Alabama Personal Injury Blog - Nursing Home

New Website to Help Families Learn About Nursing Homes

Billy Cunningham — Sat, 14 Nov 2009 08:40:00 GMT

The National Citizens for Nursing Home Reform (http://www.nccnhr.org/ ), a consumer advocacy group for nursing home residents and caregivers in nursing, homes, announced that the Brown University Center for Gerontology and Healthcare Research has introduced a website designed for nursing home researchers that provides data on nursing home care in the US. The website states that its goal is to allow researchers to trace relationships between state policies, local market forces and the quality of long-term care and enable policymakers to craft state and local guidelines that promote high-quality, cost-effective, equitable care for older Americans. NCCNHR believes the site will also be enthusiastically received by many consumer advocates looking for detailed data and more sophisticated comparison tools than provided on other website such as Nursing Home Compare.

The interactive database, www.LTCfocUS.org, incorporates information from a number of government sources-Medicare reimbursement claims, OSCAR (CMS's Online Survey, Certification and Reporting system), the MDS (Minimum Data Set), and Brown's own survey of state Medicaid policies Users can interact with the website by creating interactive maps and tables with comparative information about states, counties, or individual nursing homes. All data provided on the website are also available to download.

The website provides the type information that users can employ to choose up to five variables. It allows the user to create a chart comparing all nursing homes in a state. The broad range of variables from which to choose includes number of beds; for-profit and chain status; percent of Medicare and Medicaid beds; Alzheimer's units; occupancy rates; age ranges, gender and race of residents; direct care staffing (RN, LPN, CNA); acuity of care; certain MDS quality measures; source of admissions (hospital or home); and 30-day rehospitalization rates (a potential indicator of quality not found on Nursing Home Compare).

The website is sponsored by the National Institute on Aging-funded Shaping Long-Term Care in America project housed at the Brown center. While its stated purposes are to "allow researchers to trace clear relationships between state policies and local market forces and the quality of long-term care" and to allow policymakers "to craft state and local guidelines that promote high-quality, cost-effective, equitable care to older Americans," NCCNHR recommends that consumer go to this site to perform their researches about nursing homes in their areas before placing a loved one there. The more you can know about your options for placing loved one in a nursing home , the better equipped you'sll be to help prevent any nursing home negligence or abuse.

Originally posted at InjuryBoard by Billy Cunningham

Caps on Damages Make No Sense

Billy Cunningham — Sat, 07 Nov 2009 11:14:08 GMT

The Republican proposal on health care reform has provisions to limit compensation for non-economic injuries to persons injured or killed as the result of medical malpractice including residents of nursing home who are neglected or abused. Most of my practice over the past 23 years of my 35 year career has been representing nursing home residents. I began thinking of how I would tell clients and/or their families that nursing home neglect and abuse was included in the medical negligence bill proposed. How do I explain that injuries to the elderly, vulnerable members of our society are limited? Here are people who cannot protect themselves, who rely on nursing homes for their safety and well being, and to provide a quality of life that Congress knows what the limit of those injuries are? I thought of all the cases that I have handled involving injuries in nursing homes. The following are actual examples of victims of nursing home neglect and abuse that under the standard proposed by the Republicans would be limited in any award against the nursing home that caused the injuries or death the award.

Mr. A. who had a grapefruit sized vaginal malignant tumor that the nursing home never knew about- death case.

Mr. B. , an Alzheimer patient in a ‘special unit’ who despite no other physical diseases developed multiple state 4 pressure sores, contractures and severe weight loss – death case.

Mr. C., a smoker, who was strapped in a wheelchair and unwatched burned to death when a lighter caught his clothing on fire.

Mrs. D who was overdosed with psychotropic medications to keep her quiet and while trying to escape the torture fell in a bush and lost an eye. After this incident she was moved to a nursing home that properly cared for and weaned her off the psychotropic medications. She was discharged and the last I heard was playing the slot machines in Biloxi. Personal injury case.

Mr. E. who was beaten to death by another nursing home resident who had previously beaten other resident. No precaution was taken to protect any of these residents.

Mr. F. who was demented and known to have a desire to leave the facility and fell from an open window. death case

Mr. G. who went in a nursing home for a 21 days rehabilitation after hip surgery and developed a pressure sore so big on his leg that the leg had to be amputated- personal injury case.

