When Injuries Speak: 4N6 RNanha.org/members/AlabamaAugust2010HandoutB-W... · 2014-06-19 · 1 When...

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When Injuries Speak:

Forensic Investigation & Documentation of Ab N l t & F llAbuse, Neglect, & Falls

Daniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAANAssociate Professor, Johns Hopkins University, School of NursingForensic Clinical Nurse Specialist

4N6 RN

Forensic Nurse

Forensic = Pertaining to the Law

International Association of Forensic Nursing

www.iafn.org

1-410-626-7805

Patient Assessment

In this session participants will learn:

A. Definitions of common medical forensic terms of injuries related to abuse, neglect, and falls

B. How to better investigate root causes of injuries

C. How to document thorough investigations of all injuries

D. Common F Tags used for falls/abuse/neglect

CMS – Falls F-Tag F323 Accidents

Defined as unintentionally coming to rest on the ground, floor, or other lower level but not as the result of an overwhelming external force (e.g. resident pushes another resident).

Loss of balance and caught by staff is still a fall. Fall without an injury is still a fall. Found on floor is a fall until evidence shows it was

not a fall (e.g. credible history of patient kneeling to pick up dropped money, could not get back up without help).

Abuse

F223 – Resident has right to be free from verbal, sexual, physical, & mental abuse, corporal punishment, and involuntary seclusion (restraints)seclusion (restraints)

Resident to resident, staff to resident abuse that is willful F-223

Not so sure if were intentional or an accident F-323 Accident

Abuse

F224 – Neglect & mistreatment (Misuse of resident propertyp p y

F226 – Failure to develop/implement policies & procedures on abuse prevention, identification, screening, INVESTIGATION, reporting, & training of incidents, suspicious bruising, unexplained injuries, injury trends

– Care & safety planning around aggressive residents who need monitoring

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F225 – Deals with findings of guilt (criminal-civil) BUT includes

Injuries of an unknown source defined as: Injuries of an unknown source defined as: – Source of injury not observed..– Source of injury could not be explained by

resident– Suspicious because of the extent, location not

generally traumatized, number of injuries at one time, number over time…ie. Multiple falls…..

Resident Vulnerabilities

Environmental hazards (water on floor, equipment in the way, poor lighting)

Underlying medical conditions

Medication side effects

Lower extremity weakness

Balance disorders

Poor grip

Resident Vulnerabilities

Visual deficits

Inner ear conditions

Functional impairments

Cognitive impairments

Other causes…………

Post-fall actions include….

Assess for injuries Provide all needed emergent and follow-up

treatment What caused and/or contributed to the fall

– Multi-factorial

Think of all reasonable theories of causation Ask the patient, even if patient is confused or non-

verbal Ask the direct care staff their theories of causation

Fell down versus found down

Name of person(s) who witnessed the fall.

Name of person(s) who found the patient down.

Location of the fall or found down site…– Sidewalk, lawn, carpeted bedroom, tiled floor

Sample – clarify fell versus found down

Mrs. J. Jones reportedly found on tiled bathroom floor at 2315 hours by direct care staff R Gilbert J Gentilestaff, R. Gilbert, J. Gentile…..

Mrs. J. Jones reportedly fell at 2315 hours witnessed by direct care staff, R. Gilbert, J. Gentile…

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Prevention of future falls

Strategies tried – What was/was not helpful

REVISE THE CARE PLAN

TRAIN ALL STAFF ON THE NEW PLAN OF CARE

EVEN CMS SAYS…

A FALL BY A RESIDENT DOES NOT NECESSARILY INDICATE A DEFICIENT PRACTICE BECAUSE NOT EVERY FALLPRACTICE BECAUSE NOT EVERY FALL CAN BE AVOIDED

Review of injuries from falls

Abrasions

Avulsions, partial avulsions

Bruises/contusions

Cuts

Hematomas

Lacerations

Fractures

In order to accurately assess, document, and investigate suspected abuse, one needs to learn the correct use of many common forensic terms.

