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Here are some situations that could possibly arise in a nursing home setting. How would you react? How can high-risk incidents devastate your long-term care facility? The high-risk incidents described here involve situations of elopement, falls, pressure ulcers, and medication errors. This risk management program will explain how these incidents can lead to devastating results for the long-term care setting. These four types of high-risk incidents will be discussed in greater detail throughout this educational presentation. 7

Did you take a few minutes to think about how you really would have reacted to the incidents on the previous slide? Is your first response panic? Wondering what to do? Your reaction to these incidents can put your residents and the future of your facility at risk due to litigation. If you react to those scenarios without knowing what to do, the results can lead to injury or death of the resident. In addition, the facility and you as an individual can be charged with a criminal act and suffer fines or imprisonment! The long-term care facility can also receive sanctions, making it financially harder to continue to provide care for residents. Weinberg and Levine describe specific interventions to help reduce liability risk in long-term care settings. These key points include: 1) family education; 2) good communication skills; 3) good risk management strategies; and 4) monitoring the care being delivered to residents. 8

In the past 20 years, nursing homes have seen a large increase in the amount of malpractice litigation! This calls for a need to improve education to decrease the risk of lawsuits. As per Weinberg and Levine, the increase in nursing home litigation has led to higher medical malpractice insurance premiums for physicians practicing in these facilities. As a result, some physicians refuse to see residents in nursing homes due to increasing costs of coverage. Some long-term care Medical Directors are unable to get any medical malpractice coverage for their administrative duties. This makes them vulnerable to litigation. What can your facility do to help manage risk? You can start using prevention strategies and education by working closely with the facility s administrative team to develop an overall risk management plan. 9

Throughout this educational program, you will learn about the high-risk occurrences of wandering/elopement, falls, pressure ulcers, and medication errors. Whenever a resident is at risk for elopement, the resident is also at risk for falls! This occurs because the resident may use back exits and staircases to escape from the facility. By the end of the program, you will understand why these incidents have high morbidity and mortality rates for residents of nursing home facilities. You will also understand how employees within the nursing home can greatly impact the rates at which these events occur and the outcomes that result from these occurrences. 10

Why is elopement a high-risk occurrence? Residents who elope can get lost, injured, or die! Since the resident who eloped was in the care of the long-term care facility, the responsibility for the resident lies upon the facility and its staff members. Litigation can lead to insurance companies paying large settlement claims, which make it hard for the facility to obtain future insurance coverage at reasonable rates. Patients with psychiatric conditions, including wandering, have a need for constant observation. To help allay this cost, Rausch and Bjorklund recommend using Bachelor s prepared psychiatric liaison nurses to provide constant observation for residents. These psychiatric liaison nurses can provide the resident with the appropriate observation needed to keep them safe. This permits the skilled nurses and nursing assistants to provide higher quality care since they will have more time to care for other residents. One way to decrease the risk of injury for patients prone to wandering is to position the mattress close to the floor. 11

The greatest risk for elopement by a nursing home resident is within the first 72 hours after admission! All staff should be aware of the nursing home s policies on, and prevention strategies to reduce, wandering and elopement. Middle management personnel need to engage the staff in regular practice and policy reviews on emergency procedures when a resident elopes. Resident risk factors for elopement include: 1) history of attempts for elopement (has the resident previously tried to escape from this facility or a different facility before?); 2) desire to escape (does the resident talk to staff or residents about wanting to escape the facility?); and 3) loitering around a locked door (is the resident hanging around a locked door that leads out of the facility, awaiting a chance to escape when someone walks through it?). It is important that nursing staff develop a care plan for residents who are identified as being at high risk for elopement. Rausch and Bjorklund s psychiatric liaison nurse pilot project, performed in 2008, resulted in a decrease in elopements and their consequences, thereby decreasing the facility s costs. The out-of-pocket cost for the facility with constant observation has been shown to be less than the cost of penalties, sanctions, and/or claim settlements that occur when a resident suffers an injury or dies from wandering or elopement. 12

