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Magazine Bookstore is
proud to offer investigators Nursing Home Litigation
Investigation and Case Preparation, Second Edition: Investigation
and Case Preparation, Second Edition,
editor Patricia W. Iyer.
Each chapter in Nursing Home
Litigation Investigation and Case Preparation, Second Edition has been revised and updated
while new chapters have been added to provide detailed information
on even more issues and cases in nursing home litigation. It
is an excellent reference for your nursing home or eldercare
litigation team including attorneys representing either plaintiffs
or defendants, financial consultants, life care planners, and
other specialists with perspectives from experienced attorneys,
physicians, nursing consultants, pharmacists, and nursing home
experts.
This book is composed of four specialized sections so you can
quickly and easily find the information you need. Part One discusses
legal strategies you and your team can utilize during the investigation
and pretrial phases of nursing home cases including screening
cases, special issues unique to assisted living and nursing home
cases, and use of Legal Nurse Consultants. Part Two explains
the liability issues that arise due to the nature of the nursing
home setting including staffing concerns, services provided to
residents, administrative liability, direct and indirect medical
practitioner responsibility issues. Part Three describes common
allegations of injury, illness and other liability issues that
occur in nursing home cases including falls, skin trauma, infections,
pharmacology issues, pain management, billing fraud, and records
tampering. Part Four provides tips for defending nursing home,
long-term care and assisted living facilities with information
on defense perspectives and strategies on many types of nursing
home cases as well as insurance adjusters' perspectives on nursing
home cases pertaining to insurance claims.
This comprehensive text is a must-have legal and medical reference
for everyone who works with nursing home, assisted living, long-term
care, or elder law cases.
Topics include: (click
to view Table of Contents)
• Nursing home liability
• Physician’s liability
• Nursing
home administration liability
• Defense perspectives
• Claims adjuster’s
perspectives
• Use
of legal nurse consultants
• Screening
cases
• Investigation and
pretrial considerations
• Nursing
practice in long-term care situations
• Overview
of the nursing home environment
• Assisted
living cases- special considerations
• Falls
and restraints
• Skin trauma
• Infections
• Wandering and Elopement
• Pharmacology
and the elderly
• Pain
management
• Tampering with medical
records
• Billing
fraud
Contributors Include: Byron S. Arbeit,
Kathryn L. Locatell, Mary L. Lubin, Steven Zlotnick,
J. Scott Myers, Steven M. Levin, Mary K. Leverock,
William T. Lawson, III, Ruben J. Krisztal, Deborah D'Andrea,
Elizabeth A. Capezuti, Libby Edwards, Rose Clifford,
Monica Agosto, Sean Doolan, Jaclyn Adler, Steven Adler,
Erane Allen, Gloria Blackmon, Julie Braun, David Brinton,
Steven Castle, Margaret Chizek, Fred Feinsod,
Michelle Hammer, Kelly Jaszarowski, Jennifer Melone,
Ann Riggs, Jill Thomas, Jacqueline Vance
About the Editor:
Patricia W. Iyer, RN,
M.S.N, - is a medical
surgical nurse expert witness and president of a legal nurse
consulting firm, Med League Support Services in Flemington, NJ.
Her firm provides assistance to attorneys who handle medical
and nursing malpractice cases, personal injury, products liability
and other types of cases. It also screens nursing home cases
for merit.
She received her diploma in nursing from Muhlenberg Hospital
School of Nursing in Plainfield, NJ, and her B.S.N and M.S.N
from University of Pennsylvania in Philadelphia. She was certified
as a legal nurse consultant by the American Association of Legal
Nurse Consultants. Active in the Philadelphia and New Jersey
chapters of AALNC, Ms. Iyer was elected to the board of directors
of AALNC in 1998. She served a term as secretary and director
at large, and will complete a three-year term as president elect,
president and past president for AALNC for the years 2001Ж04.
Ms. Iyer’s experience includes working as a staff nurse,
an educator in a school of nursing, a director of nursing education
in a hospital, and a nursing quality assurance coordinator. She
is a noted national and international speaker on nursing documentation
and liability issues, and has presented seminars to attorneys
and paralegals. She has testified as an expert and fact witness.
Hardcover
720 pages
11" X 8.5"
retail $149.00
Our Price $119.20
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Table of Contents:
Preface v
Part I
Legal Strategies
Chapter 1: Introduction 3
Libby Edwards, Esq.
