Articles Posted in nursing home negligence

A Florida jury has awarded more than $1.1 billion to a man whose mother fell victim to nursing home negligence.

Our Port St. Lucie nursing home abuse lawyers understand that the jury spent little more than an hour in deliberations before deciding on $110 million in compensatory damages and $1 billion in punitive damages. It’s unclear how much of that judgement, if any, is actually going to be recovered.

A separate 2010 case lodged against this same defendant resulted in a $114 million verdict, though efforts to collect on those damages are still pending. Two other cases against the same company are still awaiting trial.

The hope is at the very least that this facility won’t be in a position to put anyone else’s loved one in harm’s way.

The case stems from the death of a 69-year-old woman who was being cared for at Auburndale Oaks Healthcare Center in Polk County. Her stay there lasted from 2004 until her death three years later.

During that time, the woman reportedly suffered 17 falls as a result of improper supervision at the nursing home.

Care at the home was supervised by Trans Healthcare Inc. and Trans Healthcare Management. Attorneys for the plaintiff say these were for-profit companies, part of conglomerate that took over the nursing home, “looted assets, short-staffed it, under-budgeted it and as a result, the nursing home residents were suffering.”

Sadly, this is not an uncommon story when it comes to for-profit nursing home facilities. Last year, federal health care inspectors issued a report indicating that the U.S. nursing home industry overbills some $1.5 billion annually for treatment that patients either don’t need or don’t get. Later, Bloomberg News conducted a more in-depth analysis of those figures and determined that for-profit nursing homes were the larger culprit, with 30 percent of their claims improper, versus 12 percent of non-profit nursing home care facilities’ claims.

The other issue that arises in this case is the seriousness of falls for elderly patients.

We don’t know all the circumstances behind each fall, but we do know that the last one resulted in a hip fracture for the patient. She was reportedly left in her hospital bed for four days before ultimately being transported to a hospital.

Staffers blamed the lack of available staff to not only supervise but also to respond to an emergency.

Falls account for more than a third of preventable hospital emergency room visits made by nursing home residents. Fall-related injuries are responsible for the deaths of approximately 1,800 nursing home residents annually. Many of those instances are preventable.

It’s estimated that in a typical, 100-bed nursing home facility, there are between 100 and 200 falls reported each year. That’s especially troubling when you consider that many times, falls aren’t reported.

Falls are dangerous to older residents as it is. In fact, the U.S. Centers for Disease Control and Prevention reports that falls are the No. 1 cause of death from injury among people over the age of 65. Twenty to 30 percent of all falls among seniors result in serious injury, such as head trauma or hip fractures.

It’s more dangerous if that individual lives in a nursing home. Adults over the age of 65 who live in a nursing home are twice as likely to suffer a fall as those who are cared for elsewhere. They are also four times as likely to die of a fall-related injury if they live in a nursing home.

Nursing homes have a responsibility to ensure not only that there are adequate prevention measures in place to prevent falls and that there is adequate staff to supervise patients in case of a fall. When facilities fail in this regard, they need to be held accountable.
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Both the Consumer Product Safety Commission and the U.S. Food and Drug Administration issued a joint announcement recently that they would be establishing a joint committee that will update the voluntary safety standards for the adult portable bed rails frequently used in nursing homes and assisted living facilities.

Indian River County nursing home negligence attorneys know this has been a long time in coming, and remains to be seen whether it will be enough to curb the tens of thousands of elderly injuries and hundreds of deaths attributed to these devices.

Part of the problem previously was that the FDA and the CSPC battled over who had regulatory jurisdiction, as there was no clear guidance on whether bed rails were consumer products or medical devices.

With this effort, it may not matter either way. In their joint statement, both agencies said that all “reasonable and timely efforts should be undertaken to address this hazard and protect the safety of the public.”

It’s really something that should have been done some time ago, considering that since 1995, there have been an estimated 550 bed-rail related deaths – 155 of those from January 2003 through September 2012. Plus, there have been nearly 40,000 people treated in hospital emergency rooms between 2003 and 2004 for injuries related to adult bed rails.That amounts to about 4,000 each year.

The majority of those injured or killed were over the age of 60. Many suffered from dementia or Alzheimer’s disease.