Forensic Terminology

correct use of many common forensic terms.

In the following session forensic definitions will be presented along with photographic samples of the defined injury.

http://cmstraining.info/pubs/AbuseAndNeglect.aspx

Abrasion

A wound caused by rubbing or scraping theA wound caused by rubbing or scraping the skin or mucous membrane.

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Abrasion

Right forehead abrasion post fallfrom a wheelchair to a carpetedsurface.

Bilateral knee abrasions post forwardfall from a wheelchair to a carpetedsurface.

Photos © 2006. Used with permission of Daniel J. Sheridan, PhD, RN. Do not reproduce photographs without permission.

Abrasion

Abrasions are common injuries incurred from accidental falls, however, certain types of abrasions are consistent with intentional mechanism of injury.

For example, if a person is laying supine and is dragged by her feet along any rough surface (carpet, sidewalk, street) you would expect to see an abrasion along the mid-spine.

If a person is dragged supine by his feet with any sort of back and forth movement, the abrasion would cover much of the mid-back from side to side as previously pictured.

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Avulsion

The tearing away of a structure or part. Often seen as a partial avulsion.

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Avulsion

Avulsion:The complete tearing– The complete tearing away of structure or part.

Often seen as a partial avulsion

– A skin tear


Avulsion

Skin tears (partial avulsions) to the elderly most often occur to the arms and hands. For the skin to tear there must have been blunt and/orskin to tear there must have been blunt and/or shearing force energies.

Skin tears in patients who are total care must have been inflicted by another person.

One needs to assess if the partial avulsion was truly accidental, the result of excessive force, or abuse by a caregiver.

Bruise

Blunt force trauma that results in a superficial discoloration due to hemorrhagesuperficial discoloration due to hemorrhage into the tissue from ruptured blood vessels from beneath the skin surface without the skin itself being broken:

also called a contusion.

Contusion

A bruise:

Traumatic injury of tissue without breakage of skin; blood accumulates in the surrounding tissue producing:– pain, swelling, tenderness, and discoloration.

1. Multiple, patterned fingertip-like & heel of hand-like bruises to right upper leg and knee secondary to excessive force.

2. Normal impression from anti-emboli stocking.3 Left arm and lateral chest bruises from excessive force

Bruise/Contusion

3. Left arm and lateral chest bruises from excessive force.

2.

1.

3.


Bruise/Contusion

1. Two bruises to left upper inner arm.2. Left temporal bruise

1.

2.

1.

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Cut

See incision.

Decubitus Ulcer

Bedsores

Decubiti (plural)

Decubitus ulcer (singular)

Pressure sore – ulceration of tissue deprived of adequate blood supply by prolonged pressure

Decubitus ulcers in various stages of healing

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Ecchymosis

A hemorrhagic spot or blotch, larger than petechia in the skin or mucous membranepetechia, in the skin or mucous membrane forming a non-elevated, rounded, or irregular blue or purplish purpuric patch.

Ecchymosis is not injury from blunt force trauma. It is NOT a bruise or contusion.

Ecchymosis is purpura usually in the skin or mucous membranes.

Ecchymosis

Ecchymosis in the elderly is often to the arms and/or hands.

Blunt force trauma to the mid face often results in the development of bilateral periorbital ecchymoses (raccoon eyes).

Discoloration from a bruise can be pulled by gravity downward. The downward discoloration is called ecchymosis while the discoloration at the point of blunt impact is called a bruise.

