HIGH RISK AREAS FOR LITIGATION

1. HIGH RISK AREAS FOR LITIGATION Maneuvering the Maze Preventing Disaster Angie Szumlinski, LNHA, RN-BC, RAC-CT, BS Erica Holman, LNHA, MSW HealthCap Risk Management Services

2. LEARNING OBJECTIVES • Identify internal causes of increased risk and preventive interventions to address risks. • Identify external causes of increased risk and preventive interventions to address risks. • State the importance of risk assessment and documentation practices.

3. REASONS FOR INCREASED RISK

4. FACILITY ISSUES

5. Failure to adequately assess and document resident conditions

6. ADMISSION ASSESSMENT Common documentation issues • Incomplete information; blanks on assessment tools • Inaccurate information • Lack of physical assessment such as skin integrity • Lack of psychosocial assessment regarding behaviors • Failure to obtain historical information; elopement history, suicidal ideation, etc.

7. MEDICAL RECORDS Medical information not updated to reflect current status: • Falls interventions not updated on care plan • Newly acquired pressure area with no measurements or care plan in place • Elopement attempts documented in nurse’s notes; lack of preventive interventions on care plan

8. GAIT AND MOBILITY ISSUES • Issues with lack of safety awareness, safe mobility not addressed immediately • Failure to determine whether resident can safely ambulate on the unit • PT/OT consults not followed up on timely • Mechanical devices to assist in mobility not made available or inappropriate

9. RESIDENTS WITH HIGH ACUITY

10. PROCEED WITH CAUTION! • Provide appropriate staffing to meet needs • Determine if licensed staff or non-licensed staff numbers need to be increased • Provide additional training opportunities to support caring for higher acuity

11. PROCEED WITH CAUTION • Remember…… • Higher acuity doesn’t necessarily mean clinical issues • Behaviors can be more challenging, etc. than clinical acuity • Proceed with caution (I know I already said that)

12. DON’T FORGET THE ENVIRONMENT • Assess environment to ensure the needs of residents exhibiting behaviors such as exit seeking can be met • Ensure that appropriate assist devices, durable medical equipment, etc. are available at admission

13. KNOWING THE INCREASED RISK… WHY DO WE ACCEPT HIGHER ACUITY

14. MOST COMMON REASON? • CENSUS BUILDING! • Facility focused on improving overall census • Critical to improving bottom line • However proceed with caution!

15. WHAT IS YOUR PROCESS? • Who determines the appropriateness of each referral prior to accepting? • Who has the final say? • How involved are the corporate support staff? • Are referrals electronic?

16. BOTTOM LINE? • Do not accept admissions the staff are unable to provide the appropriate care • On one claims call more than ½ of the claims involved residents in our facility < 30 days • This is very telling…..does anyone understand why? • What does this tell us?

17. OKAY YOU AGREE TO ACCEPT THEM • Be sure appropriate equipment is available for special needs residents • Have consultations for psychiatry immediately upon admission for mental health referrals • Pharmacy review of all medications used to alter mental status/manage behaviors • Staffing to meet the needs of the resident and the overall unit

18. STAFF TRAINING

19. TRAINING OF DIRECT CARE STAFF • License or certification not enough today • Competency evaluations are a must • Return demonstrations very beneficial in the evaluation process • Hands on exposure to new techniques • Continuous support and supervision • Availability of resources

20. STAFFING FOR ACUITY • We already discussed this but it can’t be stressed enough • “We’re meeting minimums” is not enough! • Assigning staff to units based solely on the number of residents is not enough • Perform an acuity study unit by unit to determine acuity levels is recommended

21. HOW TO DO AN ACUITY STUDY • No secret to it, not necessary to have a special computer program • It is helpful to have a QI report but in the absence of that report, use the Matrix • Identify residents with high ADL needs (feeding, incontinence, etc.) • Identify residents with behaviors

22. ACUITY STUDY • Assign a score to each category and level of care: • Total feed = 2 points • Set up/cuing = 1 point • Be consistent with the scoring • Total the number of points • Determine level that works for your facility

23. ACUITY STUDY • This can be very telling • Your facility may have negative outcomes related to weight loss • Identifying ADL acuity can help reduce weight losses as there are extra hands on deck for meals! • Think about outcomes related to ADLs (i.e., pressure sores, falls, weight loss, etc.)

24. PREVENTIVE MAINTENANCE

25. GREAT PROGRAMS • There are many great electronic/web based programs that can assist • The cost is relatively low considering the amount of support received • If your program is overwhelming or not well managed this might be a consideration

26. READY TO HANDLE IN-HOUSE? • Where do we start? • What types of “risks” do we assess and on what schedule? • How many FTEs do we need to accomplish the task? • Yikes, what’s the name of that company that does web based programs?