The FDA was warned back in 1995 that adult bed rail deaths were a growing problem. Still, it wasn’t until four years later that the agency formed a working group comprised of patient advocates, researchers and medical device manufacturers. The agency was going to impose regulations that would have required manufacturers to add warning labels to the equipment. However, the industry staunchly opposed such action, and the FDA backed down, citing the cost to smaller bed rail companies and also the trouble in getting such regulation through layers of bureaucratic approval. Never mind, apparently, that some of our most vulnerable citizens would continue to be subjected to harm without warning.

If you aren’t familiar, bed rails are those metal bars used in nursing homes and hospitals that allow patients to help pull themselves up or out of bed. In some cases, they are intended to help people roll out of bed.

The problem is that in some cases, patients – particularly elderly ones – become confused and sometimes become trapped between the mattress and the railing. This ends up resulting in serious injury and death.

Nursing homes and hospitals don’t use them quite as often as they once did, but you can still find them in many facilities. What’s especially troubling is the fact that a lot of places still use the older models for many patients.

In 2006, the FDA finally issued voluntary guidelines that offered some instruction to nursing homes and hospitals regarding the use of adult bed rails. Those guidelines recommended gap and opening size limits in the rails and made a point to identify which parts of the body are most likely to become stuck.

The newer rails are supposed to be better-designed, but they certainly aren’t without issue.

With regard to the new guidelines, it’s expected that ASTM International, which publishes voluntary technical standards for a large number of products, will head the committee.

There are many who remain skeptical that these new standards will have much impact, given that previous voluntary guidelines failed to do much to stem the tide of injuries. One Massachusetts lawmaker called the government’s response to the issue “tepid.”

It remains to be seen whether these guidelines will produce different or better results.
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A family has filed a lawsuit following the death of an 85-year-old man with Alzheimer’s disease who died of a heart attack after he was found just outside his nursing home in temperatures slightly below freezing. He was transported to a nearby hospital in New York where he was declared dead.

Our West Palm Beach nursing home negligence lawyers know that while many patients may have complex medical conditions, an injury, illness or death caused by wandering is 100 percent preventable. It amounts to negligence and neglect and families should not ignore the fact that the nursing homes have a responsibility to prevent this kind of thing.

Some families might chalk it up to their loved one’s propensity to wander. But often, that is why families and loved ones came together to make the difficult choice to place the person in a full-time care facility in the first place. Staffers are fully aware of a patient’s condition (or should be) and measures should be in place to prevent such occurrences.

If a person ends up wandering away regardless of those policies, either the staff didn’t properly follow procedure or the procedures were inadequate. Either way, the nursing home is responsible.

As the U.S. continues to gray, the number of people with Alzheimer’s and other forms of dementia is going to continue to rise. We worry that nursing homes in Florida may be ill-equipped to handle this increase.

Studies have shown that between 11 and 50 percent of all long-term care patients will wander at some point during their care. For dementia patients, that figure is closer to 60 percent, with certain individuals prone to wandering again and again.

There have been some high-tech solutions to the issue of wandering patients. For example, a former rehab hospital director recently helped to invent a GPS shoe, which could be worn by Alzheimer’s patients so facilities could quickly locate patients who do slip through the doors.

Facilities should have a good plan for what to do if a patient does wander – sometimes called “elopement.” But really, patients shouldn’t even make it out the door in the first place. Doors should be locked and guarded and there should be enough staffers and controls in place to prevent patients from simply walking out. In addition to solid supervision, that might mean activity programming that is engaging to the residents, leaving them less likely to wander off. It could also mean multiple levels of environmental deterrents, such as alarms in the foyer or near the doorway.

Patients who have a strong propensity to wander should be identified early on, with all staffers involved in that individual’s care aware of the situation and can actively take steps throughout the course of care to prevent wandering.

A typical person who wanders is a male with an average age or 74 who is functionally impaired, may have sleep problems, is prescribed psychotropic medications and may have had a more active adult lifestyle.

Researchers suggest there could be biomedical reasons for wandering tendencies, and nursing home facilities should strive to help address those by allowing safe spaces for wandering, providing ample opportunity for exercise, and providing the individual with meaningful activities and a safe, comforting environment.
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In many cases, harm inflicted upon nursing home patients doesn’t happen because staffers are evil or harbor ill will toward residents.

In fact, our Port St. Lucie nursing home abuse lawyers believe that in most cases, staffers started out in their careers with a desire to help people.

