In a facility in a small city in New York, the plaintiff attorney alleged that our insured failed to develop care plans and failed to properly supervise the plaintiff. It is also alleged the insured failed to conduct a proper evaluation, which would have lead the defendant to the conclusion that the plaintiff was not suited for the level of care the facility was equipped to provide.
This claim started with a resident who sustained a fracture to her right humerus and right femur resulting from a fall. The resident was simply observed sliding down the wall of the facility. The resident was to of used a walker and had been observed earlier in the day using the walker. Due to inadequate documentation, these appear to be the only facts of the incident we have from eye witnesses.
Careful review of the current facts accumulated to date and the experts consulted led to a settlement in the amount of $175,000 plus expenses of $20,000.
Had proper documentation and record keeping procedures been implemented in this facility, the expected result of this claim could have been minimized as the defense attorney could have had more fuel for his fire to prepare a stronger defense for this case.
Records are a durable account of what has happened. Courts may place more trust in records than in eyewitnesses. 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. The record can be the facilities tool in defending against charges of errors and misconduct. In addition to background material, treatment plan, record of treatment interventions, progress notes, critical incident reports and routine information, the record should contain documentation of all unusual events and incidents.
No doubt almost everyone in America has heard horror stories about care facilities. Almost all of the industry’s problems can be solved through good risk management practices as stated in an October 28, 2003 report published by the Joint Commission on Accreditation of Healthcare Organizations. The following tools were reported as necessary practices for all care facilities: