to be liberally applied in a proper case, that is, in a case involving extraordinary circumstances or extreme hardship. U.S.S. v. Cirami, C.A.2 (N.Y) 1977, 563 F.2d 26, on remand 92 F.R.D. 483.   See, also, Marquette Corp. v. Priester, D.C.S.C.1964, 234 F.Supp. 799;U.S. v. $3,216.59 in U.S. Currency, D.C.S.C.1967, 41 F.R.D. 433. Subd. (b)(4) to (6) of this rule that court may relieve party from final judgment if it is void, if it is no longer equitable that judgment should have prospective application or for any other reason justifying relief from operation of judgment, is to be liberally construed to carry out purpose of avoiding enforcement of erroneous judgment. Blanchard v. St. Paul Fire & Marine Ins. Co., C.A.5 (Fla.) 1965, 341 F.2d 351, certiorari denied 86 S.Ct. 66, 382 U.S. 829, 15 L.Ed.2d 73.  This rule should be liberally construed for purpose of doing substantial justice. In re Hankins, N.D.Miss.1973, 367 F.Supp. 1370. See, also, Fackelman v. Bell, C.A.Ga.1977, 564 F.2d 734; Radack v. Norwegian America Line Agency, Inc., C.A.N.Y.1963, 318 F.2d 538; Triplett v. Azordegan, D.C.Iowa 1977, 478 F.Supp. 872; Tann v. Service Distributors, Inc., D.C.Pa.1972, 56 F.R.D. 593, affirmed 481 F.2d 1399. This rule establishing requirement for granting relief from a final judgment or order is to be given a liberal construction. U. S. v. One 1966 Chevrolet Pickup Truck, E.D.Tex.1972, 56 F.R.D. 459. 7. —- Void judgment clause: Although this rule providing for relief from judgment is not substitute for appeal and finality of judgments ought not be disturbed except on very narrow grounds, liberal construction should be given this rule to the end that judgments which are void or are vehicles of injustice not be left standing. Brennan v. Midwestern United Life Ins. Co., C.A.7 (Ind.) 1971, 450 F.2d 999, certiorari denied 92 S.Ct. 957, 405 U.S. 921, 30 L.Ed.2d 792.

A claim for relief from judgment on basis of “any other reason justifying relief from operation of the judgment” is cognizable where there is evidence of extraordinary circumstances or where there is evidence of extreme hardship or injustice, and, once extraordinary circumstances or hardship is found, this rule is to be liberally applied to accomplish justice. U. S. v. McDonald, N.D.Ill.1980, 86 F.R.D. 204.

Attorney’s motion for reconsideration on ground that court lacked jurisdiction to order him to pay court reporter could be entertained under rule governing relief from judgment and was not subject to time constraints of rule governing motion to amend judgment. U.S. v. 789 Cases of Latex Surgeon Gloves, C.A.1 (Puerto Rico) 1993, 13 F.3d 12

Void judgments are those rendered by a court which lacked jurisdiction, either of the subject matter or the parties, Wahl v. Round Valley Bank 38 Ariz. 411, 300 P. 955 (1931); Tube City Mining & Milling Co. v. Otterson, 16 Ariz. 305, 146 P. 203 (1914); and Milliken v. Meyer, 311 U.S. 457, 61 S.Ct. 339, 85 L.Ed. 2d 278 (1940).

A void judgment which includes judgment entered by a court which lacks jurisdiction over the parties or the subject matter, or lacks inherent power to enter the particular judgment, or an order procured by fraud, can be attacked at any time, in any court, either directly or collaterally, provided that the party is properly before the court, Long v. Shorebank Development Corp., 182 F.3d 548 ( C.A. 7 Ill. 1999).

A void judgment is one which from the beginning was complete nullity and without any legal effect, Hobbs v. U.S. Office of Personnel Management,  485 F.Supp. 456 (M.D. Fla. 1980). Void judgment is one that, from its inception, is complete nullity and without legal effect, Holstein v. City of Chicago, 803 F.Supp. 205, reconsideration denied 149 F.R.D. 147, affirmed 29 F.3d 1145 (N.D. Ill 1992).

Void judgment is one where court lacked personal or subject matter jurisdiction or entry of order violated due process,  U.S.C.A. Const. Amend. 5 – Triad Energy Corp. v. McNell  110 F.R.D. 382 (S.D.N.Y. 1986).

Judgment is a void judgment if court that rendered judgment lacked jurisdiction of the subject matter, or of the parties, or acted in a manner inconsistent with due process, Fed. Rules Civ. Proc., Rule 60(b)(4), 28 U.S.C.A.; U.S.C.A. Const. Amend. 5 – Klugh v. U.S., 620 F.Supp. 892 (D.S.C. 1985).