But these workers are grappling with work environments that are increasingly a challenge, particularly as a result of privatization which can lead to understaffing, long hours, low pay and a management system that offers little guidance or oversight.

Of course, this does not excuse negligence and it certainly is not an excuse for abusive behavior. But it may help us to explain it, which in turn might help us to address it.

Take, for example, the case of a licensed practical nurse in suburban New York who is facing numerous misdemeanor charges – bumped down from felonies – for reportedly neglecting to give residents their medications and then falsifying documents indicating that she had administered the drugs.

Make no mistake – this was a potentially fatal error on her part, and should without question be addressed and punished.

But her criminal defense lawyer has an interesting take on the matter. He indicates that having been in the elder care field for more than a decade, she did care about her patients. However, she was burdened by the conditions in a facility that was going through the process of privatization, had undergone a mass exodus of regular staffers and management that was thoroughly disorganized.

In fact, less than a year earlier, inspectors with the state’s health department had cited the facility for violations that included having bloodied rags in the kitchen and medications that were administered to the wrong patients.

So while, yes, this one staffer certainly needs to be held accountable for her negligence, we shouldn’t overlook the fact that it likely occurred as part of a larger problem – one that is present in facilities across the country.

As one aging ombudsman was quoted as saying, some of these nurses might have an entire wing of patients to themselves. Granted, these aren’t intensive care unit patients, but they do require around-the-clock care, and it’s simply too much to ask one person to handle.

The buck truly stops with the nursing home facilities who overburden staffers with unrealistic responsibilities, without providing them the tools that would allow them to offer minimum standards of care to residents. It doesn’t help that certified nursing assistants are only paid about $10 an hour.

In 2010, federal officials testified before Congress that about 7 percent of complaints made to aging ombudsmans at the state and county level concerned provable case of neglect and abuse.

A 2011 study conducted in New York found that actual abuse rates are about 24 percent higher than what is reported to authorities. There are approximately 3.2 million people currently living in nursing homes nationwide.

Research has repeatedly borne out the theory that nursing homes tend to have more deficiencies because they often fail to expend as many resources on staffing and training.
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In the aftermath of the devastation wrought by a colossal, deadly tornado in Oklahoma recently, we began hearing calls for storm preparedness at facilities that house our most vulnerable.

This talk has primarily centered on schools, as nine of the two dozen killed were children, hunkered down in a poorly-constructed elementary school.

This is a discussion with which Floridians are familiar, as our state is well-known for powerful hurricanes, sudden lightning strikes and even deadly tornadoes. Our Fort Pierce nursing home negligence attorneys know that the safety of nursing home residents must not be overlooked.

The aftermath of what we saw in New York nursing homes after Hurricane Sandy shows us why we can’t become complacent. There, The New York Times reports, nursing home residents at one facility in Queens failed to provide even the most basic care to patients during and after the storm. There wasn’t enough food or medication stocked up for an emergency. There wasn’t additional staff on hand either. Even the nursing home director left, and did not return until after the storm had passed. For more than 24 hours, patients were cold, hungry, in pain and literally in the dark, trapped with the first floor flooded.

By the following evening, EMS crews arrived and decided it was so bad that at least 200 patients had to be evacuated to emergency city shelters. The transition involved no staff members accompanying patients, many of whom were forced to travel without medical records – both violations of state law. Without those records, some patients were unable to tell anyone who they were or what they needed. Family members spent weeks in some cases, searching for loved ones who were stuck in emergency shelters or in other nursing homes throughout the region.

Scenarios like this remind us why all nursing homes must have staff that is well-trained and solid preparedness policies inked well in advance of an environmental disaster. With Florida’s hurricane season beginning June 1, it’s a lesson we simply can’t afford to forget.

Federal law requires that all facilities that are Medicare/Medicaid-certified have written plans and procedures that will meet all potential emergencies, as well as have adequate training for employees.

An August 2006 report on nursing home emergency preparedness by the Office of the Inspector General found that the vast majority of nursing homes in Gulf states had adequate written emergency preparedness plans. However, 20 percent failed to have adequate emergency training for staffers.