27. INDIVIDUALITY • Each building is unique • Long-term care settings typically face the same challenges no matter what level of care • A list of common areas of risk include:

28. NOT COMPREHENSIVE! • Door and stairwell alarms • Wanderguards and batteries • Courtyards and grounds free of hazards • Gate security • Water temperatures monitored and logged • “Wheelchair clinics” • Environmental rounds • Document, document, document

29. REMEMBER • Set realistic expectations early in admission process • Provide information for residents that will enhance their stay • Be available to resolve issues immediately so that they don’t fester • Document complaints/concerns on a log along with resolution

30. HIGH RISK….JUST BECAUSE! • A gazillion other reasons! • Critically look at your facility and systems

31. REASONS FOR INCREASED RISK EXTERNAL INFLUENCES

32. RESIDENT/FAMILY EXPECTATIONS • Preconceived ideas of what nursing homes are • Expectations that hospital routine and staffing levels will be similar • Physician availability • Adjustment concerns • Financial concerns • Personality differences with staff

33. FAMILY DENIAL • Residents usually admitted following catastrophic event • Family not accepting prognosis or long term plan • Expressing anger toward staff causing decreased communication • Disrupt direct care givers causing lapses in care to resident.

34. PROMISES AT ADMISSION • Know what the admission person is telling residents and families • Know what hospital discharge planners are telling referrals • Review admission packet to ensure information is accurate and clear • Never make promises….never!

35. LACK OF COMMUNICATION POST ADMISSION • No management staff in building during peak visiting hours (week-ends; evenings) • No follow up calls to assess level of satisfaction • Risks in resident status not shared with guardian/DPOA • Negative outcomes not communicated timely

36. FAILURE TO NOTIFY FAMILY • Post fall, skin integrity issue, weight loss, behavior, etc. • Medication changes to address behaviors • Attempts to leave building unattended • Non-compliance with drug regime or treatment modalities • Etc.

37. REGULATORY WOES • Actual harm citation • Substandard level of care citation • Immediate jeopardy citation • All increase risk to the facility as they question the quality of care provided

38. THE BIG THREE! • Many different claims filed annually • Most common areas of litigation - Pressure sores - Falls - Elopement

39. DIFFERENT BUT THE SAME? • What do each of these three areas have in common? • Hmmmmmmm

40. FAILURE TO ASSESS AND DOCUMENT Lack of assessment and supportive documentation the most common reason identified: • Staff are unaware a resident is at risk due to poor assessment • Family is not aware of the resident being at risk • Resident experiences negative outcomes

41. WHEN TO ASSESS AND DOCUMENT Pressure Sore Risk Falls Risk Elopement Risk

42. RISK ASSESSMENTS • Upon admission and weekly x4 weeks for pressure sore risk • Quarterly • Annually • Significant Change in Condition (Follow the RAI process and recommendations)

43. PRESSURE SORE ASSESSMENT • Head to toe physical examination. • History of previous skin integrity issues. • Medical conditions that may contribute to increased risk (i.e., low visceral protein stores, weight loss, diabetes, etc.). • Use accepted, objective assessment tool i.e., Braden, Norton Scale. • Therapy screen for mobility & seating/posture. • Nutritional assessment and interventions

44. FALL RISK ASSESSMENT • Head to toe physical examination. • History of previous fall/balance/gait issues. • Medical conditions that may contribute to increased risk (i.e., recent fall with fracture, unstable blood pressure, use of assistive devices, medications, etc.). • Use accepted, objective assessment tool • Therapy screen for mobility & seating/ posture.

45. ELOPEMENT RISK ASSESSMENT • Head to toe physical examination. • History of previous wandering/elopement attempts. • Medical conditions that may contribute to increased risk (i.e., early dementia, acute infection, transfer trauma, delirium, etc.). • Use accepted, objective assessment tool. • Therapy screen for mobility & seating/ posture. • Social Service/activity assessment and planning.

46. KEY – INTERDISCIPLINARY! • This is not an individual assessment. • All disciplines must be involved. • Care plans must reflect the interventions identified. • It is critical to monitor ongoing and update interventions as needed. • Don’t expect what you don’t inspect…. perform regular rounds

47. INTERDISCIPLINARY APPROACH • Each resident is assessed with any change in condition and quarterly. • An interdisciplinary team approach is essential!

48. CARE PLAN DEVELOPMENT • Each team member should participate in care planning identified issues. • Care plans should be updated at a minimum on a quarterly basis. • Acute care plans should be initiated for new onset, unexpected changes in condition. • Acute care plans should be discontinued when no longer pertinent. • Care plans should address interdisciplinary interventions and be resident specific.

49. MONITORING AND UPDATING • Ongoing process of maintaining accurate resident care information. • Monitoring and assessing residents on a regular basis to ensure medical record is accurate. • Avoid discrepancies between care plans and actual care delivery. • Remember if you don’t inspect it, don’t expect it!!!!

50. QUALITY ASSURANCE • Process of keeping the interdisciplinary team focused on outcomes. • Holds team members accountable for outcomes directly related to delivery of care. • Interdisciplinary team/peer review encourages open communication. • Corrective action initiated when trends are observed. • QA process can assist in improving care.