A void judgment is one which, from its inception, was, was a complete nullity and without legal effect, Rubin v. Johns, 109 F.R.D. 174 (D. Virgin Islands 1985).

A void judgment is one which, from its inception, was a complete nullity and without legal effect, Lubben v. Selevtive Service System Local Bd. No. 27,  453 F.2d 645, 14 A.L.R. Fed. 298 (C.A. 1 Mass. 1972).

A void judgment is one which, from its inception, is and forever continues to be absolutely null, without legal efficacy, ineffectual to bind the parties or to support a right, of no legal force and effect whatever, and incapable of enforcement in any manner or to any degree – Loyd v. Director, Dept. of Public Safety, 480 So. 2d 577 (Ala. Civ. App. 1985).

A judgment shown by evidence to be invalid for want of jurisdiction is a void judgment or at all events has all attributes of a void judgment, City of Los Angeles v. Morgan,  234 P.2d 319 (Cal.App. 2 Dist. 1951). Void judgment which is subject to collateral attack, is simulated judgment devoid of any potency because of jurisdictional defects,  Ward v. Terriere,  386 P.2d 352 (Colo. 1963).

A void judgment is a simulated judgment devoid of any potency because of jurisdictional defects only, in the court rendering it and defect of jurisdiction may relate to a party or parties, the subject matter, the cause of action, the question to be determined, or relief to be granted, Davidson Chevrolet, Inc. v. City and County of Denver, 330 P.2d 1116, certiorari denied 79 S.Ct. 609, 359 U.S. 926, 3 L.Ed. 2d 629 (Colo. 1958).

Void judgment is one entered by court without jurisdiction of parties or subject matter or that lacks inherent power to make or enter particular order involved and such a judgment may be attacked at any time, either directly or collaterally,  

People v. Wade,  506 N.W.2d 954 (Ill. 1987). Void judgment may be defined as one in which rendering court lacked subject matter jurisdiction, lacked personal jurisdiction or acted in manner inconsistent with due process of law Eckel v. MacNeal,  628 N.E. 2d 741 (Ill. App. Dist. 1993).

Void judgment is one entered by court without jurisdiction of parties or subject matter or that lacks inherent power to make or enter particular order involved; such judgment may be attacked at any time, either directly or collaterally

People v. Sales, 551 N.E.2d 1359 (Ill.App. 2 Dist. 1990). Res judicata consequences will not be applied to a void judgment which is one which, from its inception, is a complete nullity and without legal effect, Allcock v. Allcock 437 N.E. 2d 392 (Ill. App. 3 Dist. 1982).

Void judgment is one which, from its inception is complete nullity and without legal effect In re Marriage of Parks,  630 N.E. 2d 509 (Ill.App. 5 Dist. 1994). Void judgment is one entered by court that lacks the inherent power to make or enter the particular order involved, and it may be attacked at any time, either directly or collaterally; such a judgment would be a nullity People v. Rolland 581 N.E.2d 907, (Ill.App. 4 Dist. 1991).

Void judgment under federal law is one in which rendering court lacked subject matter jurisdiction over dispute or jurisdiction over parties, or acted in manner inconsistent with due process of law or otherwise acted unconstitutionally in entering judgment, U.S.C.A. Const. Amed. 5, Hays v. Louisiana Dock Co.,  452 n.e.2D 1383 (Ill. App. 5 Dist. 1983).

A void judgment has no effect whatsoever and is incapable of confirmation or ratification, Lucas v. Estate of Stavos,  609 N. E. 2d 1114, rehearing denied, and transfer denied (Ind. App. 1 dist. 1993).

Void judgment is one that from its inception is a complete nullity and without legal effect Stidham V. Whelchel,  698 N.E.2d 1152 (Ind. 1998).

Relief form void judgment is available when trial court lacked either personal or subject matter jurisdiction,  Dusenberry v. Dusenberry,  625 N.E. 2d 458 (Ind.App. 1 Dist. 1993).

Void judgment is one rendered by court which lacked personal or subject matter jurisdiction or acted in manner inconsistent with due process, U.S.C.A. Const. Amends. 5, 14 Matter of Marriage of Hampshire,  869 P.2d 58 ( Kan. 1997).

Judgment is void if court that rendered it lacked personal or subject matter jurisdiction; void judgment is nullity and may be vacated at any time, Matter of Marriage of Welliver, 869 P.2d 653 (Kan. 1994).