When you look at the data which shows that medical malpractice is a very miniscule part of the cost of health care, you have to ask yourself whether proposed limits are fnecessary for health care reform or fair to the victims.

Originally posted at InjuryBoard by Billy Cunningham

Contact You Congressman to Pass the Fairness in Nursing Home Arbitration Act

Billy Cunningham — Sat, 31 Oct 2009 10:53:09 GMT

Last January I wrote a blog on the Fairness in Nursing Home Arbitration Act (then Senate Bill . 2838 and now Senate Bill 512) The last report from Congress is that the bill was referred to committee in July. I said then that we all need to keep an eye out for the bill and write our Senators. With Congress in the midst of debating and considering the health package now is a good time to ask them to pass this bill to protect our elderly.

The bill would amend the Federal Arbitration Act (FAA) to invalidate mandatory binding arbitration contracts that are unfair to the elderly because they take away their right to be heard in a court of law and increase their vulnerability to neglect and abuse in a care facility.

The bill does not prohibit arbitration. Rather, it would ensure that the resident or his or her representative could voluntarily choose arbitration after a dispute arose. If arbitration is truly fair and efficient, as some have argued, then both sides should be able to voluntarily choose arbitration after - not before - a dispute arises.

I have seen nursing home corporations insert forced arbitration clauses in their contracts and have them signed by residents who have dementia, by family members who are told they have to sign the whole agreement or their loved one will not be admitted and by the nursing homes own employees who forge signatures. Why do the nursing homes want arbitration so badly? Because it means they will never be held publicly accountable for their actions, no matter how egregious their conduct. Then when a decision is made by most likely a hand-picked arbitrator, the patient is denied the opportunity for judicial review.

On the other hand, if allowed to utilize the court system, society benefits from an open legal process that exposes nursing homne neglect and abuse. One of the most important benefits of civil lawsuits is the discovery process, which often discloses shoddy corporate practices, such as staff reductions, that lead to neglect. Forced arbitration, on the other hand, restricts residents’ ability to get information and keeps abusive business practices hidden.

So again I urge you to contact your representatives in Congress and let’s get this bill passed!

Originally posted at InjuryBoard by Billy Cunningham

The Consumer's Role in the Nursing Home/Healthcare Reform Battle

Billy Cunningham — Sat, 24 Oct 2009 12:10:28 GMT

Health care reform is the big issue today- as it should be. But how will it affect our elderly in nursing homes? Nursing home owners say they are looking at $16 billion dollars in cuts from Medicare over the next 10 years. Is that so? The Washington, DC-based Center for Medicare Advocacy (http://www.medicareadvocacy.org/ ) reviews reports from the Government Accountability Office (GAO) and the Medicare Payment Advisory Commission (MedPAC) and advises that those reports show that Medicare overpays nursing homes billions of dollars a year. MedPAC found that the aggregate profit margins for freestanding nursing facilities exceeded 10 percent for seven years in a row. In 2007, their profit margin was 14.5 percent. Moreover, they didn’t add staff. So the Center for Medicare Advocacy believes that the nursing home operators are pocketing much of the profits, rather than reinvesting them. The reports also cannot account for money paid out to associated groups who own the property, manage the facility etc.

We read every day about Congress wrestling with health care reform. Hand in hand with Congress are the groups we refer to as lobbyist- there to make sure their particular industry is protected. One of those groups, of course, is the nursing home industry, which claims it is facing a $16 billion cut in direct support from Medicare over the next 10 years, as well as Medicaid cuts in many states.

The nursing home operators warn that further cutbacks in Medicare-which are part of the reform legislation– will drive many facilities out of business. Some homes are laying off employees now, and a few have recently closed. We are also seeing the nursing home reduce Registered Nurses with Licensed Practical Nurses in many areas. Meanwhile, the need for these institutions is increasing. As the number of people going into nursing homes increases so does the level of nursing care.

Are the nursing home owners trying to defeat healthcare reform because Medicare benefits reduction will affect care .or their bottom line? Is the advocacy center right that profits are really higher than reported? Nursing home owners have been known to put their own profits before people. There are cuts in Medicaid. We should all be concerned about the care our elderly will receive.