In the December 2010 issue of Healthcare Risk Management s Legal Review and Commentary, the authors described an elopement case that occurred in a hospital setting. An 88-year-old woman was hospitalized after wandering to her son s house, apparently confused. She was fitted with a vest-restraint type of system to keep her from wandering in the hospital. A plan of care was developed to address her wandering and confusion issues. Her confusion appeared to be intermittent and she continually complained about her lack of tolerance of the restraints. Three days after being admitted, there were orders to discontinue the restraints. However, the plan of care for the woman had not changed. A physical therapist noted in the medical chart the next day that the woman had a tendency to wander but didn t tolerate the restraints. An occupational therapist went to see her for a therapy session. Later, her son visited with her. The son told the nurses that his mother was able to recognize him and have a conversation. After he left her room that day, no one saw the woman for the next 14 to 16 hours. It was then she was found on the roof of the hospital. She had died from hypothermia. The hospital denied any wrongdoing. A lawsuit ensued, and the family received a settlement of $900,000. 13

This is a fictional case scenario to help you review what you have learned. Please read this scenario, then answer the matching questions on the next slide. 14

According to CDC data from 2010, one in three adults over age 65 falls each year. In 20% to 30% of these falls, a moderate to severe injury occurs. More than 660,000 elderly patients who were evaluated in Emergency Departments had to be hospitalized due to nonfatal fall injuries in 2009. Costs of fall injuries appear to be growing each year. In 2000, the cost of elderly adult falls was $19 billion. The costs rose to $30 billion in 2010. By 2020, it is predicted that falls for elderly adults will rise to $55 billion. 15

Creating a safe environment for all residents is necessary to prevent falls. When a staff member is going off shift and a new staff member is coming on, it is essential that these staff members talk face to face to discuss residents who are at risk for falling. This will ensure that there are adequate measures in place to help prevent patients at moderate or high risk from falling. 16

For residents who are identified as a moderate fall risk, an appropriate plan of care and interventions should be documented. Johnson and colleagues identified interventions to help prevent falls for residents in this category. This includes: use of a yellow flagging system, alert bands, wall charts, and signs. By decreasing the incidence of falls, the facility saves money. 17

Residents who have been identified with a moderate fall risk should have greater supervision while performing hygiene activities. Patients should be referred to occupational therapy and to physical therapy as needed to help with gait, transfers, or any other issues that can increase their chance of incurring a fall. Occupational therapists and physical therapists should respond to this referral request within a 48-hour timeframe. 18

Falls cause injury, death, and lawsuits against your facility. This is why it is necessary for your facility to find a prevention program that can be implemented to reduce this risk. One way your staff can remember how to prevent falls is the mnemonic FALLS, utilized by the state of Maryland s fall prevention program. 19

An article by Johnson and colleagues explains that long-term care facilities should develop and follow a plan of care for patients identified as having a high risk for falls. This plan of care should include locating the resident s room closer to the nurse s station to improve supervision. Special beds that have alarms built into them can be purchased for residents at high risk for falls. The alarms will alert the staff to a resident trying to get out of bed. Another helpful suggestion is to provide beds that are lower to the ground to provide easier resident access and to help decrease the risk of injury should a resident happen to fall when getting out of bed. In general, residents at high risk for falling should have higher surveillance with activities of daily living. Residents need to be reassessed for risk of falls whenever there is a change in medical condition. As a nurse manager, it is important to monitor the staff for use of appropriate interventions. Never assume that the resident s risk of falling has abated. 20

In addition, other aspects of care should be incorporated into caring for residents at high risk for falls. These include removing clutter; keeping personal belongings at the bedside table within the patient s reach; cleaning up any spills quickly; locking beds and wheelchairs; providing adequate lighting; and encouraging patients to call for assistance. 21