A void judgment is one rendered by a court which lacked personal or subject matter jurisdiction or acted in a manner inconsistent with due process In re Estate of Wells, 983 P.2d 279, (Kan. App. 1999).

Void judgment is one rendered in absence of jurisdiction over subject matter or parties 310 N.W. 2d 502, (Minn. 1981). A void judgment is one rendered in absence of jurisdiction over subject matter or parties, Lange v. Johnson, 204 N.W.2d 205 (Minn. 1973).

A void judgment is one which has merely semblance, without some essential element, as when court purporting to render is has no jurisdiction, Mills v. Richardson, 81 S.E. 2d 409, (N.C. 1954).

A void judgment is one which has a mere semblance, but is lacking in some of the essential elements which would authorize the court to proceed to judgment,  Henderson v. Henderson, 59 S.E. 2d 227, (N.C. 1950).

Void judgment is one entered by court without jurisdiction to enter such judgment,  State v. Blankenship  675 N.E. 2d 1303, (Ohio App. 9 Dist. 1996).

Void judgment, such as may be vacated at any time is one whose invalidity appears on face of judgment roll, Graff v. Kelly, 814 P.2d 489 (Okl. 1991). A void judgment is one that is void on face of judgment roll, Capital Federal Savings Bank v. Bewley, 795 P.2d 1051 (Okl. 1990).

Where condition of bail bond was that defendant would appear at present term of court, judgment forfeiting bond for defendant’s bail to appear at subsequent term was a void judgment within rule that laches does not run against a void judgment  Com. V. Miller,  150 A.2d 585 (Pa. Super. 1959).

A void judgment is one which shows upon face of record a want of jurisdiction in court assuming to render the judgment,  Underwood v. Brown,  244 S.W. 2d 168 (Tenn. 1951).

A Void judgment is one which shows upon face of record want of jurisdiction in court assuming to render judgment, and want of jurisdiction may be either of person, subject matter generally, particular question to be decided or relief assumed to be given,  State ex rel. Dawson v. Bomar,  354 S.W. 2d 763, certiorari denied, (Tenn. 1962).

A void judgment is one in which the judgment is facially invalid because the court lacked jurisdiction or authority to render the judgment, State v. Richie,  20 S.W.3d 624 (Tenn. 2000).

A void judgment is one which shows on face of record the want of jurisdiction in court assuming to render judgment, which want of jurisdiction may be either of the person, or of the subject matter generally, or of the particular question attempted to decided or relief assumed to be given,  Richardson v. Mitchell, 237 S.W. 2d 577, (Tenn.Ct. App. 1950).

Void judgment is one which has no legal force or effect whatever, it is an absolute nullity, its invalidity may be asserted by any person whose rights are affected at any time and at any place and it need not be attacked directly but may be attacked collaterally whenever and wherever it is interposed,  City of Lufkin v. McVicker,  510 S.W. 2d 141 (Tex. Civ. App. – Beaumont 1973).

A void judgment, insofar as it purports to be pronouncement of  court, is an absolute nullity, Thompson v. Thompson,  238 S.W.2d 218 (Tex.Civ.App. – Waco 1951).

A void judgment is one that has been procured by extrinsic or collateral fraud or entered by a court that did not have jurisdiction over the subject matter or the parties.” Rook v. Rook, 233 Va. 92, 95, 353 S.E.2d 756, 758 (1987)

A void judgment is a judgment, decree, or order entered by a court which lacks jurisdiction  of the parties or of the subject matter, or which lacks the inherent power to make or enter the particular order involved,  State ex rel. Turner v. Briggs, 971 P.2d 581 (Wash. App. Div. 1999).

A void judgment or order is one that is entered by a court lacking jurisdiction over the parties or the subject matter, or lacking the inherent power to enter the particular order or judgment, or where the order was procured by fraud, In re Adoption of E.L.,  733 N.E.2d 846, (Ill.App. 1 Dist. 2000). Void judgments are those rendered by court which lacked jurisdiction, either of subject matter or parties,  Cockerham v. Zikratch,  619 P.2d 739 (Ariz. 1980).

Void judgments generally fall into two classifications, that is, judgments where there is want of jurisdiction of person or subject matter, and judgments procured through fraud, and such judgments may be attacked directly or collaterally,  Irving v. Rodriquez,  169 N.E.2d 145, (Ill.app. 2 Dist. 1960). Invalidity need to appear on face of judgment alone that judgment or order may be said to be intrinsically void or void on its face, if lack of jurisdiction appears from the record,  Crockett Oil Co. v. Effie,  374 S.W.2d 154 ( Mo.App. 1964).

