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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. LEARNING OBJECTIVES. Identify internal causes of increased risk and preventive interventions to address risks.

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High risk areas for litigation

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


Learning objectives

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.


High risk areas for litigation

REASONS FOR INCREASED RISK


High risk areas for litigation

FACILITY ISSUES


High risk areas for litigation

Failure to adequately assess and document resident conditions


Admission assessment

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.


Medical records

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


Gait and mobility issues

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


High risk areas for litigation

RESIDENTS WITH HIGH ACUITY


Proceed with caution

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


Proceed with caution1

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)


Don t forget the environment

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


Knowing the increased risk

KNOWING THE INCREASED RISK…

WHY DO WE ACCEPT HIGHER ACUITY


Most common reason

MOST COMMON REASON?

  • CENSUS BUILDING!

  • Facility focused on improving overall census

    • Critical to improving bottom line

    • However proceed with caution!


What is your process

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?


Bottom line

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?


Okay you agree to accept them

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


High risk areas for litigation

STAFF TRAINING


Training of direct care staff

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


Staffing for acuity

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


How to do an acuity study

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


Acuity study

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


Acuity study1

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.)


High risk areas for litigation

PREVENTIVE MAINTENANCE


Great programs

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


Ready to handle in house

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?


Individuality

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:


Not comprehensive

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


Remember

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


High risk just because

HIGH RISK….JUST BECAUSE!

  • A gazillion other reasons!

  • Critically look at your facility and systems


Reasons for increased risk

REASONS FOR INCREASED RISK

EXTERNAL INFLUENCES


Resident family expectations

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


Family denial

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.


Promises at admission

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!


Lack of communication post admission

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


Failure to notify family

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.


Regulatory woes

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


The big three

THE BIG THREE!

  • Many different claims filed annually

  • Most common areas of litigation

    - Pressure sores

    - Falls

    - Elopement


Different but the same

DIFFERENT BUT THE SAME?

  • What do each of these three areas have in common?

  • Hmmmmmmm


Failure to assess and document

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


When to assess and document

WHEN TO ASSESS AND DOCUMENT

Pressure Sore Risk

Falls Risk

Elopement Risk


Risk assessments

RISK ASSESSMENTS

  • Upon admission and weekly x4 weeks for pressure sore risk

  • Quarterly

  • Annually

  • Significant Change in Condition

    (Follow the RAI process and recommendations)


Pressure sore assessment

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


Fall risk assessment

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.


Elopement risk assessment

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.


Key interdisciplinary

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


Interdisciplinary approach

INTERDISCIPLINARY APPROACH

  • Each resident is assessed with any change in condition and quarterly.

  • An interdisciplinary team approach is essential!


Care plan development

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.


Monitoring and updating

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!!!!


Quality assurance

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.


Case studies

CASE STUDIES

  • The Pressure Sore Case Study

  • The Falls Case Study

  • The Elopement Case Study


High risk areas for litigation

All cases are real, only the identities of the parties have been changed to protect the innocent!


Pressure sore

PRESSURE SORE

  • Mrs. Prafo is an 86 year old widow who has lived alone for many years.

  • Her family lives out of state and visits only on the holidays.

  • She has many friends and neighbors who “look in on her” regularly, however, during the winter months she finds herself home alone most of the time.

  • It is difficult to get out to shop for essentials and it is becoming more difficult to maneuver around the house.


Mrs prafo

MRS. PRAFO

  • By the end of February Mrs. Prafo had been in her home alone for almost two months.

  • When her neighbor came by to check on her she found Mrs. Prafo sitting quietly in front of the television, apparently dehydrated with sunken eyes and poor skin turgor.

  • The neighbor called 911 and had Mrs. Prafo taken to the hospital.


Mrs prafo1

MRS. PRAFO

  • Mrs. Prafo stayed in the hospital for three days to be re-hydrated and receive physical and occupational therapy.

  • Her children were unable to come and live with her so the decision was made to transfer her to a nursing home.

  • On the fourth day post-admission to the hospital Mrs. Prafo was sent to a local nursing facility with

    orders for physical and occupational therapy.


Mrs prafo2

MRS. PRAFO

  • Mrs. Prafo arrived at the nursing facility at 4:30 pm on Tuesday.

  • The admission process was rushed and did not include a thorough skin assessment, weight, height, etc.

  • Later that week the MDS nurse was visiting with Mrs. Prafo to complete the 5 day assessment.

  • Upon performing a thorough skin assessment, the

    MDS nurse documented that Mrs. Prafo had an

    unstageable pressure sore on her left heel.