Fall prevention programs have been developed and initiated in Maryland and Minnesota. In 2009, Maryland began their Keeping Residents Safe from Falls initiative. This was developed as a patient care bundle. In Minnesota, the Minnesota Hospital Association began a statewide campaign for prevention of falls, which included participation by 100 hospitals. 22

The Final Recommendations on Financial Support for the Maryland Patient Safety Center report explains that by utilizing this preventative strategy, Maryland health care facilities were able to reduce the number of falls in acute care and long-term care facilities by preventing both frequency and severity of falls. This allowed a cost containment of $1.3 million for acute care hospitals and $2.4 million for long-term care facilities in 2010. It was found that the fall prevention program eliminated 623 falls in long-term care facilities. This report speculates that the use of the fall prevention program saved long-term care facilities more than $10 million per year. For more specific information about the financial aspects of Maryland s fall prevention plan, the Website References Section at end of this educational program provides a link for the report. You will also find a link to The Joint Commission Center for Transforming Health Care Preventing Falls with Injury. The Minnesota Hospital Association initiated a statewide campaign to decrease falls. More than 100 hospitals participated in this prevention program. It recommended that residents be made aware of their risk for falls and given information on their individual plan of care to help prevent them from falling. By using this type of communication with the residents of your facility, it can help promote greater program participation. 23

Take a minute and think about this question: If you walked into your long-term care work environment right now, what percentage of the residents presently have a pressure ulcer? Are you surprised to learn that approximately 43% of nursing home residents have pressure ulcers? Pressure ulcer incidence has increased over the years and is now at epidemic proportions in bed-bound residents. This results in high care costs. In fact, it is estimated that $11 billion are spent each year on treatment and resulting morbidity from pressure ulcers. Brem and colleagues conducted a research study to investigate the cost of pressure ulcers. They found that $129,248 were spent on hospital-acquired stage IV pressure ulcers during one hospital stay. The treatment cost for community-acquired stage IV pressure ulcers was found to be $124,327. 24

Accreditation and licensing sanctions can occur when residents develop pressure ulcers in nursing homes. As a result, lawsuits and criminal proceedings can occur from residents developing pressure ulcers while being cared for in their facility. It is important that staff caring for residents follow standards of care and document this care on a daily basis. Staff should be educated on facility and national guidelines for pressure ulcer prevention and treatment. 25

The Center for Medicaid and Medicare Services has decided that any stage III and IV pressure ulcers that develop in a hospital will be considered a never event. Therefore, CMS will not reimburse facilities for treatment or morbidity related to hospital-acquired pressure ulcers. Using cost-effective pressure ulcer treatments is necessary. Prevention of pressure ulcers is the key to improving the financial success of the long-term care facility. 26

Several pressure ulcer risk assessment scales have been developed to help identify residents who are at a high risk for developing pressure ulcers. The Norton Scale has been shown to have a decent sensitivity score of 46.8% and specificity score of 61.8%. It also has reasonable risk prediction scores with a 95% confidence interval of 1.03 to 4.54. 27

The Braden Scale is another assessment tool that is used to determine which residents are at a higher risk for pressure ulcers. This scale has the best balance of sensitivity and specificity. Its sensitivity score is 57.1% and its specificity score is 67.5%. The scale has a 95% confidence interval of 2.56 to 6.48. These scores exhibit the Braden Scale s optimal validation. 28

The Norton Scale and Braden Scale both meet the standard of care for pressure ulcer risk factor assessment. These tools are not meant to be absolute measures of health, but are predictors for residents who are more likely than others to develop a pressure ulcer. Nursing homes should determine which pressure ulcer assessment tool is the best tool for their facility. This tool needs to be used for every resident upon admission to the facility. For residents who are identified as high risk, an individualized plan of care should be developed and followed to help prevent and/or intervene with early pressure ulcer development. Residents who are found to be at high risk for pressure ulcers are monitored more stringently than those not at high risk. This allows direct care providers to prevent pressure ulcers and to detect any skin changes that are early signs of pressure ulcer development. Prevention and early intervention are keys to diminishing pressure ulcers in long term care facility settings. By decreasing the frequency and severity of pressure ulcers, long term care facilities can diminish out of pocket costs that are linked to higher pressure ulcer rates. 29