Decision is void on the face of the judgment roll when from four corners of that roll, it may be determined that at least one of three elements of jurisdiction was absent: (1) jurisdiction over parties, (2) jurisdiction over subject matter, or (3) jurisdictional power to pronounce particular judgment hat was rendered, B & C Investments, Inc. v. F & M Nat. Bank & Trust, 903 P.2d 339 (Okla. App. Div. 3, 1995). Void order may be attacked, either directly or collaterally, at any time,  In re Estate of Steinfield, 630 N.E.2d 801, certiorari denied, See also Steinfeld v. Hoddick, 513 U.S. 809, (Ill. 1994).

Void order which is one entered by court which lacks jurisdiction over parties or subject matter, or lacks inherent power to enter judgment, or order procured by fraud, can be attacked at any time, in any court, either directly or collaterally, provided that party is properly before court,  People ex rel. Brzica v. Village of Lake Barrington, 644 N.E.2d 66 (Ill.App. 2 Dist. 1994).

While voidable orders are readily appealable and must be attacked directly, void order may be circumvented by collateral attack or remedied by mandamus,  Sanchez v. Hester,  911 S.W.2d 173, (Tex.App. – Corpus Christi 1995). Arizona courts give great weight to federal courts’ interpretations of Federal Rule of Civil Procedure governing motion for relief from judgment in interpreting identical text of Arizona Rule of Civil Procedure,  Estate of Page v. Litzenburg, 852 P.2d 128, review denied (Ariz.App. Div. 1, 1998).

When rule providing for relief from void judgments is applicable, relief is not discretionary matter, but is mandatory, Orner v. Shalala,  30 F.3d 1307, (Colo. 1994).

Judgments entered where court lacked either subject matter or personal jurisdiction, or that were otherwise entered in violation of due process of law, must be set aside,  Jaffe and Asher v. Van Brunt, S.D.N.Y.1994. 158 F.R.D. 278.

A  “void” judgment as we all know, grounds no rights, forms no defense to actions taken thereunder, and is vulnerable to any manner of collateral attack (thus here, by ).

No statute of limitations or repose runs on its holdings, the matters thought to be settled thereby are not res judicata, and years later, when the memories may have grown dim and rights long been regarded as vested, any disgruntled litigant may reopen the old wound and once more probe its depths. And it is then as though trial and adjudication had never been. 10/13/58 FRITTS v. KRUGH. SUPREME COURT OF MICHIGAN, 92 N.W.2d 604, 354 Mich. 97.

On certiorari this Court may not review questions of fact. Brown v. Blanchard, 39 Mich 790. It is not at liberty to determine disputed facts (Hyde v. Nelson, 11 Mich 353), nor to review the weight of the evidence. Linn v. Roberts, 15 Mich 443; Lynch v. People, 16 Mich 472. Certiorari is an appropriate remedy to get rid of [({a  void judgment one which there is no evidence to sustain.})] Lake Shore & Michigan Southern Railway Co. v. Hunt, 39 Mich 469. 

In Stoesel v. American Home,  362 Sel. 350, and 199 N.E. 798 (1935), the court ruled and determined that, “Under Illinois Law and Federal Law, when any officer of the Court has committed “fraud on the Court”, the order and judgment of that court are void and of no legal force and effect.” In Sparks v. Duval County Ranch, 604 F.2d 976 (1979), the court ruled and determined that, “No immunity exists for co-conspirators of judge. There is no derivative immunity for extra-judicial actions of fraud, deceit and collusion.”  In Edwards v. Wiley,  374 P.2d 284, the court ruled and determined that, “Judicial officers are not liable for erroneous exercise of judicial powers vested in them, but they are not immune from liability when they act wholly in excess of jurisdiction.” See also,  Vickery v. Dunnivan,  279 P.2d 853, (1955). In Beall v. Reidy,  457 P.2d 376, the court ruled and determined, “Except by consent of all parties a judge is disqualified to sit in trial of a case if he comes within any of the grounds of disqualification named in the Constitution. In Taylor v. O’Grady,  888 F.2d 1189, 7^th Cir. (1989), the circuit ruled, “Further, the judge has a legal duty to disqualify, even if there is no motion asking for his disqualification.”  Also, when a lower court has no jurisdiction to enter judgment, the question of jurisdiction may be raised for the first time on appeal. See DeBaca v. Wilcox,  68 P. 922.  The right to a tribunal free from bias and prejudice is based on the Due Process Clause. Should a judge issue any order after he has been disqualified by law, and if the party has been denied of any of his/her property, then the judge has engaged in the crime of interference with interstate commerce; the judge has acted in his/her personal capacity and not in the judge’s judicial capacity. See U.S. v. Scinto,  521 F.2d 842 at page 845, 7^th circuit, 1996. Party can attack subject matter jurisdiction at anytime in the proceeding, even raising jurisdiction for the first time on appeal, State v. Begay,  734 P.2d 278.  “A prejudiced, biased judge who tries a case deprives a party adversely affected of due process.” See Nelson v. Cox,  66 N.M. 397.