What’s more, almost every nursing home evaluated in its reaction after a recent storm had some type of problem that related back to a lack of emergency planning or a failure to properly execute that emergency plan. Whether the facility evacuated or sheltered in place, the IG found that many facilities struggled with issues of maintaining a basic level of supplies, staff and services. Many patients suffered dehydration, skin tears and depression.
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The New York Times recently explored the growing phenomenon of adult day care centers, which have been cropping up all over the country in recent years.

Our Wellington nursing home abuse attorneys know that while these centers may not be as rife with mistreatment as those facilities where individuals are reliant on staff to meet all of their daily and nightly needs, people who frequent these centers may still be vulnerable.

A recent case out of Texas illustrates the concerns. In Corpus Christi, the former owner of an adult daycare center was recently sentenced to four years in prison for abuse of her elderly clients. The 69-year-old defendant was convicted on charges of abusing the elderly and assault. She had faced a maximum of 10 years in prison.

According to media reports, state authorities had shut down the center amid claims that mistreatment was occurring. Among the bizarre accusations that led to her conviction were that she placed bags of feces and urine around the necks of patients.

She would later argue that this was a form of “sensory therapy” that was intended to help remind individuals to use the restroom. However, medical professionals who have worked in geriatrics for years testified that such practice had no place in medicine and in fact, was nothing more than a form of cruelty.

We may be seeing more of these kinds of cases as adult day cares continue to proliferate with the ongoing aging of the baby boom generation. Already, we have seen aggressive marketing in this arena.

In the first three quarters of last year, these centers collectively raked in about $25 million. Rates typically average anywhere from $2,000 to $4,000 monthly, just depending on type of care and the frequency of attendance.

There are concerns, however, that because these facilities are often funded by federal dollars through Medicaid, they have incentives to set low eligibility standards – decisions that aren’t overseen by the government. Beneficiaries are supposed to need at least four months of assistance with things like walking, bathing or taking their medications.

While the case out of Texas involves an extreme example, the list of concerns and risks for patients of an elderly day care center are much the same as they would be for someone in a nursing home.

Among those are abuse, neglect, negligence and communicable disease.

With abuse, it could be direct physical abuse, such as slaps or punches, burns or cuts. There could be financial abuse if staffers somehow gain access to a client’s credit card or bank accounts. There might also be psychological abuse in the form of intimidation, isolation, humiliation or verbal insults.

In terms of neglect or negligence, bear in mind that those attending adult day care facilities usually need help with basic daily needs. If the staff isn’t properly trained or fails to act on those needs, it can lead to conditions including sores, rashes, malnutrition and dehydration.

Communicable diseases are also a big concern. You have of course the obvious colds, flu viruses and even measles. It becomes a greater problem when staff fail to become vaccinated or properly clean themselves, the facility or food products. While it may mean a brief illness for a younger staff member, the flu could mean a hospital stay or even death for an older, more frail patient.

The one piece of good news is that those who attend these adult day care centers are more likely than those living in nursing homes to be seen daily, or at least regularly, by loved ones. That means they may be more likely to pick up on key abuse or neglect indicators.
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Our Martin County nursing home abuse lawyers are troubled that some nursing home facilities view the overmedication of patients as an appropriate form of patient management, allowing for less intensive care, fewer staffers and a reduction of combative patients.

Of course, the glaring gap that this perspective fails to address is the health and well-being of the patient – the ones for whom these facilities have pledged to provide quality care.

Yet we continue to see evidence of this kind of protocol throughout the country.

In some cases, overmedication of patients are due to staff errors or a lapse in facility procedure.

The Centers for Medicare and Medicaid Services reported in 2010 that approximately 17 percent of all nursing home patients were being prescribed antipsychotic medications that exceeded the recommended amount – on a daily basis.

Florida nursing homes have the worst track record in the country for this, with CMS reporting that an astonishing 71 percent of all nursing home patients are overmedicated.

Perhaps even more troubling (if that’s possible) is that about 40 percent of those patients receiving antipsychotic medications have never actually been diagnosed with any kind of pyschosis.

The U.S. Food & Drug Administration reports that some 15,000 nursing home residents are estimated to die every year from overmedications.

Sadly, many of those cases go unnoticed or unreported.

Recently, the California Department of Health slapped a nursing home facility with a $100,000 fine for the overmedication – and subsequent death – of an 82-year-old stroke patient who had essentially overdosed on Coumadin, which is a blood-thinning medication.