At Risk MedsAt Risk Meds

Aspirin Aspirin -- antiplateletantiplatelet

Warfarin (Coumadin) Warfarin (Coumadin) -- anticoagulantanticoagulant

Ibuprofen, ketorolac Ibuprofen, ketorolac -- NSAIDsNSAIDs

Heparin Heparin -- anticoagulantanticoagulant

Valproic acid Valproic acid -- Depakote (thrombocytopenia)Depakote (thrombocytopenia)

Prednisone Prednisone -- steroidssteroids

At Risk SupplementsAt Risk Supplements

Bilberry Bilberry -- may prolong coagulation timesmay prolong coagulation times Garlic Garlic -- reduces coagulationreduces coagulation

GiGi i i k f bl di hi i k f bl di h Ginger Ginger -- increases risk of bleeding when increases risk of bleeding when used concurrently with anticoagulants, used concurrently with anticoagulants, bilberry, or aspirinbilberry, or aspirin

Ginko Ginko -- increases risk of bleeding when used increases risk of bleeding when used concurrently with anticoagulants or bilberryconcurrently with anticoagulants or bilberry

Basic LabsBasic Labs

Look for baseline lab data (preLook for baseline lab data (pre--injury)injury) Get the health provider to order the following:Get the health provider to order the following:

CBC with PlateletsCBC with Platelets–– CBC with PlateletsCBC with Platelets–– Bleeding timesBleeding times–– Basic chemistries: CHEM Basic chemistries: CHEM –– 7; albumin [malnutrition] 7; albumin [malnutrition]

;BUN/Creatinine [dehydration]);BUN/Creatinine [dehydration])–– Liver functionLiver function–– Coagulation panel (PT/PTT)Coagulation panel (PT/PTT)–– UrinalysisUrinalysis

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Ecchymosis

Bilateral Periorbital EcchymosesPhotos © 2006. Used with permission of Daniel J. Sheridan, PhD, RN. Do not reproduce photographs without permission.

Ecchymosis

Skin tears with ecchymoses. Two areas of ecchymoses.


Hematoma

A localized collection of blood

Hematoma

Hematoma:– A localized collection of

blood from a broken blood vessel (s).

Hematoma is not a synonym for a bruise or a contusion.

Hematoma

Many health professionals mistakenly call a bruise a hematoma and vice versaa bruise a hematoma and vice-versa.

While a hematoma may be imbedded within a bruise as a palpable mass, hematomas can be caused by non- traumatic means ie., a spontaneous blood clot to the brain.

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Hemorrhage

The escape of blood from a ruptured vessel.The escape of blood from a ruptured vessel. It can be internal, external, or into the skin or other tissue.

An Incision = A cut.

Incision

A cut that is deeper than it is wide is a stab wound

A wound made by a sharp instrument or object (a sharp injury).– Scalpel, knife, razor, paper

Laceration

The act of tearing or splitting. A wound d d b th t i litti f b dproduced by the tearing or splitting of body

tissue often from blunt impact, usually over a bony surface, that is distinguished from a cut or incision.

Incision/cut

Open stab wound to left lateral chestand sutured chest tube incisioninsertion site.

Superficial cut to palm of left hand


Incision/cut

Superficial cut from trying to unsuccessfully wardoff kitchen knife.

Stab wound to navel region with surgical incision to stop internal bleeding.


Incision/cut

The inside edges of a sharp wound (cut, incision) are relatively smooth and equidistance in depth.

If a serrated knife is used, the inside edges may have a more scalloped appearance.

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Laceration

Lacerations to the skin are usually jagged or y j ggstellate (star-shaped) in appearance.

The depth of lacerations is variable and often tunnels under the skin.

Patterned Injury

An injury where one is reasonably certain an j y yobject caused the injury, or certain which object caused the injury and/or by what mechanism an injury was caused.

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Patterned Injury

Patterned punch-like bruise to right lower abdomen with circular knuckle imprinted bruising. The resident was forced to lay down after being punchedresulting in ecchymotic spread of blood upwards towards the navel. g y p p


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Pattern of Injury

Injuries in various stages of healing, g gincluding new and old scars, contusions, fractures, wounds.