There is no time limit when a judgment is void:

       Precision Eng. V. LPG, C.A. 1^st (1992) 953 F.2d 21 at page 22, Meadows v. Dominican Republic CA 9^th (1987) 817 F.2d at page 521, In re: Center Wholesale, Inc. C.A. 10^th (1985) 759 F.2d 1440 at page 1448, Misco Leasing v. Vaughn CA 10^th  (1971) 450 F.2d 257, Taft v. Donellen C.A. 7^th (1969) 407 F.2d 807, and Bookout v. Beck CA 9^th (1965) 354 F.2d 823. See also, Hawkeye Security Ins. V. Porter, D.C. Ind. 1982, 95 F.R.D. 417, at page 419, Saggers v. Yellow Freight D.C. Ga. (1975) 68 F.R.D. 686 at page 690, J.S. v. Melichar D.C. Wis. (1972) 56 F.R.D. 49, Ruddies v. Auburn Spark Plug. 261 F. Supp. 648, Garcia v. Garcia, Utah 1986 712 P.2d 288 at page 290, and Calasa v. Greenwell, (1981) 633 P.2d 555 at page 585, 2 Hawaii395.   “Judgment was vacated as void after 30 years in entry,” Crosby. V. Bradstreet, CA 2^nd (1963)  312 F.2d 483 cert. denied 83 S.Ct. 1300, 373 US 911, 10 L. Ed. 2.d 412.  “Delay of 22 years did not bar relief,” U.S. v. Williams, D.C. Ark. (1952) 109 F.Supp. 456.

– – – – –

>A motion to set aside a judgment as void for lack of jurisdiction is not subject to the time limitations of Rule 60(b). See Garcia v. Garcia, 712 P.2d 288 (Utah 1986).

>A judgment is void, and therefore subject to relief under Rule 60(b)(4), only if the court that rendered judgment lacked jurisdiction or in circumstances in which the court’s action amounts to a plain usurpation of power constituting a violation of due process. United States v. Boch Oldsmobile, Inc., 909 F.2d 657, 661 (1st Cir. 1990)

>Where Rule 60(b)(4) is properly invoked on the basis that the underlying judgment is void, “‘relief is not a discretionary matter; it is mandatory.'” Orner v. Shalala, 30 F.3d 1307, 1310 (10th Cir. 1994) (quoting V.T.A., Inc. v. Airco, Inc., 597 F.2d 220, 224 n.8 (10th Cir. 1979)).

>In order for a judgment to be void, there must be some jurisdictional defect in the court’s authority to enter the judgment, either because the court lacks personal jurisdiction or because it lacks jurisdiction over the subject matter of the suit. Puphal v. Puphal, 105 Idaho 302, 306, 669 P.2d 191, 195 (1983); Dragotoiu, 133 Idaho at 647, 991 P.2d at 379.

>A court may not render a judgment which transcends the limits of its authority, and a judgment is void if it is beyond the powers granted to the court by the law of its organization, even where the court has jurisdiction over the parties and the subject matter. Thus, if a court is authorized by statute to entertain jurisdiction in a particular case only, and undertakes to exercise the jurisdiction conferred in a case to which the statute has no application, the judgment rendered is void. The lack of statutory authority to make particular order or a judgment is akin to lack of subject matter jurisdiction and is subject to collateral attack. 46 Am. Jur. 2d, Judgments § 25, pp. 388-89.

>”A court cannot confer jurisdiction where none existed and cannot make a void proceeding valid. It is clear and well established law that a void order can be challenged in any court”, OLD WAYNE MUT. L. ASSOC. v. McDONOUGH, 204 U. S. 8, 27 S. Ct. 236 (1907).

>”Jurisdiction, once challenged, cannot be assumed and must be decided.” Maine v Thiboutot 100 S. Ct. 250.

>”The law requires proof of jurisdiction to appear on the record of the administrative agency and all administrative proceedings.” Hagans v Lavine 415 U. S. 533.