The Omnibus Budget Reconciliation Act (OBRA) of 1987 set standards for Medicarecertified skilled nursing facilities that linked assessments directly to plans of care that are individualized for each patient. In order to utilize this law, the Department of Health and Human Services developed the Resident Assessment Instrument (RAI) which includes three components: the Minimum Data Set (MDS); Resident Assessment Protocols; and Care Plan. The MDS is used to collect data on residents for determining reimbursement. MDS 2.0 was released in 1995. Due to many criticisms of MDS 2.0, MDS 3.0 was created and later implemented on October 1, 2010. Since this date, there have been numerous updates. Section M of MDS 3.0 specifically addresses coding of skin conditions. At the end of this program, you will find website information to assist you with finding more specific information about MDS 3.0. 30

In general, for the majority of bed-bound residents, repositioning should be performed at least every 2 hours for pressure ulcer prevention. However, the policy in some facilities states that residents should be repositioned based on individual need because each resident may not need to be repositioned within a particular timeframe. Some residents may be in special beds that do not require repositioning. Other residents disease states may not allow for repositioning every 2 hours, depending on equipment that is used for their care or end-of-life quality issues. Long-term care facility policies should include preparing an individualized plan of care that addresses each resident s specific repositioning needs. These policies should follow the pressure ulcer standard of care as recommended by national guidelines. 31

Standards of care include initial assessment of the resident s skin upon admission. Assessments should continue on a regular basis, and the best time to do this is during the resident s shower. Nursing assistants providing showers should contact the registered nurse if any changes are found. Once a skin change is noticed, it must be documented. When documenting skin lesions, proper terminology should be used. Brown s 2006 article provides a helpful list of accepted pressure ulcer documentation terminology. Utilization of pressure ulcer-related terms helps the multidisciplinary team to understand the lesion s appearance. It also provides a more unified manner of wound documentation. In addition, proper terminology in reference to pressure ulcers is needed in case the medical record is evaluated during litigation. Documenting when the resident s physician was notified of skin changes, lesions, and pressure ulcers is vital to prevent future litigation. It is also just as important to document the pressure ulcer treatments performed, response to treatment, and progress of wound healing. Attorneys will search medical records for this information to determine if the facility notified the attending physician in a timely manner. The amount and type of documentation can relieve the facility of lost reimbursement funds and help to avoid lawsuits. 32

In 2009, the European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP) collaborated together and developed international pressure ulcer staging guidelines. Stage I consists of non blanchable erythema. The resident s skin will have redness that does not turn lighter when pressed. It is usually located over a bony prominence. Stage II consists of partial thickness changes. This will appear as a shallow open ulcer with a pink area inside the wound. Stage II can also include a blood filled blister. Stage III pressure ulcers include full thickness skin loss. Subcutaneous fat may be seen. Stage III ulcers will not have bone, tendon or muscle present. Stage IV pressure ulcers include full thickness tissue loss. These lesions will have bone, tendon, or muscle exposed. These lesions can be deep into muscle and supporting structures. Slough or eschar may be present. These pressure ulcers usually exhibit undermining and tunneling. In addition to these four stages, the United States has included the categories of Unstageable/Unclassified and Suspected Deep Tissue Injury. They are listed separately in the 2009 international guidelines since the European countries usually categorize these types of lesions in Stage IV. The Unstageable/Unclassified Category of pressure ulcers includes full thickness skin or tissue loss with an unknown depth. The reason this is unstageable is that too much eschar and slough are present to determine the wound s characteristics and therefore stage it. The last category is Suspected Deep Tissue Injury. These pressure ulcers have an unknown depth. The lesions appear darker in color, such as purple or maroon, and may have a bloodfilled blister due to underlying damage to soft tissue. 33