Central Clearing

PetechiaPetechia

Minute, pinMinute, pin--point, nonpoint, non--raised, perfectly raised, perfectly round, purplishround, purplish--red purpuric spots caused by red purpuric spots caused by intradermal or subintradermal or sub mucous hemorrhagemucous hemorrhageintradermal or subintradermal or sub--mucous hemorrhage, mucous hemorrhage, which later turns blue and yellow.which later turns blue and yellow.

Petechia

Petechia are caused by the rupture of capillaries. When blood is not allowed to leave the head/face because of occlusion or compression of the jugular veins, capillaries will burst in and around the eyes and face.

Puncture

The act of piercing or penetrating with a i t d bj t i t tpointed object or instrument.

Purpura is a hemorrhagic rash with leakage

Purpura

p g gof blood into the tissue.

Often associated with bleeding or clotting disorders. Ecchymosis and petechia are forms of purpura.

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Skin Tear

Skin tear:– See Avulsion


Trace Physical Evidence

Often embedded in an injury or the clothes of the patient will be trace physical evidence. One needs to ask herself if the trace physical evidence in wound or clothing (either observed in-person or by history) supports or distracts from the reported history or theory of causation.

Unexplained Injury

It is relatively common, especially for institutionalized elderly to hear frominstitutionalized elderly to hear from caregivers that they have no idea how the patient received her/his injuries.

All significant unexplained injuries to vulnerable patients should raise one’s suspicions of possible abuse or neglect.

Wound

A bodily injury caused by physical means, with disruption of the normal structures

t d hi h ki i b k– contused w. - one which skin is unbroken

– incised w. - one caused by cutting instrument

– lacerated w. - one in which tissues are torn

– open w. - one having free outward opening

– penetrating w. - one caused by a sharp, slender object that passes through the skin into tissue

Decubitus ulcers

Are they a sign of neglect?

Take Home Points

ALL Pressure ulcers are NOT preventable, but many are preventable…..

ALL Pressure ulcers are NOT curable, but many are curable.…

HOWEVER….

ALL PRESSURE ULCERS ARE TREATABLE !!!!!!!!!!!!!!!!

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Documentation PearlsDocumentation Pearls

If you did not chart it………If you did not chart it………

You did not do it!!!!!You did not do it!!!!!

Avoid personal opinionAvoid personal opinion

Avoid charting arguments with coAvoid charting arguments with co--workersworkers

Avoid derogatory remarks about client, Avoid derogatory remarks about client, family, or other providersfamily, or other providers

Write legibly, legibly, legibly, legiblyWrite legibly, legibly, legibly, legibly

Forensic DocumentationForensic Documentation

As verbatim as possibleAs verbatim as possible

Do not sanitizeDo not sanitize

Do not “medicalize”Do not “medicalize”

Avoid pejorative documentationAvoid pejorative documentation

Document excited utterancesDocument excited utterances

Document medical exceptions to hearsayDocument medical exceptions to hearsay

Avoid pejorative documentationAvoid pejorative documentation

Stop charting “refused”Stop charting “refused”

Stop charting “uncooperative”Stop charting “uncooperative”

Stop charting “nonStop charting “non--compliant”compliant”

Stop charting “alleged” and “allegedly”Stop charting “alleged” and “allegedly”

Stop charting your feelingsStop charting your feelings

Stop charting your angerStop charting your anger

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Visually Documenting Abuse or Neglect

There are four common methods of photographically recording injury and wounds from suspected abuse or neglect:g

– Video cameras– Polaroid cameras– 35 mm color print cameras– Digital cameras, including those that can record

several seconds of streaming video.

Video Cameras

An on-site investigator should consider using a video camera to record an extraordinarilya video camera to record an extraordinarily cluttered, dirty, or unsafe facility.

Types of Cameras

There are three different styles of cameras commonly used for medical photographic documentation.

They are:

1. Polaroid

2. 35 mm

3. Digital(Sheridan, 2003)

Digital Cameras

Digital cameras are rapidly replacing 35 mm cameras.

Th f di it l There are scores of digital cameras on the market in all shapes and sizes, including a few that look and feel like traditional 35 mm cameras.