Though not specifically alleged, defendant’s challenge to subject matter jurisdiction implicitly raised claim that default judgment against him was void and relief should be granted under Rule 60(b)(4). Honneus v. Donovan, 93 F.R.D. 433, 436-37 (1982), aff’d, 691 F.2d 1 (1st Cir. 1982).

>”A judgment is void if the court acted in a manner inconsistent with due process. A void judgment is a nullity and may be vacated at any time.” 261 Kan. at 862.

>A judgment obtained without jurisdiction over the defendant is void. Overby v. Overby , 457 S.W.2d 851 (Tenn. 1970).

>Although Rule 60(b)(4) is ostensibly subject to the “reasonable” time limit of Rule 60(b), at least one court has held that no time limit applies to a motion under the Rule 60(b)(4) because a void judgment can never acquire validity through laches. See Crosby v. Bradstreet Co., 312 F.2d 483 (2nd Cir.) cert. denied, 373 U.S. 911, 83 S.Ct. 1300, 10 L.Ed.2d 412 (1963) where the court vacated a judgment as void 30 years after entry. See also Marquette Corp. v. Priester, 234 F.Supp. 799 (E.D.S.C.1964) where the court expressly held that clause Rule 60(b)(4) carries no real time limit.

Challenge to Jurisdiction

Challenging jurisdiction is one of the best defenses you can make, because if you use the right argument it is almost impossible for you to loose!

If they attempt to tell you that you can’t question their jurisdiction you can easily shut them up with these court rulings!

Are we on the record? I don’t say anything further until we are.

Where is the competent fact witness? Where is the damaged party?

Who brings the claim? Who is underwriting this action?

As a man, as an accused by law, I come with the presumption of innocent and I can go with that.

Hey, as keeper of the records for the thing, I’m willing to plead the defendant guilty upon validated proof of claim.

Where is the Form 1099OID?

Who are you people and why do you deem yourselves better than me?

Equality under the Law is paramount and mandatory by law.

I am unrepresented, I don’t “do Attorneys” as I have found them to be injurious to my freedom, life, liberty and pursuit of happiness.

Am I under arrest or am I free to go?

I am a man, not a corporation or a legal “person” nor am I a surety for one.

I am a man. I am competent. I am here under duress. I do not consent to this matter.

I reserve all rights at all times in all places and I waive no rights at any time or in any place. I do waive benefit privilege.

If I am here at all, I am here in special appearance to challenge jurisdiction and to have this matter dismissed.

I see a yellow fringe around your flag which clearly advertises “admiralty matters settled here” – so again I say, where is the contract?

Where is the contract wherein I knowingly and willingly, with full disclosure, consented or otherwise agreed to be treated this way?

I believe this court lacks a jurisdiction. I want to see the supposed jurisdiction that was duly placed into evidence.

Can this court move on facts not in evidence ?

I do not understand the nature and cause of the accusation with regard to the elements of personal jurisdiction, venue, underwriting and the nature of the action until the prosecution properly alleges them.

I cannot rebut an unstated presumption.

I am therefore unable to plea to the charges until I have had an opportunity to raise a meaningful defense against the elements.

https://www.law.com/nationallawjournal/sites/nationallawjournal/2018/02/01/minority-attorneys-take-a-closer-look-at-the-scotus-diversity-dearth/?kw=Minority%20Attorneys%20Take%20a%20Closer%20Look%20at%20the%20SCOTUS%20Clerk%20Diversity%20Dearth&et=editorial&bu=National%20Law%20Journal&cn=20180202&src=EMC-Email&pt=Afternoon%20Update

I’m sure this comes a no shock to anyone, but law clerks for the US Supreme Court are demanding more diversity.  Few persons of color have that job.  Too few women are selected still when law schools are 50% male.

Read on for an interesting article on the issue:

Justices of the U.S. Supreme Court pose for a formal group photograph in the East Conference Room of the Supreme Court in Washington, D.C., U.S., on Thursday, June 1, 2017.

U.S. Supreme Court justices should step up and state publicly that they want greater diversity among their law clerks, said Howard University School of Law Dean Danielle Holley-Walker.

“The first step,” Holley-Walker, a Harvard Law alum, said, “is always to say, ‘This is something that is important to us. We want to see a change happen and we are committed to taking steps to make a difference in terms of the makeup of our clerks.’ That is not something that I’ve heard expressed by many of the justices.”

Holley-Walker made the statement in response to The National Law Journal’s research, first released in December, on the persistent dearth of minority law clerks at the nation’s highest court.

NLJ research found that since 2005—when the Roberts court began—85 percent of all law clerks have been white. Only 20 of the 487 clerks hired by justices were African-American, and nine were Hispanic. Twice as many men as women gain entry, even though as of last year, more than half of all law students are female.

