As resident acuity levels increase, assisted living providers must keep close tabs on the services they provide to steer clear of litigious situations. How can caregivers continue to deliver detailed, resident-focused services while also keeping a close eye on regulatory and legal issues? An attorney who’s also an RN weighs in…
Double-Duty Documentation
Whoever said, “nothing is certain but death and taxes,” didn’t
get it quite right. The quote should be, “nothing is certain but death,
taxes, and the fact the residents will fall.”
It is of course important to develop a system for preventing
resident falls, but when it comes to staying out of litigious
situations, it is equally as important to thoroughly document detailed
assessments about why the resident fell or has fallen multiple times.
Is the resident falling on the way to the bathroom during the night
shift? Is the resident falling routinely at sunset? Is the resident
falling near the kitchen in the afternoons? Does the resident appear to
be over-medicated? This kind of analysis not only helps hone
appropriate resident-focused care, it also serves as verification that
the assisted living community took the appropriate steps to care for
the resident and remedy any risky situations.
When it comes to medication management, a host of clinical
issues center around administration errors, delegation and training,
medication review (especially psychotropic medication), and a
resident’s right to refuse medication. Community policies should be
clear on medication management and the resident’s right to refuse. A
physician’s order for every medication should be readily available and
include all the required information regarding dosing and
administration. Medication administration training should be thorough
and in accordance with the state’s regulatory guidelines.
Providers also should consider random community-level audits
of medication administration records. This will help expose medication
documentation shortcomings, such as medication documentation errors or
omissions and inaccurate or inappropriate documentation of medication
administration holds or refusals.
Nurses in Charge
With more and more nurses being hired into assisted living
companies as managers, clinicians, and supervisors, another emerging
care issue is nurse delegation. These issues usually center around
medication administration, but can also impact resident care where a
particular treatment is delegated. Nurse delegation is generally a
creature of state statute and regulation, but key to its successful
implementation are an understanding by both the nurse and the delegated
caregiver of what the delegated task is, an appropriate level of
supervision and monitoring, and documentation of the delegated task.
Again, thorough and detailed documentation is critical to not
only providing appropriate care, it also is important as it pertains to
regulatory and legal issues. And here the old nurse’s
adage rings true and that is, “if it’s not documented, it’s not done.”
Detailed documentation preserves the record, serves as a communication
tool, and can insulate against regulatory and civil legal liability.
In the current model of assisted living, identifying key
clinical issues affecting residents and taking proactive approaches to
those issues not only enhances the quality of care and quality of life
for residents, it gives providers the ability to better meet the needs
of those residents while reducing their potential regulatory and civil
liability.
Robert J. Lightfoot II is an attorney and shareholder at the
law firm of Murphy Desmond SC in Madison, Wisconsin. He is also a
registered nurse. Reach him at [email protected].
By: Robert J. Lightfoot II, Esq.
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