Knowing what is going on in your local nursing homes is probably the best each of us can do on an individual level. Check them out carefully before placing your loved one in a nursing home. The earlier you know what to look for to prevent nursing home neglect or abuse, the better for your loved one. Here are some cites that will give you information about getting good care: the National Coalition for Nursing Home Reform http://www.nccnhr.org/ , a governmental agency, the National Center Elder Abuse Http://ncea.aoa.gov , and Medicare web site http://www.medicare.gov/nursing/overview.asp.

There are warning signs that nursing home abuse or neglect may have occurred. It is not uncommon to hear reports of various forms of violence and irresponsible, inhumane treatment being inflicted upon residents, including: physical assault and battery ; sexual assault and battery; rape; deprivation of food and water; unreasonable or unwarranted physical or chemical restraint; withholding of needed medication ; overmedicating; suspicious injuries; appearance of untreated wounds, cuts, bruises, welts; reports by residents of being slapped, struck, pushed, shaken, beaten or likewise mistreated; improper confinement; serious injuries requiring emergency treatment or hospitalization; and incidents that result in broken bones, especially a fractured hip.

Originally posted at InjuryBoard by Billy Cunningham

Nursing Home Direct Care Givers are Essential to Good Care

Billy Cunningham — Sat, 05 Sep 2009 11:44:04 GMT

The SCAN Foundation, a California philanthropic organization which was established to advance the development of a sustainable continuum of quality care for seniors released a paper which confirmed that direct care workers (“DCWs”) are essential to quality nursing home and home health care for the elderly. Having well trained direct care workers reduces the chances of nursing home abuse or neglect. The paper is authored by Sarah Wells, the Executive Director and Alice Hedt, Consultant with NCCNHR, the National Consumer Voice for Quality Long-Term Care.

The paper involved a study of California nursing home and home health patients who are dependent on DCWs to address their most fundamental human needs. These DCWs often act as liaison to the nursing staff, reporting the care-receiver’s medical and emotional status to key nursing and medical personnel. The DCWs are likely the patient’s key connection to the outside world. Older adults who need assistance with almost every aspect of their lives often each morning are seen a greeted by a DCW who is assigned to them and who may spend only 20 to 40 minutes but who in that short time directly affect :

• When and whether they get out of bed

• How long they have to lie in wet pants

• What they want to wear

• Whether teeth are brushed, nails filed and body washed

• If the curtains are closed to protect privacy

• If the nurse is notified of the red spot on a heel that could easily become a bedsore

• Whether there is enough to eat and the patient is positioned correctly so not to choke

• Whether the water by the bed can be reached and if there is a straw that if needed

• Whether there is access to morning activities

• If the patient hears a few kind words

• Whether the patient is rushed or relaxed

• Whether the patient can call for help the rest of the morning by providing a telephone or call button

This scene is replayed daily in 1.6 million nursing home residents’ rooms throughout the country and in thousands of homes where older adults receive much needed medical care and assistance from home health care providers. No matter what laws and regulations are in place, no matter if the care is from a for-profit or not-for-profit organization no matter the amount of money being paid by the individual or by the State’s Medicaid program -- the experience of the older adult is determined by his or her interactions with the DCW.

The paper reiterates the 1985 NCCNHR study which identified the key components of quality from the consumer’s perspective. Nursing home residents throughout the country explained that the most important elements of quality in their day-to-day lives were the accessibility and attitude of the DCW. Since the 1985 study NCCNHR has actively and consistently studied how nursing home residents, individuals receiving care in their homes, family members and advocates have stressed that a good long-term care experience is dependent on having enough DCWs who are well trained and have a positive attitude. Training of the DCW is essential to providing this care. Poor training about dementia and mental health issues has been identified as a factor that contributes to nursing home neglect and abuse.

The paper cited that, for example, the third highest complaint in California is about staff attitudes - staff not treating residents with respect and dignity. The number one complaint category handled by California ombudsmen is another important DCW competency - handling roommate and resident conflict. Other important ‘non-medical care’ that promote quality of life as well as DCW job satisfaction include resident/care receiver rights, organizing work, empowerment, teamwork, stress management and cultural sensitivities. In other words, how a long term patient feels about their day to day existence and how a DCW feels about her job can affect how the patient responds both physically and emotionally. One long-time CNA summarized the link between quality of life and quality of care when she addressed a Career Nursing Assistants’ meeting saying, “We have all been taught how to clean up messes. The trick of being a good CNA is how to clean up messes and not make the resident feel bad, how to be supportive in my tone of voice and attitude.”