Former clerks have their pick of top-tier job offers and can command $350,000 law firm hiring bonuses. Four current justices were formerly clerks at the court—a record number, as are the general counsel of Apple Inc. and Facebook Inc. For aspiring appellate litigators and academics, a Supreme Court clerkship opens the creakiest doors.

But this term, of the 36 clerks hired by sitting justices this term, only one is African-American, two are Hispanic and three are Asian-Americans, based on the NLJ research.

Some prominent minority lawyers have commented on why the numbers are so low, and what the court and others involved in clerkship recruiting should do about it.

“It’s an uncomfortable topic for all of us in the bar, in the courts, law professors and the like because we all bear some of that responsibility for what these numbers are,” said Neal Katyal, a partner at Hogan Lovells. “I don’t think this conversation should be about blaming nine justices. Katyal, a Yale Law School graduate, clerked for Justice Stephen Breyer. A former acting solicitor general, Katyal, who is Asian-American, shared his thoughts in a December podcast about law clerk diversity hosted by The National Law Journal.

Crystal Nix-Hines, a partner at Quinn EmanuelUrquhart & Sullivan, Harvard Law School alum and a former clerk for Justice Thurgood Marshall, agreed.

“I think there’s a broader systemic problem. It starts in law school or perhaps even earlier,” said Nix-Hines, who is African-American. “If you’re not at a great law school, and you’re not on the law review, or at the top of your class, or known to a feeder professor or judge, the chances of getting a Supreme Court clerkship are pretty slim.”

The low numbers span the court’s ideological spectrum. Since Chief Justice John Roberts Jr. joined the court in 2005, just 8 percent of the law clerks he’s hired have been racial or ethnic minorities. Only 12 percent of the clerks hired by Justice Ruth Bader Ginsburg and Justice Clarence Thomas since 2005 were minorities. Ginsburg has hired only one African-American clerk since she joined the high court in 1993, and the same goes for Justice Samuel Alito Jr., who became a justice in 2006.

By contrast, more than 30 percent of Justice Sonia Sotomayor’s clerks have been nonwhite, making her chambers the most diverse among those justices who have been on the court for more than a year. (Justice Neil Gorsuch has hired seven clerks so far over two terms, three of whom are nonwhite, for a total of 43 percent.)

Holley-Walker, who is African-American, said justices and feeder judges need to cast their net wider to achieve a diverse class of clerks. “If you only hire from one or two law schools or at the most, five law schools, and those schools only have a certain number of diverse graduates every year, then you’re really cutting down on the number of potentially diverse clerks that you could hire,” said Holley-Walker, who noted that only one student from Howard Law, a historically black institution, has ever served as a Supreme Court clerk. James McCollum Jr., a Howard graduate, clerked for now-retired Justice John Paul Stevens in 1984 and 1985.

Since 2005, Breyer, Ginsburg, Elena Kagan and Anthony Kennedy have hired 10 percent or fewer of their clerks from law schools outside the U.S. News & World Report Top 10. The late Justice Antonin Scalia hired just a single graduate from a school outside the top 10 during that period.

Harvard and Yale law schools have tightened their grip on the clerk “market,” providing half of the court’s law clerks since 2005, compared to 40 percent in 1998.

As one possible resource to diversify clerk ranks, Holley-Walker pointed to Just the Beginning Foundation, formed by African-American federal judges to connect minority and other students with the law and judges.

Holley-Walker said she was surprised to learn from the NLJ stories that liberal Justice Ginsburg has hired only one African-American law clerk since she joined the high court in 1993.

“It was surprising because we know that she has a deep commitment to diversity and inclusion in terms of women and also people of color,” Holley-Walker said. “I don’t doubt her commitment at all.”

In terms of gender diversity, Ginsburg and Breyer have hired men and women in equal numbers. In contrast, other chambers continue to be male-dominated. For instance, Kennedy, has hired six times as many men as women law clerks since 2005. And Gorsuch, in his second term, has hired just one female law clerk.

“The justices, and the legal profession as a whole, should aspire to be as intentional as Justice Stephen Breyer, who has hired more black clerks than any other justice and as many women as men. This doesn’t just happen,” said Yolanda Young, a Georgetown University Law Center alum who heads Lawyers of Color, a nonprofit devoted to promoting diversity in the legal profession. Young is African-American.

For Katyal, knowledge also makes a difference. He said he was among minority law students who arrived at law school not knowing the shortcuts to clerkships—such as becoming a research assistant to a well-connected professor. Students need that information early in their time at law school.

