MANAGING LEGAL RISKMANAGING LEGAL RISKTOP TEN LISTTOP TEN LIST

presented to

2014 National Association of State Veterans HomesJuly 31, 2014

presented by:Sandra L.W. Miller, Esq.Womble Carlyle Sandridge & Rice, LLPPhone: (864) 255-5425samiller@wcsr.com

Janice Sumner, RN, CLNCHMR Veterans Services, Inc.

Phone:  (864) 622-2709jsumner@hmrvsi.com

IMPORTANTIMPORTANT

The materials provided and information presented in The materials provided and information presented in this seminar are intended to be informational only and this seminar are intended to be informational only and do not constitute legal advice regarding any specific do not constitute legal advice regarding any specific situation.situation.

ADMISSION RISKSADMISSION RISKS

THE FIRST 72 HOURS DAYS ARE CRITICAL

You don’t know the resident.

You may be given incomplete information about the resident’s condition.

The family may have miscommunicated the resident’s condition or past history of behavior, diet, tendency to wander and previous elopement attempts.

ANTICOAGULANTSANTICOAGULANTS

SPECIAL ATTENTION - SPECIAL RISK

Laboratory monitoring is essential.

Fall precautions take on additional importance. A small head bump can result in a life threatening subdural hematoma.

C-DIFFC-DIFF

BEWARE OF THE C-DIFF SCOURGE

This infection is becoming more prominent in hospitals and long term care facilities and any episode of diarrhea should involve taking into consideration the possibility of a C-diff infection and include an evaluation of recent antibiotic use.

DIABETESDIABETES

SPECIAL MANAGEMENT CHALLENGES

Residents who have been on stable regimens prior to admission can develop uncontrolled blood sugars from the change in routine and eating habits that accompanies admission.

If the resident has acute problems on admission, assume that to some degree their diabetes management needs to be closely watched and may need adjustment.

FALLSCLEARLY DOCUMENT FALL RISK & PRECAUTION

Resident’s fall risk must be identified upon admission.

Documentation should include specific actions to prevent falls.

New incident? → Revise the care plan.

Communication with the family.

The physician must document and be involved in communications about fall risks and falls.

FALLS (Continued) A system must be in place to monitor for

implementation of precautions.

PHYSICIAN COMMUNICATIONPHYSICIAN COMMUNICATION

COLLABORATION AND FREQUENT COMMUNICATION IS CRITICAL

All communications must be documented, along with the physician direction received.

It is always better to “over-communicate” than to “under-communicate.”

RESIDENT TO RESIDENT RESIDENT TO RESIDENT ALTERCATIONSALTERCATIONS

FAILURE TO PROTECT A RESIDENT FROM

PHYSICAL OR EVEN VERBAL ABUSE BY

ANOTHER RESIDENT INFLAMES A JURY AND

CREATES SIGNIFICANT RISK IN LITIGATION

Residents who are mobile and confused present increased risk of:

(1) physical abuse between residents; and

(2) false allegations from residents who are confused and paranoid or who have delusions or hallucinations.

Careful placement on the front end is best. Psychiatric consultation is critical.

RESIDENT TO RESIDENT RESIDENT TO RESIDENT ALTERCATIONS (Continued)ALTERCATIONS (Continued)

SKINSKIN INTEGRITYINTEGRITY

THERE IS NO SUBSTITUTE FOR PREVENTION

An accurate body audit should be done within the first hour after admission.

Accurate admission documentation is critical.

Diagnosis must be accurate: Is it arterial, venous stasis, or pressure related?

The care plan should include assessment of skin breakdown or abrasions from other equipment (e.g., wander guards).

SKINSKIN INTEGRITY (Continued)INTEGRITY (Continued)

Is it really a rash or excoriation on the buttocks or is it the first sign of underlying skin breakdown about to erupt into a visible major decubitus ulcer?

In post-surgical residents, consider surgical positioning during the initial body audit.

What is going on under a cast or brace? Obtain clear orders as to whether any brace or other equipment is to be removed.

STANDING ORDERSSTANDING ORDERS

SYMPTOMATIC STANDING ORDERS SHOULD BE RESIDENT SPECIFIC

Treating symptoms without assessment can mask early signs of acute and potentially serious conditions.

UNREALISTIC FAMILY UNREALISTIC FAMILY EXPECTATIONSEXPECTATIONS

UNREALISTIC FAMILY UNREALISTIC FAMILY EXPECTATIONS (Continued)EXPECTATIONS (Continued)

DECLINE IS MOST OFTEN INEVITABLE

Unrealistic family expectations are commonplace. There is no such thing as too much communication with family members.

Communications should be documented including what the family is told and their response.

AND NOW, AND NOW,

FOR THE BIG FINALE!FOR THE BIG FINALE!