Through the paper, NCCNHR proposes that the DCW be taught the importance of cultural diversity, individualized care plans, systemic issues( pay issues, staffing issues, etc), dementia training and adult learning. The paper also points out the importance of supervisor training to learn and follow these same principles needed for these DCWs to perform their job. Utilizing these tools will help nursing homes and home health workers to provide better care for the patients and reducing nursing home neglect and abuse issues.

The paper can be read in its entirety at http://www.thescanfoundation.org/documents/reports/Convening%20Paper.pdf Please go to http://www.nccnhr.org/ for a review of all the many services NCCNHR can assist family members

Originally posted at InjuryBoard by Billy Cunningham

Nursing Homes Owners: Care Givers or Money Grubbers?

Billy Cunningham — Wed, 19 Aug 2009 18:53:32 GMT

While we have learned about nursing home owners and operators setting up sham corporations to own property, rent facilities, ‘manage’ nursing, and ‘consult’ with nursing homes allowing them to rake in money, I never thought I would see them scoop so low as to rip off their own underpaid employees. But more than 90 Missouri nursing homes figured it out by making payday loans to their own employees at high interest rates, then deduct payment of the loan, interest and fees from the workers' next paychecks!

The Better Business Bureau exposed this outrage on Tuesday. The reaction was swift and overwhelming. Missouri Gov. Matt Blunt announced: Nursing home operators will no longer be allowed to operate on-site payday loan operations that lend money to the nursing homes’ employees. Good for him. Those owners should be ashamed. Those of you old enough will remember that old Tennessee Ernie Williams song “16 Tons” where he laments that he loaded 16 tons of #9 coal, was another day older and deeper in debt. He cried “St. Peter, don’t you call me cause I can’t go- I owe my soul to the company store.” This practice is no different.

Before Gov. Blunt jumped in Missouri had 971 nursing homes and about 60 of them were operating payday loans in the facilities. While the arrangement may be legal, the BBB questioned the ethics of employers making money off the wages of their workers. Questioned? How about flat out, no excuse unethical. Let’s see. I want you to work a double shift because you owe us money and also it will keep us from having to hire more caregivers. Before the governor intervened, Missouri payday loan lenders could charge an annual percentage rate, or APR, of up to 1,950 percent on two-week payday loans. A spot check by the BBB found that one nursing home charged an APR of 912.5 percent, another charged 365 percent and a third charged 304 percent. Then to make sure they collect these outrageous fees, the lender is able to deduct the loan, interest and fees straight from the paychecks of nursing home workers, the BBB said.

The Better Business Bureau released the names of two allied groups of 62 nursing homes who hold payday loan licenses. Principals in the two groups are James and Judy Lincoln of Sikeston; Mathias Dasal of Eldon; Gary Crane of Rogers, Ark.; and Timothy Drake of Pascagoula, Miss. The lone director of the third group, with 30 nursing homes, is Don Bedell of Sikeston. The BBB said Bedell is also the sole director of a payday loan company that has licenses at those nursing homes.

A spokeswoman for the Community Financial Services Association, a national trade association for the payday loan industry, said she was unaware of any other states with a similar arrangement between nursing homes and payday loan operators. Well, look out for them. If you know of this practice going on in your state, contact someone and let’s get this stopped now!

Originally posted at InjuryBoard by Billy Cunningham

Nursing Home Caregivers Strike

Billy Cunningham — Sat, 08 Aug 2009 12:45:53 GMT

Over 300 union members at the four OMNI nursing homes in New Jersey have been without a contract since 2007. Two years ago, the owner of these homes, Avery Eisenreich, walked away from the negotiations and unilaterally implemented a number of changes including a loss of pension payments. He is currently being investigated by the National Labor Relations Board’s regional office in Newark for ‘bargaining in bad faith.

This news caught my eye because at a recent nursing home seminar I became aware of a lawsuit recently settled in New Jersey against one of the nursing homes purportedly owned by OMNI. I say purportedly owned by OMNI because during the course of that litigation a New Jersey lawyer, Saul Gruber, discovered a multitude of legal entities set up by Eisenreich to suck money away from the actual nursing home operation by setting up management companies, real estate investment trust and lease arrangements favorably to him.