There is controversy regarding the helpfulness of pressure ulcer photography as documentation in case of litigation. It depends on how this photography is used as to whether or not it is helpful or harmful. If pressure ulcer photography is used on an ongoing basis in conjunction with the direct care provider charting the course of the pressure ulcer, then it is helpful. Regular photography that has text to identify pertinent structures accompanying the written wound documentation can be an asset during litigation. If pressure ulcer photography is used intermittently, then it is harmful, given that random photographs can be used against a nursing home facility during litigation. Photography should supplement written assessment notes, not replace them. 34

When a pressure ulcer has been identified, the resident s attending physician and family members must be notified. Treatment orders will be written by either the physician or a wound care specialist. The pressure ulcer will be assessed and staged. A treatment plan will be decided. Therapy goals should be outlined so the resident and family members understand the treatment plan. The pressure ulcer is usually debrided by a wound care specialist and an appropriate dressing is prescribed. The nurse should always assess any pain associated with a pressure ulcer by using a pain scale. The choice of pain assessment scale will depend on the resident s ability to communicate. The amount of pain identified by the resident should be documented and addressed in the nursing notes. The attending physician should be notified and appropriate measures performed as recommended to help reduce pressure ulcer pain and increase comfort. 35

Middle managers of long-term care facilities should develop policies and documentation requirements as recommended by Raso and Gulinello. These recommendations include: 1) comprehensive skin assessments for every resident upon admission, 2) periodic reassessments, and 3) thorough skin assessments prior to transferring a resident. Next, pressure ulcer risk assessments should be performed. The nursing home managers should determine a policy for frequency of these assessments. Turning and positioning residents to prevent pressure ulcers should be determined based on each individual s needs. The nurse manager can determine the facility s policy for repositioning based on national guidelines. Monthly prevalence rounds should be performed to share and benchmark overall facility goals for pressure ulcer reduction. Progress toward the goals should be shared with the staff. To help nurses and nursing assistants on an everyday basis, managers may consider appointing unit champions as a staff resource to provide daily coaching. Another option is to incorporate certified wound care nurse specialists into the facility s pressure ulcer care both to help with individual residents and to educate staff. 36

SKINSAVERS is a mnemonic that represents a bundled pressure ulcer preventative measure. Nurse Managers can utilize this bundled prevention strategy in policies and staff education to help reduce the incidence of pressure ulcers within the facility. 37

A report released by the Institute of Medicine showed that the cost of medicationrelated illness and deaths in long-term care facilities has a cost of $7.6 billion per year. The residents, mostly frail and elderly, are usually taking multiple medications at the time of admission. Many of the indications for these drugs have been resolved, but the health care provider never discontinued the medication. In addition, medication dosages for this population can be different than the usual dosing recommendations. 38

Certain medications cause more of a risk to the elderly due to a high risk for adverse reactions, such as delirium. These drugs include meperidine, diphenhydramine, and amitriptyline. By reducing the use of these three medications, it is believed that delirium will decrease. This will help reduce length of hospital stays and costs. 39

Why do medication errors keep occurring? This is a very good question that led The Joint Commission to include medication errors as one of its top 10 Sentinel Events. One of the most frequent causes of medication errors includes nurses being interrupted while preparing to administer a medication, which leads to more than 10% in procedural failures and clinical errors. Another frequent cause is clinicians drawing up medications in syringes and not labeling them. This leads to errors because the nurse administering the drugs can get distracted and then forget which medication is in which syringe. 40

According to the Joanna Briggs Institute, a study conducted in the United States showed that the most common error occurred due to nurses not having enough information about the medication prior to administration. The second most common error that occurred is not having enough information about the patient prior to medication administration. The lack of knowledge about the medical history of the patient can lead to administering drugs that are not appropriate. Solutions to help with prevention of medication errors include having nurses double-check the orders and then prepare the medication dosage prior to administration to the resident. It is also helpful to identify a dedicated medication administration nurse on each unit to assist in reducing medical errors that occur from distractions. 41