Mrs prafo3

MRS. PRAFO

  • Upon reviewing the medical record there was no

    mention of a pressure sore on the heel upon admission.

  • No treatment order was obtained upon admission and

    no treatment record was initiated.

  • When the admission nurse was questioned it was determined that no skin assessment had been completed upon admission.


Mrs prafo4

MRS. PRAFO

  • Was this wound considered facility acquired?

  • What could have been done to prevent this wound?

  • Would this wound be considered unavoidable?


Mr femur

MR. FEMUR

  • Mr. Femur, a long-term resident at a local nursing

    facility, was generally independent with ambulation

    and refused assistance from staff.

  • On Monday morning the nurse was administering medication in the room across the hall and observed Mr. Femur thrashing about on his bed.


Mr femur1

MR. FEMUR

  • When she went to investigate she found Mr. Femur diaphoretic, groaning and clutching his right leg in pain.

  • When he was asked what happened Mr. Femur stated “I fell on the floor”.


Mr femur2

MR. FEMUR

  • The nurse immediately called for assistance and

    performed a head-to-toe assessment on Mr. Femur.

  • There was a contusion to the right hip area but no other injuries were noted.

  • The leg was in proper alignment with no evidence of lengthening or external rotation.

  • A portable x-ray was obtained that was negative for

    fracture.


Mr femur3

MR. FEMUR

  • Mr. Femur continued to complain of pain and refused to get out of bed.

  • The following morning Dr. Bone ordered a transfer to the hospital.


Mr femur4

MR. FEMUR

  • Mr. Femur was assessed in the emergency department,

    held for 23 hour observation and was returned to the

    nursing center the following morning with a diagnosis of contusion to the right hip.

  • The resident did not attempt to get up and required medication around the clock for pain management.

  • At 5:00 am the second day post re-admission Mr. Femur was observed lying on the floor next to his bed…..dun, dun


Mr femur5

MR. FEMUR

  • Upon assessment there was evidence of external

    rotation, lengthening of the right leg and an increase in the level of pain.

  • Mr. Femur was sent to the hospital and admitted for an ORIF of the right hip.

  • What could have been done to prevent the second fall?


Mr femur6

MR. FEMUR

  • Was there an assessment to determine the residents safety awareness?

  • Did the pain medication affect his safety?


Elopement

ELOPEMENT

  • Mrs. Houdini was a resident in a facility for mentally impaired resident for several years.

  • As her overall mental status and cognitive level

    declined the facility relocated her to another unit

    within the center.

  • Mrs. Houdini did not appear to be adjusting well to her new environment and continued attempting to leave the building


Mrs houdini

MRS. HOUDINI

  • There was no formal assessment performed to determine the level of risk of elopement.

  • There were no interventions initiated to provide a safe environment for Mrs. Houdini.


Mrs houdini1

MRS. HOUDINI

  • It was very cold outside with below zero temperatures for several days.

  • On Tuesday afternoon Mrs. Houdini did not come to lunch.

  • At dinner the evening aide asked “where is Mrs. Houdini”, she hasn’t come to dinner.

  • It was then that the staff realized that Mrs. Houdini had been missing since before lunch and no one had attempted to locate her.


Mrs houdini2

MRS. HOUDINI

  • A search was conducted, the police were called, and

    the family was notified.

  • Mrs. Houdini was found in the courtyard behind the first unit she had lived in.

  • Mrs. Houdini had frozen to death and had been dead for at least 4 hours.


Mrs houdini3

MRS. HOUDINI

  • The staff interviewed indicated that there were no procedures for monitoring residents with a history of elopement.

  • No assessments were in place to determine a residents elopement risk.

  • What could have been done to prevent this incident?


To summarize

TO SUMMARIZE…..

  • Perform a thorough assessment for risk in all areas including environment!

  • Document identified risks and appropriate interventions.

  • Monitor for changes in resident condition and update care plan interventions timely.

  • Perform regular rounds focusing on areas of risk and address issues immediately.


Questions

QUESTIONS?

Thank you for allowing us to share your

conference with you!


References

REFERENCES

  • CDC “Preventing Falls: What Works “ 2008

  • Hamilton, PM. (2008). Pain Management: Legal and Ethical Issues. Wild Iris Medical Education. Retrived from http://www.nursingceu.com/courses/278/index_nceu.html

  • Pressure Ulcer Prevention Points (2007). Retrieved 1/29/11 from http://www.npuap.org/PU_Prev_Points.pdf

  • RAI User’s Manual, MDS 3.0 (2010). HCPro.

  • Weinzweig, A. “Zingerman’s Guide to Giving Great Service.” 2008


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