2013 Spring Webinar Series 2013 Christian Brothers Services, Romeoville, IL. All Rights Reserved. No part of this presentation may be reproduced, stored in a retrieval system, or transmitted by any means without the written permission of Christian Brothers Services. Christian Brothers Risk Management Services Nursing Home & Health Care Ministry Documentation: Are you open for a lawsuit? February 21, 2013 2013 SPRING WEBINAR SERIES Opening Prayer Creator God, through your world and people that surround us, we pray that we may grow more aware this day of your life giving presence. Open our minds and hearts to apply the knowledge from today s webinar for the good of all. We ask these things in Jesus Name. Amen 1
Christian Brothers Risk Management Services Nursing Home & Health Care Ministry Documentation: Are you open for a lawsuit? Michael Airdo Partner Kopon Airdo, LLC Patrick Cella Partner Kopon Airdo, LLC 2013 SPRING WEBINAR SERIES LEGAL DOCUMENTS 5 Nursing Home Chart 6 2
Humorous Nurses Notes 7 Pt alive but hope to remedy situation by AM Alert and organized x3 Patient is confident of bowel and bladder. The patient has no previous history of suicides. Patient has chest pain if she lies on her left side for over a year. On the second day, the knee was better, and on the third day it disappeared. LITIGATED MATTERS 8 Common basis for lawsuits against nursing homes Falls Pressure ulcers and bed sores Dehydration and malnutrition Physical or verbal abuse Medication errors Failure to timely notify a physician and/or family Failure to recognize the signs and symptoms of a potential problem 9 If it s not in the chart, it didn t happen. 3
Policies and Procedures 10 Well-crafted charting policies Best possible resident care and treatment Protection in litigation Only Create Policies/Procedures that can, and will, be followed Train Supervise Audit GENERAL CHARTING PRACTICES 11 Documentation Practices Legibility Abbreviations Basic information Resident Author Date and time GENERAL CHARTING PRACTICES, CON T 12 Documentation Practices, Con t Specific and substantive terminology Correcting documentation errors Documenting medications Contemporaneous documentation Transfer/Discharge forms and instructions Criticizing care subjective versus objective 4
NURSING HOME CHART CONTENTS 13 Doe, Jane Face Sheet Transfer Forms Medical History and Physical Examination Intake Evaluation Care Plan Nursing Notes Physician s Orders and Progress Notes Social Service Notes Advanced Directives DOCUMENTING COMMUNICATIONS 14 Who to Contact Physician/nurse practitioner Family/Guardian Resident When to Contact Significant changes in resident s condition Changes in resident s treatment plan What to Document Time and date Information communicated Physician Visits Attempted Communications 15 5
16 DOCUMENTING PRESSURE SORES/ULCERS Rise in Pressure Sore/Ulcer Lawsuits Pressure Sore/Ulcer Documentation Staging Accurate Timely Assessments Accurate Regular Notification Treatment plan Ways to Decrease Exposure to Liability Procedures for prevention Proper documentation 17 18 6
19 DOCUMENTING RESIDENT FALLS 20 Increased Freedom = Increased Falls = Increased Lawsuits Fall Incident Documentation Resident interview Contemporaneous Verbatim if possible Notification Ways to Decrease Exposure to Liability Procedures for prevention care plans Proper documentation Communicate with physician and family THE USE OF RESTRAINTS 21 Balancing Fall Prevention with Resident Freedom What Constitutes a Restraint Any manual method or physical or mechanical device, material, or equipment attached or adjacent to a [nursing home] resident s body that the resident cannot remove easily and restricts freedom of movement or normal access to one s body. 210 ILCS 45/2-106 7
DOCUMENTING USE OF RESTRAINTS 22 Decision Making Process Communication with Resident and Family Physician s Order Medical Reason for Restraint Description of Restraint Used Alternative Methods of Restraint Attempted Ongoing Assessments of Resident s Response to Restraint UNINTENDED WEIGHT LOSS 23 Signs and Symptoms Needs assistance eating and drinking Eats less than half of meals/snacks Refuses meals Mouth pain Improperly fitted dentures Difficulty chewing and/or swallowing food Chokes or coughs when eating Depressive symptoms Diabetes, chronic obstructive pulmonary disease (COPD), cancer, HIV, or other chronic diseases 24 Documenting and Reporting Weight Loss Steps for Proper Documentation 1. Recognize S/S 2. Document S/S 3. Weigh the Resident 4. Physician Notification 5. Create and Document Treatment Plan 8
DEHYDRATION SIGNS AND SYMPTOMS 25 Early to Mild Dehydration Flushed face Extreme thirst Dry, warm skin Reduced amounts of urine dark yellow in color Dizziness made worse when standing Weakness Cramping in the arms and legs Crying with few or no tears Irritability Headaches Dry mouth and tongue with thick saliva Moderate to Severe Dehydration Low blood pressure Fainting Several muscle contractions Convulsions Bloated stomach Heart failure Sunken dry eyes Skin loses its firmness Lack of elasticity of the skin Fast, weak pulse DOCUMENTING DEHYDRATION 26 Recognize S/S Document S/S Document Intake & Output Notification Create and Document Treatment Plan 27 9
28 Assessments 29 Document all assessments Even if no change in condition is noted Be specific and detailed Note everything that was assessed and any determination made You will forget the moment Documentation is best evidence to establish that you looked for the signs and symptoms of a particular problem DOCUMENTING NON-COMPLIANCE 30 Resident or Personal Representative Refuses Treatment Date and time Staff teaching and instructions Notification Resident Checks Himself/Herself Out Conversations Notification 10
CONCLUSION 31 Perform and document a thorough initial assessment Plan of care should reflect problems identified in assessment Document all conversations with family Document all interdisciplinary conversations (with physicians, physical therapists, etc.) Document all staff teaching and instructions Document all nursing interventions Document objectively For Questions Regarding Nursing Home and Health Care Ministry Documentation Contact: Jeff Harrison at jeff.harrison@cbservices.org 800.807.0300 x 2543 11
For the link to the handouts from today s webinar email: cbs.webinars@cbservices.org Thank You 2013 Christian Brothers Services, Romeoville, IL. All Rights Reserved. No part of this presentation may be reproduced, stored in a retrieval system, or transmitted by any means without the written permission of Christian Brothers Services. 12