Digital Cameras

Digital cameras have advantages over 35 mm and Polaroid cameras:

– Improved image quality

– Instant display of the desired image

– No film, thus no film development issues

– Can be transmitted electronically for expert review

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Who Should Take Pictures

The RN or LPN

Medical documentation of injury/wounds

Can testify what is in the picture

Treat the pictures confidentially

Do not need “chain of custody” – not taken as evidence

Serial Photography

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Labeling Photographic Images

Label all pictures with:Victim/Patient/Client/Resident name• Victim/Patient/Client/Resident name

• Date of birth & ID number• Facility name • Date and time of photo• Location of injury on the body• Photographer’s name• Location• Case number (if assigned)

Labeled Photo Example

Photographic Documentation

Photographs should be developed, maintained, and stored in a confidential manner, as with other medical records and reports.

M di l h t b bi d ith di l d b i ti Medical photos can be combined with medical records by printing digital images on a blank facility progress form or taping photographs on facility progress forms.

Health care providers should take their own photographs and not rely on law enforcement photographs.


Medical photographs can be subpoenaed and presented in court as evidence if the case goes to trial.

R id t h ld i “ t t h t h” f b f Residents should sign a “consent to photograph” form before health care providers take medical photographs.

Use body maps as well as photographs to show accurate bruise coloring or unnoticeable tenderness that may not be visible in a photograph.

High quality photographs are important as part of prudent documentation.

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Photographic documentation is part of the medical record and can be in al able in criminal and/or ci il co rt proceedingscan be invaluable in criminal and/or civil court proceedings.

The photograph must be a true and accurate representation of what the health care provider examined and treated on the day of the exam.


Medical forensic photography should be taken before and after an injury has been cleaned and treated.

Forensic photos should be viewed as part of the medical examination process (the same as X-rays, CAT scans, etc.).

Photographs cannot be released to law enforcement or the courts without a “release of information” signed by the victim or a valid subpoena/court order.

Photographic Documentation Scales

A measurement scale (ruler) should be included in each photograph to indicate the approximate size of the injuryphotograph to indicate the approximate size of the injury.

It is important to ensure that the injury is clearly visible along with the scale.

Common Forensic Photographic Scales

Rule of Thirds

No matter which camera is used, photographs should be taken using a forensic photography technique called the “Rule of “Thirds.”

– Start with a front-facing, full body photo of the residentPh t f h i j d h ld b t k f th– Photos of each injured area should be taken from three different distances 6 feet (farthest distance) 4 feet (mid-distance) 2 feet (close-up)

– If your camera can focus closer than 2 feet, take additional close-ups images (e.g., Rule of Fourths, Rule of Fifths).

Rule of Thirds

1.

22.

3.

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Collecting and Preserving Evidence

Whenever clothing or sheets are collected, place them in paper bags rather than plastic bags Paperthan plastic bags. Paper bags are air permeable. If there is any moisture (blood, body fluids, water) on the clothing or sheets, the moisture will evaporate through paper and will minimize evidence-destroying mold and bacterial growth.



Trace physical evidence on the clothing and/or on theclothing and/or on the patient may fall off while getting undressed.

Therefore, whenever possible, have the patient stand on two sheets while the patient is undressing.



To minimize cross To minimize cross-contamination, do not pile clothing items on top of each other.


If obvious blood or


other trace physical evidence is found on the clothing, collect it.



While wearing gloves, individually

place each item of clothing into a

paper bag.




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Stock several sizes of


paper bags to package items of different sizes.



Fold the bag over. Secure with tape. Label with a patient ID sticker. Then sign with the date and time.Photos © 2006. Used with permission of Daniel J. Sheridan, PhD, RN. Do not reproduce photographs without permission.


All envelopes, no matter the size, used for any evidence collection need to be sealed and labeled in a similar fashion.


The envelopes or bags must also be


labeled with the contents of the bag.