Computer prescriber order entry is one method that can help nursing homes in preventing medication errors. However, some problems can arise within this system. In one facility, physicians were ordering medications for the wrong patients because patients within the facility had similar names. This happened several times per month. In addition, physicians did not close one medical record in the computer before ordering medications for another patient. To help eliminate these computer prescriber order entry situations, the facility should limit computer access for each physician to include his or her patients only. This way physicians cannot access a chart for someone who is not under their care. To prevent future medication errors, facilities need to create committees to develop quality improvement and risk management programs. In order for these committees to identify the causes of errors and actively work to find solutions, there needs to be an accepting environment for staff members to report errors. Many facilities currently have cultures that punish nurses for reporting medication errors. It is important to encourage reporting errors so that more data can be collected for committees to analyze. This culture change will lead to greater success in problem-solving. 42

Polypharmacy is a large problem for elderly nursing home residents. Many enter with multiple medications, some of which may no longer be needed. Many drug-to-drug interactions can cause morbidity and mortality. Upon admission to a long-term care facility, staff should review of all medications and supplements to ensure that each one is still needed by the resident. If a medication is no longer needed, it should be discontinued from their regimen. 43

To help reduce liability of medication errors, here are three solutions that can help your facility. 1) Check timing of IV push or IV bolus medication prior to administration. Nurses need to be vigilant about verifying the length of time to push the IV medication because it can cause severe reactions in the resident if not done properly. The nurse can verify this information with the ordering physician, pharmacist, and/or medication reference material available on the unit. 2) Educate nursing staff about repercussions of falsifying a medical document to cover up a mistake. Falsification of medical records is a criminal act that that can result in fines and imprisonment! 3) Train your facility s staff members and attending physicians regarding policies and procedures for telephone orders. It is imperative that all staff within the facility is aware that only registered nurses can take a telephone order! Medication errors have occurred because a registered nurse was not present when a physician wanted to give a telephone order. Adequate staffing of registered nurses in the long-term care facility is vital, especially in evening and night hours. 44

According to Patricia Iyer, the majority of suits involve institutionalized elderly patients of hospitals or nursing homes. Elderly women are more likely to be the recipients of deficient care because women constitute approximately 85% of the nursing home population. In addition, elderly women have higher incidences of morbidity. Liability to nursing homes results from residents having issues with the care delivered to them. Usually the resident s family members file suit against the nursing home. The Omnibus Reconciliation Act is legislation that brought attention to the quality of care, staffing patterns, and accidents that occur in long-term care facilities. Nurse managers working in a nursing home setting should be vigilant about staying abreast of legislation that can affect their facility, staff, or residents. 45

If you implement the information that you have learned in this program, your facility should be able to reduce liability and enhance quality care for your residents. This can be achieved if you practice risk management strategies and educate staff about reduction of liability issues. You can start with strategies such as initiating prevention programs, incorporating national standards of care into facility policies, and scheduling adequate unit staffing. This will help avoid lawsuits, sanctions, fines, and imprisonment! 46

The next few slides provide website resources to help you reduce your facility s liability risk. By changing your facility s environment to increase quality care and diminish liability risk, you can help the facility avoid devastation and become a quality leader in the nursing home community. 47

This slide lists resources for more detailed financial information on preventing falls. Reviewing the funding specifics can help you create a fall prevention program for your facility. The first link is to the Maryland fall prevention program mentioned earlier in this program. The second link is to The Joint Commission Center for Transforming Health Care. That website provides the project details on fall prevention programs that were launched at the end of 2011, including a fact sheet and a video clip describing this program. 48

The links on this slide provide you with a wealth of pressure ulcer resources. The NPUAP provides resources for staging pressure ulcers and identifying standards of care. The other organizations listed help provide national standards for pressure ulcer guidelines. Have these links available to your staff to reference when needed. By encouraging staff to refer to national guidelines on pressure ulcer care, your facility will lower its pressure ulcer liability risk. 49