The union news release reports that the workers at these home work hard to care for the elderly, but because of the low wages, many of them have to work two jobs just to make ends meet. While many Omni workers are paid wages that are less than $7.90 an hour – barely over the minimum wage, the union claims their employer, Avery Eisenreich, pays himself more than $1,500 an hour!

I posted a blog on 2009 about the problem of nursing home owners setting up these multiple legal entities to avoid liabilityand to syphon money away from the operation of the nursing homnes and into their own pocketbooks. I reported that Congress was considering legislation called the “Nursing Home Transparency and Improvement Act which is a part of the draft health care reform bills that the House and Senate are considering. The bills would make nursing homes disclose their owners and operators. At that time I reported that several large chains have been bought out by global private equity investors. Now we are seeing entrepreneurs like Eisenreich taking advantage of the elderly and their caregivers for the sake of making more money. InjuryBoard member Jessica Smagacz posted a blog yesterday on the report from the British Medical Journal that the best care is given at non-profit nursing homes. We now know that a majority of nursing homes are owned by for profit corporations. While our economic system encourages investing and making profits, it should not do so at the expense of elderly patients and without fairly compensating the care givers. The system can work. We have all seen it work and seen excellent care given. There is no excuse for nusring home abuse.

There are few, if any, unions in the South to protect workers in nursing homes. I hope the strike will make Mr. Eisenreich come to the table, treat the workers fairly and allow them to provide the proper care for the elderly. Maybe the word will get out to other owners who are in the buiness of operating nursing homes.

Originally posted at InjuryBoard by Billy Cunningham

Best Nursing Homes and Tips to Help Find Them

Billy Cunningham — Tue, 07 Jul 2009 13:16:25 GMT

The U.S. News and World Report’s July 7, 2009 issue has some very helpful information for those of us faced with putting a loved one in a nursing home. It also lists the 41 best nursing homes in the country. Sadly, none of those homes are in Alabama or Mississippi where I practice. On a bright note, Alabama and Mississippi are not on the list of 10 worst states either. That honor goes to Louisiana, Georgia, Tennessee, Oklahoma, West Virginia, New Mexico, Kentucky , Texas, Indiana and Ohio.

The article gives consumers steps to follow in deciding to place a loved on in a nursing home along with what to do after the placement is made. There is a ton of information. One easy way to access the article is online at : http://health.usnews.com/articles/health/best-nursing-homes/2009/07/02/best-nursing-homes-the-us-news-honor-roll.html

Here are some of the steps the article suggests for families’ to take:

(1) Decide if a nursing home is necessary. There may be other options like having a geriatric evaluation for the loved one, look in the community for ideas and help, or hire a geriatric manager.
(2) Build a short list of nursing home possibilities: Consider where you are and where the nursing home is. Count the number of nurses and aides as it is an excellent indicator of the care that may be available. Contact a local ombudsman. Obtain state information on the homes.
(3) Size up a nursing home by visiting. This can tell you many things. Talk to the administrator and question him politely about the information you gathered prior to visiting. Tailor your questions to your loved ones needs. Talk to the staff. Observe a meal. Observe an activities program. Notice the smell there.
(4) Follow up to see how the nursing home does in caring for your loved one. Be aware of an adjustment period. Remember this is long term. Observe special skills. Be firm in your loved ones needs. Work with the staff and win them over. Asked them about problems both in their work and in caring for your resident.
The article also gives information on ways to cover the cost of long term care.
We all hope to to push back the day of reckoning for months or years.. However, a frail elderly person who may have already fallen and broken a hip or who has been wandering the neighborhood because of progressing dementia must have full-time care. Use the steps recommended and it will help you and your loved one in the long run. We all want to prevent nursing home neglect or abuse. Taking these steps early is a preventive measure to secure good care.

Originally posted at InjuryBoard by Billy Cunningham

No Arbitration in Nurisng Homes Cases In Illinois

Billy Cunningham — Fri, 05 Jun 2009 13:05:06 GMT

In the case of SSC Odin Operating Co. v. Carter, Sue Carter the U. S. Supreme Court on June 1, 2009 by refusing to review an Illinois appellate court ruling, has tacitly agreed that a state law nullifying nursing home arbitration agreements supersedes the Federal Arbitration Act which favors arbitration agreements. This may be another chink in the arbitration armor used by nursing homes to force residents and their families to give up their rights to a jury trial.