The male patient had been partially-paralyzed after having a stroke back in 2005. The following year, he was taken to a nursing home in northern California.

Sometime during the spring of 2011, the man fell from his wheelchair, striking his head and causing severe facial bruises, including a blackened eye. Regulators say at that point, the man should have been hospitalized immediately.

However, it wasn’t until several days later – and only at the insistence of the man’s daughter – that he was rushed to a nearby hospital. At that time, hospital staff learned that the man was suffering from severely low blood pressure and organ failure. His Coumadin levels? Nearly 20 times the normal amount.

He died a short time later.

At the time this happened, the facility at which he was housed was owned by a firm that in 2010 was found guilty of elder abuse, and ordered to pay nearly $30 million in damages to the family of a deceased patient.

Overmedication can be tough for family members to spot, but it’s important to educate yourself as much as possible to catch it early if you can. Some signs that something may be amiss include:
–Unexplained and/or erratic changes changes in your loved one’s behavior or personality;
–A sudden reclusive attitude, even toward beloved family members;
–Constant exhaustion or fatigue;
–Regularly oversleeping;
–Unusual physical symptoms or medical complications;
–Easy confusion or disorientation.
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A recent study published in The Journal of Internal Medicine found that doctors regularly prescribe risky drugs to elderly patients, and that those living in the South were especially at risk.

Our Lake Worth nursing home negligence attorneys understand that the study, conducted by medical doctors at the Alpert Medical School at Brown University, focused on a list of more than 100 medications that the National Committee of Quality Assurance has deemed dangerous for older patients. Many of the medications have a wide swath of use, as the side effects in younger patients are mild or moderate. However, the drugs are known to have risks that are amplified for older patients.

One of those, for example, is Valium. It’s a type of benzodiazepine, and older patients are known to have a tougher time metabolizing the drug. That means the drug is going to stay in their system for longer stretches of time. That puts them at risk for longer periods of sedation, which may result in falls and fractures that could be deadly. Not only that, but the drug is known to be highly addictive. It’s only supposed to be used as a last-resort drug, and what researchers learned was that almost always, there is a safer alternative available.

Similar trends were spotted with the prescription of medications for diabetes and muscle relaxants.

The study’s author said he has been aware for sometime that these medications were over-prescribed. However, he wanted to get a better sense of the full extent of the problem, and what types of factors would lead doctors to prescribe medicine they know to be potentially harmful to their older patients.

In seeking answers, researchers combed through records of six million older adults in the U.S. with enrollment in the Medicare Advantage plan in 2009. Of those, some 1.3 million – or about 1 in 5 – were prescribed at least one high-risk medication that year. That was despite the fact that the majority of those drugs had safer alternatives.

Additionally, about 5 percent of those older patients were being prescribed more than one potentially dangerous medication.

Researchers noted one city in Georgia where 40 percent of older adults had been prescribed at least one dangerous drug. Another city in Louisiana had the most seniors who had been given more than one high-risk medication. The south overall appeared to display higher rates of the problem.

It’s unclear why this might be. Researchers speculated it might have something to do with patients simply asking for these drugs more regularly. Regardless, it is the doctor’s responsibility to exercise caution.

The practice of using many different medications at once is known as polypharmacy, and it’s worth noting that another recent study found that it’s a big problem for older adults. The average 65-year-old in the U.S. takes at least four prescription medications, which can often lead to reactions that are not only unexpected but dangerous. In fact, adverse reactions to these medications account for more than one-third of all hospital admissions.

Family members of Lake Worth nursing home residents should not be lulled into a false sense of security by thinking that just because a loved one is in a nursing home that medical staff will catch such adverse effects, especially when facilities are under-staffed and workers are under-qualified.
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Choosing long-term care options for your parents or loved ones is never easy, and our Parkland nursing home abuse lawyers know there is much to consider.

Now, at least with regard to cost, a new study shows that in-home care may be the most preferable option – if it’s feasible.

Genworth Financial’s 10th Annual Cost of Care Survey found that while the cost for assisted living and nursing home facilities has skyrocketed to rates well above inflation, the cost for in-home care has risen by just 1 percent or so in the last five years.

The survey included cost information from some 15,000 long-term care providers, broken down into differing types of care for nearly 440 metro areas in the U.S. While homemaker services and home health aide rates have essentially stayed flat during the time frame, the median annual cost for nursing homes has shot up from $65,200 to $83,900, rising four percent in the last 12 months alone.