All envelopes and bags must be sealed with tape. Do not use staples to seal the bag since staples can puncture the skin through the gloves resulting in a needle stick situation.


Any evidence collected by staff needs to signed into a locked evidence storage locker. Old file cabinets that have been drilled with ventilation holes are an inexpensive way to secure evidence.

Access to the locked evidence file cabinet should be restricted to trained and authorized supervisory staff who understand the importance of chain of custody.

There must be a sign in and sign out sheet.


The facility’s evidence collection protocol should include directions on how staff should properly collect, package, label, seal, and preserve evidence. , , p

Any evidence collected by facility staff must be signed into a locked evidence storage locker (file cabinet, for example).

Access to the locked evidence cabinet should be restricted to trained and authorized supervisory staff who understand the importance of chain of custody, including having the police sign out the evidence on a log.

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If the police are present to collect evidence, the officer must ask the resident for permission to collect evidence from the body, such as foreign material, fingernail scrapings, and samples taken with swabs.

The facility should develop a policy on how evidence can be collected from a resident who is unconscious or not able to give informed consent.

Sexual assault evidentiary exams must be collected by a trained sexual assault forensic examiner. The police are never allowed in an exam room during a sexual assault forensic examination.

Common Documentation Errorsto Avoid

1. Insufficient documentation

2. Documentation mechanics

3. Content-related issues

Insufficient documentation

Missing or substandard documentation– facts surrounding an adverse outcome

li i l i l f– clinical rationale for tx or non-tx

– phone conversations with MDs, supervisors, administrators, etc…..

– accurately ID’ing all care givers by name

– time and date of care given

Documentation mechanics

Inaccurate factual statements

Errors in transcribing or writing errors

Delayed or post-dated notes

Illegible notes

Incorrect methods of amending notes

Documentation mechanics - p. 2

Delays in documentation look bad when made after an adverse reaction - looks defensive

Correcting errors in documentation look bad when Correcting errors in documentation look bad when made after an adverse reaction - looks defensive

Make corrections by using a single line through the inaccurate entry - write “error” or “inaccurate entry,” then initial and date.

Once litigation or investigation begins, don’t alter

Documentation mechanics - 3

NEVER:– Erase the error

Whi h– White out the error

– Obliterate the error

– Tear out the error

– Remove the page with the error

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Content-related issues

Inappropriate charting – Patient found on floor next to broken wheelchair

that was supposed to be fixed last weekthat was supposed to be fixed last week versus

– Patient found on floor next to wheelchair with detached left front wheel

Risk management issues in the chart versus a memo or corrective action form

Red Flags When charts are reviewed

1. Are ALL entries legible?

2. Are there gross grammatical and/or spelling errors?

3. Is the charting objective , accurate, and complete?– Facts, concrete observations,– Patient’s statement of problem or a statement that states

client unable to make a statement


4. Avoid Vague and Subjective Entries

D ’ i d i f d– Don’t write - wound appears infected

– Do write - Wound mottled with about 5 cc’s of greenish-brown foul-smelling drainage


5. Are all entries signed correctly and legibly…if someone else can’t read your signature also print itsignature, also print it.

6. Are all entries dated and timed

7. Is the chart free of erasures and alterations

8. Are entries made in black or blue ink


9. Are flow sheets filled out completely and when service was rendered. Flow charts are to check “Normals ” Deviation from normalto check “Normals.” Deviation from normal requires a progress note?

10. Have all telephone communications and attempts at communication documented?

11. Has hearsay been attributed correctly?

Daniel J. Sheridan, RN, PhD

[email protected]– Home Office 6210 Fairbourne Ct.

– Hanover, MD 21076Hanover, MD 21076

– 410-379-8577 410-379-8572 fax

– Johns Hopkins University

– School of Nursing, Room 467

– 525 N. Wolfe St

– Baltimore, MD 21205 410-614-5301

– 410 - 955 - 7463 fax [email protected]

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