The state legislature of Illinois had the wisdom to recognize that arbitration clauses in nursing home contracts are unconscionable and passed the Illinois Nursing Home Care Act (NCHA) which has provisions prohibiting the facility from enforcing an arbitration agreement. Apparently, despite the law, Odin Healthcare Center in Odin, Illinois required Joyce Gott to sign an arbitration agreement agreeing that in event she or her family wanted to pursue a claim against the nursing home there would no trial but instead the dispute would be decided by arbitration.. Her family recognizing that the legislature prohibited such agreements filed a wrongful death claim in state court. The nursing home operator asked the trial court to enforce the arbitration agreement and argued that the Federal Arbitration Act should overrule any state law governing arbitration agreements, especially in light of the fact that the NHCA applies to nursing home contracts in a broad and more generalized way, rather than specifically singling out arbitration agreements. A state appellate court ruled that the NCHA applied and struck down the arbitration clause. The Illinois Supreme Court refused to review the decision in October of last year. With its refusal to hear the case, the U.S. Supreme Court has let the lower court's ruling stand, thereby setting a precedent under which other states' laws might trump the Federal Arbitration Act.

The failure of the Supreme Court to consider this case should give those of us who believe the right to a jury trial is right granted to us under the constitution, have family members in a nursing home and/or who represent nursing home residents cause to rejoice. This is the way it should be. As I have written numerous times in blogs on InjuryBoard, arbitration is just not designed for consumer situations and most especially should not apply to the elderly in nursing homes. We have opportunities to use this ruling to show other sates how it can be done and to urge Congress to get the Fairness in Nursing Home Arbitration Act passed.

Originally posted at InjuryBoard by Billy Cunningham

Fairness in Nursing Home Arbitration Act Does Not Become Law

Billy Cunningham — Sat, 30 May 2009 09:05:53 GMT

In January I wrote a blog on S. Bill 2838, Fairness in Nursing Home Arbitration Act. This bill never became law. The last action taken by the Senate on the bill was in September when it was reported favorably out of committee and then on October 1, 2008, it was placed on the Senate Legislative Calendar under General Orders. Calendar No. 1109. This bill has now been proposed in previous Sessions of Congress last two years. At the end of each session all proposed bills and resolutions that haven't passed are cleared from the books. The bill was never debated by the Senate. This means the bill will have to be reintroduced under a new number in the next session.

The bill was sponsored by Sen. Mel Martinez [R-FL] and co-sponsored by Sen. Patrick Leahy [D-VT], Sen. Russell Feingold [D-WI], Sen. Richard Durbin [D-IL] and Sen. Herbert Kohl [D-WI]. I would urge all you to contact your Senators and Congressmen before the next session and urge them to get this bill reintroduced and passed.

Nursing home abuse continues and arbitration is not the way to handle these cases. When loved ones are put in nursing home today the facility often presents a series of documents to be signed in order for the family member to be admitted. Often stuck in the middle of all those is an arbitration agreement. I have never seen one drafted that is designed to favor or even equally treat the resident. Those agreements are signed by residents with dementia who do not have the capacity to enter into any other kind of contract. Or they may be signed by a family member who does not have a power of attorney or court appointment authorizing them to enter into contracts on their behalf. The nursing home does not care who signs them- it is just part of a process. That process is not in the best interest of the resident. I have seen forged signatures on nursing home arbitration agreements and had one facility admit it forged the signature.

One way to protect against this happening is for everyone to have a power of attorney that prohibits the attorney in fact from entering into any contract that has an arbitration clause or agreement in it. Here is an example of the clause that should be in every power of attorney:

“NO POWER TO AGREE TO BINDING ARBITRATION. Although I have given my attorney-in-fact this general and durable power of attorney, I specifically withhold from my attorney-in-fact the power to agree or consent to binding arbitration, or to agree to any other process that would preclude the right to have a jury decide any issue in controversy concerning my person or my property; this does not, however, preclude non-binding alternative dispute resolution processes such as mediation. “

There are things we can all do to protect our loved ones in nursing home. Let’s start a letter writing campaign now to get the Fairness in Nursing Home Arbitration Act reintroduced and passed.

Originally posted at InjuryBoard by Billy Cunningham