The fact is, many people want to be treated at home anyway. It’s what is comfortable.

This option may make a lot of sense for your loved one. However, it also requires a heightened level of commitment from close relatives and family members. When bringing him home care, you must never assume that just because someone has earned some level of medical education or training they are 100 percent trustworthy.

It’s important to carefully research both the agency and the professional with whom your loved one will interact. The reality is, your loved one may be more isolated at home than in a nursing home. There is less direct oversight from a physician and there aren’t other health care workers around to observe certain problems or concerns. The home health care worker might be more prone to cut corners with regard to care or even to take advantage of your loved one.

We are certainly not implying that this happens in all or even most cases – but it does happen, and it’s something about which family members and loved ones need to be aware.

This applies also to your loved ones’ finances. It’s not uncommon for aides or caregivers to help with paying certain bills or purchasing groceries or other necessities, particularly if the elderly person is widowed or otherwise living alone. But relatives must take care to closely watch transactions and bank balances to ensure this access is not abused.

Because you are trusting this person with the health and well-being of someone who is precious to you, don’t be worried about taking up someone’s time with your questions. You’ll want to ask about the agency’s licensing, whether it is certified by either Medicare/Medicaid or The Joint Commission. Ask too whether they carry malpractice and liability insurance.

With regard to quality of services, inquire about references and ask how long the agency has been operational. Ask whether an outside agency conducts regular inspections – and ask those inspection reports. (Be wary of an agency that is not inspected.)

You’ll want to know too about the individual workers, and whether the agency verifies employee references. Ask about the specific job descriptions and qualifications and whether workers receive special training or ongoing instruction.

If you do at any point suspect abuse or negligence on the part of your loved one’s home health care workers, do not hesitate to call us and learn more about your rights.
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If you went to a restaurant and ordered lobster and the waitstaff instead brought you fish sticks, you would likely refuse to pay for it.

Our Hollywood nursing home negligence attorneys know this is essentially what is happening with the nursing home industry and the taxpayers.

A recent Inspector General report found that in 2009 alone, nursing home conglomerates were paid $5 billion in taxpayer dollars for care that was either substandard or negligent. A total of 37 percent of all nursing homes that received federal dollars in the form of Medicaid reimbursements weren’t actually meeting plan-of-care standards for the patients for whom the facilities were collecting payment.

Brian Lee, Florida’s former Long Term Care Ombudsman, now leader of advocacy group Families for Better Care, said the laundry list of tragedies in our state alone each year could fill books. These include examples such as a military veteran whose care plan was not followed and he waited months for his catheter to be changed properly.

Skilled nursing facilities are required to hammer out and implement a care plan for each person in their care. Adherence to those plans is critical in assuring that the patient is going to receive an appropriate level of care. Not only were these nursing facilities delivering a poor quality of care with regard to medication management, wounds and therapy, 26 percent of them weren’t even taking the time to develop an adequate care plan in the first place.

The care plans are supposed to address problem areas, define clear objectives and detailed time frames. They are to be developed by an interdisciplinary team of medical professionals. Nearly 30 percent failed to meet at least one of these three criteria.

Almost all of these instances were preventable had the nursing homes simply formulated a good plan and then adhered to those basic standards of care. This is what they are supposed to be doing. This is why the government is cutting them a check. They don’t do it. The government still pays them.

In wound care, the report found one case in which a woman was admitted to a skilled nursing facility with a bed sore. During her time there, rather than improve, she developed three more sores. The wounds were not tracked or treated properly – yet the facility was reimbursed through Medicaid for her care.

In medication management, there were numerous reports of facilities overmedicating patients in order to keep them sedated and subdued.

In therapy, there was an example of a terminally ill cancer patient who was offered physical therapy five times a week by the skilled nursing facility – something for which the agency would be reimbursed by Medicaid. At some point, the patient informed the staff she did not want to continue. The staff ignored her request and forced her to continue the therapy throughout the remainder of her time there.

Many of these nursing homes, Lee said, are able to get away with it by essentially creating shell operations of LLCs that on paper appear to be quite poor. In reality, profits are funneled to publicly-traded Fortune 500 companies. These complex corporate structures are often difficult to unearth.

That’s why you need a law firm with experience and dedication.
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