Duty: Communicate Client Information to Authorized Persons Task : E.01 Report abuse of client E.02 Report client s unusual behavior E.03 Complete incident report E.05 Respond to authorized persons request for information E.06 Address client s concerns Duty: Perform administrative tasks G.02 Complete client documentation G.07 Complete medication documentation G.10 Document work completed G.11 Document client s behavioral issues G. 16 Complete daily staff notes
Objectives: Identify signs and symptoms of elder abuse or neglect. Describe steps to take when abuse or neglect is suspected. Describe guidelines for documenting client care. Identify the purpose of an incident report. Describe confidentiality when sharing client health information with authorized persons. Identify client rights
Anyone who cares for the elderly must learn to recognize the various forms and signs of elder abuse. Aides are in the best position to observe and report signs of abuse and neglect. Be alert for possible abuse and report any unexplained injuries or sudden behavioral changes. Report it immediately. Failure to report any suspected abuse or neglect is grounds for legal action
Active neglect -purposely harming a person physically, mentally, or emotionally by failing to provide needed care. Passive neglect - unintentionally harming a person by failing to provide needed care. Self-neglect the older person fails to meet hi or her physical, psychological or social needs. Physical abuse -any treatment, intentional or unintentional, that causes pain or injury to a person s body. Psychological or mental abuse -any behavior that causes a person to feel threatened, fearful, intimidated, or humiliated in any way; includes verbal abuse, social isolation, and seclusion.
Verbal abuse -oral or written words, pictures, or gestures that threaten, embarrass, or insult a person. Sexual abuse - forcing a person to perform or participate in sexual acts against his or her will; includes inappropriate touching of the body, sexual contact, penetration, or sharing sexual stories or material. Financial / Material abuse -stealing, taking advantage of, or improperly using the money, property, or other assets of another.
Possible causes of abuse: Caregiver stress from the responsibility and demands of caregiving Dependency or impairment of the older person, increasing stress on the caregiver External stresses on the caregiver such as financial, job, or other family responsibilities Social isolation Cycle of violence within a family Substance abuse or mental disorder of the abuser
These suspicious injuries should be reported: Teeth marks Belt buckle or strap marks Old and new bruises, contusions, or welts Scars Fractures, dislocation Burns of unusual shape and in unusual locations, cigarette burns, scalding burns Scratches and puncture wounds Scalp tenderness and patches of missing hair Swelling in the face, broken teeth, nasal discharge Bruises, bleeding, or discharge from the vaginal area
Signs that could indicate abuse include: Fear, apprehension, fear of being alone Constant pain Withdrawal or apathy Alcohol or drug abuse Agitation or anxiety, signs of stress Low self-esteem Mood changes, confusion, disorientation Private conversations are not allowed, or the family member/caregiver is present during all conversations Yelling, obscenities or threatening language Personal belongings are missing Missing bank statements, unusual banking activity
Signs that could indicate neglect include: Pressure sores Poor personal hygiene Soiled bedding or incontinence briefs not being changed Poorly-fitting, soiled clothing Unmet needs relating to hearing aids, glasses, etc. Weight loss, poor appetite Dehydration Living conditions that are unsafe, unclean, or inadequate
Suspicions of abuse must be reported. The aide should report her observations to her supervisor who will follow through with reporting it to the correct community agency. Hamilton County Department of Jobs and Family Services Adult Protective Services If the aide does not work for an agency, he/she is required by law to report the suspicion of abuse or neglect directly. Reporters can remain anonymous if they choose.
Maintaining documentation means keeping a record of everything that was done with and for the client during the visit. Accurate documentation: Is the only way to clearly communicate between all team members. Creates a sequential record of all client care. Provides an up-to-date record of the status and care of the client.
The medical chart is a legal document. What is written in it is considered in court to be what actually happened. In general, if something does not appear in the client s chart, it did not legally happen. Failure to document could cause serious legal problems for the aide and the agency. It could also cause harm to the client. Remember: if you did not document it, you did not do it. All medical charts are confidential. Keeping the information confidential is the aide s legal, ethical and moral responsibility.
Client care records may be handwritten or entered on a computer. The aide should always follow the agency policies for documentation. Visit records, progress notes or care logs record the aide s care and observations during each visit. This should include personal care provided, homemaking tasks completed, environmental safety concerns, physical, emotional or behavioral changes, client and/or family concerns, food and fluid intake, irregular elimination, medication non-compliance. Some agencies use a check-off sheet. This may be referred to an ADL (activities of daily living) sheet.
Guidelines for completing aide visit records/progress reports: Complete record during or immediately after visit. Never record care before it has been done. Write facts, not opinions. Write neatly with black ink; do not use pencil. Correct errors properly - do not erase, black out, or use white-out on errors; put one line through the mistake so it can still be read, initial and write correct statement. Accuracy is essential Date, time and sign full name and title. Document per care plan.
An incident report is a written report that details an accident or other significant event that occurs during a visit. Examples of events that are considered incidents and should be documented and reported: Client falls Damage to or missing client property Sexual advances or remarks Unsafe situations Injury from accidents Blood or body fluids exposure
The client s health information may be requested by another member of the medical team. All health information is protected by the Health Insurance Portability and Accountability Act (HIPPA). The aide should validate the authorization of the person requesting the information before sharing it. Aides have both a legal and moral responsibility to keep all client health and personal information confidential. Care should be taken to protect the confidentiality of protected information during the process of transferring it to an authorized person. Clients have a right to access their own medical records and to obtain copies of their own records.
Clients of Home Care have the right to: The right to be treated with respect and dignity. The right to be treated fairly without discrimination based on race, color, sex national origin, age, religion, and disability. The right to self-determination, including participation in developing ones own plan of care and the choice of caregivers or service providers. This includes the right to be informed so that you can make sound decisions. The right to be given a fair and comprehensive evaluation of health and safety factors with regard to functional, psychosocial and cognitive ability. The right to have access to needed health and social services. The right to be told of realistic care alternatives.
Clients of Home Care have the right to: The right to privacy and confidentiality. The right to review your records and to have the information explained when necessary. The right to be notified in advance of any change in services or issues that may affect the continuation of services. The right to voice dissatisfaction and/or initiate the grievance procedure. The right to know the cost of any service prior to receiving the service.