Records and documentation are a durable account of what has happened in your facility. Courts may place more trust in records than in eyewitnesses that are asked to testify. This may be true because documentation is an immediate response, and eyewitness accounts may be told long after the event is fresh in the observer’s memory. Proper documentation and records can be the facility’s tool in defending against charges of errors or misconduct. In addition to background material, treatment plan, record of treatment interventions, progress notes, critical incident reports and routine information, the records should contain documentation of all unusual events that may have occurred. This documentation should be a clear and accurate accounting of the situation. Do not make assumptions in your account of what has happened; simply state the facts as you know. Make sure you include the following information in your write-up:
Date & Time of the incident
These records and documentation can always be used to defend your facility in the event of a lawsuit or they can be viewed the licensing authorities in your state to defend any complaints that may have been reported.
An 88 year-old resident was not a known wanderer, and was fairly aware of what was going on in the surroundings around her. The resident was last seen on the facility’s (insured) premises at 10pm. The night shift aide for the upstairs area checked resident’s room at 1:30am and did not find her. She checked the sign out log, and found that she was not signed out. The aide made the assumption that resident was at her home. This was not unusual, as numerous times the resident had gone home to stay overnight, and forgotten to sign out. Questions arose regarding the resident’s whereabouts during the 7am shift change. The resident’s son was called, and a search was immediately initiated. She was found at 7:15am, about 100 yards from facility. She was transported to the hospital, where she died a few hours later, apparently from hypothermia.
This case was settled last week for $36,000. This is a classic example of trying to do all the right things and still things can go south. This claim settled quickly with little cost as a result of having the proper documentation, communication and procedures in place. MORAL All documentation should be a clear and accurate accounting of the situation. Do not make the assumption that you will remember the incident exactly as it occurred. Record the incident as soon as possible following the occurrence. When documenting the incident, deal only with the facts and what actually happened; do not provide opinions or personal feelings in your documentation. Be specific, include what staff members had been present, date, time, witnesses other than staff, include conversations with any physicians, family members, other responsible party and other medical professionals. Always keep in mind that these documents could be used in defending a court case, review by the licensing department and others outside the company. For more information, and a template for documentation Procedures and Policies, visit the PCALIC website at www.pcalic.com; enter through the member login, under the “Member Insured Menu” select “Risk Management”, then click on “Documentation and Records”. In my years of providing protection for adult residential care communities, I have found that it pays many times over to be proactive rather than reactive.