Another factor is financial, Katyal said. Students of all backgrounds with student loan debt may find law firm salaries more attractive than the $79,720 salary of U.S. Supreme Court law clerks.

“As I talk to minority student groups across the country, I get that question a lot which is ‘How can I afford [clerkships]?’” Katyal said. “The last thing we should do is be having people pull their punches just because of money.”

Lisa Helem contributed to this story.

From an email I received today:

Where did the term boycott originate? One of the first examples (although there were boycotts earlier; they just weren’t called boycotts yet) involved Charles Cunningham Boycott (March 12, 1832 – June 19, 1897). Boycott was an English land agent who was ignored and ostracized by his Mayo Irish community in Ireland after treating them badly. In fact, he was so bad that they named the action after him.

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After Boycott retired from the British Army, he worked as a land agent for Lord Erne, a major landowner in the Lough Mask area of County Mayo who lived off the exorbitant rents he charged tenants. Evictions by Boycott were many, and bloody. In 1880, Boycott’s opponents Charles Stewart Parnell and the Land League campaigned for the Three Fs (fair rent, fixity of tenure, and free sale) and in opposition to evictions. When Boycott set about evicting 11 tenants, the Mayo branch of the Irish Land League urged Boycott’s employees to withdraw their labor, and began a campaign of isolation against Boycott in the local community. The nearby shops in Ballinrobe refused to serve him, people quit working for him, and Boycott found himself a marked man. Boycott was furious and made a crucial mistake: he complained to the London media. If he had kept his mouth shut he might have been fine, but now it was a story, and the boycott campaign became a YUGE issue. Here is his complaint:

“Sir, The following detail may be interesting to your readers as exemplifying the power of the Land League. On the 22nd September a process-server, escorted by a police force of seventeen men, retreated to my house for protection, followed by a howling mob of people, who yelled and hooted at the members of my family.

“On the ensuing day, September 23rd, the people collected in crowds upon my farm, and some hundred or so came up to my house and ordered off, under threats of ulterior consequences, all my farm labourers, workmen, and stablemen, commanding them never to work for me again.

“My blacksmith has received a letter threatening him with murder if he does any more work for me, and my laundress has also been ordered to give up my washing…The shopkeepers have been warned to stop all supplies to my house, and I have just received a message from the postmistress to say that the telegraph messenger was stopped and threatened on the road when bringing out a message to me and that she does not think it safe to send any telegrams…I can get no workmen to do anything, and my ruin is openly avowed as the object of the Land League unless I throw up everything and leave the country. I say nothing about the danger to my own life, which is apparent to anybody who knows the country.”

The story exploded in the media. About 50 Ulster Loyalists volunteered to come to Boycott’s aid and bring in his crops. Then it went international. The Brooklyn Eagle reported on November 9, 1880:

“Four troops of Hussars were dispatched hence for Ballinrobe by special trains at 2 o’clock this morning. Four hundred infantry have just arrived at Ballinrobe and will encamp near Lough Mask.

“These precautions are taken in view of the intention of the Northern Orangemen to send laborers to harvest the crops of Mr. Boycott, Lord Erne’s agent, for whom the local peasantry, at the instigation of the Land League, refuse to work. The Government will protect a moderate force of laborers, but refuse to furnish anything approaching armed demonstrations, which would certainly provoke a collision.”

All of this led to a ridiculous scene. Dozens of reporters rushed to the West of Ireland to report on 50 men harvesting crops surrounded by a regiment of the 19th Royal Hussars and more than 1,000 men of the Royal Irish Constabulary.

Cost to guard harvesters: £10,000

Profit from harvest: £500

The fact that an armed thug for a greedy landowner is ostracized to the point that the “boycott” is named after him: Priceless

Charles Boycott got out of town, clearly an unwelcome member of the community. He left Ireland on December 1, 1880, in disgrace, his name forever attached to a campaign to bring down tyrants. In 1886, Boycott became a land agent for Hugh Adair’s Flixton estate in Suffolk. He died at the age of 65 on June 19, 1897, in his home in Flixton, after an illness earlier that year. His name lives on, in infamy, forever.

The practice of boycotting spread and gave the peasants bargaining power. By the end of 1880, Irish peasants were boycotting all over Ireland, as the Land League implemented one of the most successful non-violent actions against unfair conditions and oppressive landowners in the world’s history.

Boycotting is effective. It is easy to feel powerless when we are under the rule of tyrants, but we will not be subjugated. As Resisters, it is our duty to use every tool at our disposal so that when the history is written we will have shown that we fought back, we would not lay down, we would not capitulate.