1.1 Scope of the Issue 3
A. Overview of nursing home litigation 3
B. Historical perspective of nursing home care 3
C. Aging demographics in the United States 4
D. More than $100 billion is spent annually on care
provided in skilled nursing facilities (SNFs) 4
E. Regulation 4
F. Perspectives on the evolving quality of care 5
1.2 Current Status of Nursing Home Litigation 6
A. Increase in nursing home cases 6
B. Size and number of verdicts 6
C. Tort reform applied by the states 6
D. Public perception of nursing home cases and
elderly rights 6
1.3 Hurdles to Overcome 6
A. Nursing home cases are complex 6
B. The flood of information to be processed 6
C. The expense of litigation 9
D. The jury's preconceived opinions about nursing homes 9
1.4 Summary 9
References 9
Chapter 2: Screening the Nursing Home Case 11
Steven M. Levin, Esq. and David H. Brinton, Esq.
2.1 Introduction 11
2.2 The Initial Contact 11
2.3 Gathering Information Before the Initial Meeting 12
A. General information and potential parties 12
B. Medical records 12
C. Other legal issues 12
2.4 The Initial Interview 12
A. Allegations 12
B. Family dynamics 13
C. Determining statute of limitations 14
D. Motivations of the client, potential remedies,
and distribution of proceeds 14
E. Potential defendants 15
F. Effect of recovery on benefits 16
G. Fear of retaliation 16
H. The client's legal authority 16
I. Accept or reject the case 16
2.5 Damages 17
A. Punitive damages 18
B. Noneconomic losses 18
C. Effect of injuries 19
2.6 Preliminary Investigation: Re-evaluation 19
2.7 Drafting the Complaint 20
A. The plaintiff 20
B. The defendants 21
2.8 Summary 22
References 22
Additional Reading 23
Chapter 3: Nursing Home Cases:
Investigation and Pretrial Considerations 25
Ruben Krisztal, Esq.
3.1 Introduction 25
3.2 Overview of Nursing Home Structure 26
3.3 Establishing the Foundation of a Nursing Home Claim 27
A. Documents to obtain prior to the commencement
of litigation 27
B. Other information needed 31
3.4 Opening the Estate 31
3.5 Common Allegations 32
3.6 Developing a Claim 33
A. Parties to the litigation 33
B. Nursing home officer 33
C. Caps 33
D. Wrongful death 33
E. OBRA violations 33
F. Admissibility of prior behavior 35
G. Punitive damages 37
H. Loss of chance 37
I. Breach of contract 40
J. Wrongful death 41
K. Possible claim against the treating physician 41
L. False Claims Act 42
3.7 Request for Production of Records 42
3.8 Interrogatories 45
3.9 Motion to Compel and for Sanctions 45
3.10 Expert Opinions 46
3.11 Depositions 47
A. Why depose 47
B. Who to depose 47
C. When to depose 47
D. Recording of depositions 48
3.12 Other Factors Influencing Litigation 48
A. Medicare lien 48
B. Effects on future Medicare/Medicaid benefits 48
3.13 Summary 48
References 49
Chapter 4: Assisted Living Cases: Investigation and
Pretrial Considerations 51
Sean Doolan, Esq. and Monica Agosto, BA, JD
4.1 Introduction 51
A. Overview of the assisted living industry 51
B. Definitions 52
C. Statutory and regulatory protections of
residents 52
4.2 Case Selection 54
A. Initial intake 54
B. Family dynamic 54
C. Liability 55
D. Who is the defendant? 55
E. Statute of limitations issues 55
4.3 Pre-suit Discovery Considerations 56
A. Documents to request 56
B. Physical evidence 56
4.4 Typical Assisted Living Facility Case
Scenarios 56
A. Elopement 56
B. Falls 56
C. Pressure ulcers 57
D. Medication errors 57
E. Sexual assault 57
F. Failure to supervise 58
G. Medicaid fraud 58
4.5 Theories of Liability 58
A. Common law negligence 58
B. Statutory violations 59
C. Wrongful death 59
D. Consumer fraud 59
E. Breach of contract 59
F. Premises liability 59
4.6 Discovery Considerations 59
4.7 Motion Practice 60
A. Motions a plaintiff's attorney should expect 60
B. How to respond to defendant's delay tactics 60
4.8 Settlement Considerations 61
A. Medicare/Medicaid 61
B. Valuing the claim 61
4.9 Summary 62
Endnotes 62
Additional Reading 63
Chapter 5: The Legal Nurse Consultant:
An Essential Team Member 65
Patricia W. Iyer, MSN, RN, LNCC and
Deborah D. D'Andrea, BSN, BA, RN
5.1 Introduction 65
5.2 American Association of Legal Nurse
Consultants 65
5.3 Qualifications 66
A. Education 66
B. Clinical experience 66
C. Preparation 66
D. Business structure 66
E. Certification 66
F. Communication skills 66
G. Organizational skills 68
H. Resourcefulness 68
I. Ability to work with difficult people 68
5.4 Roles of the LNC 68
A. Educator 68
B. Analyst 68
C. Preparer of reports 70
D. Medical resource person 74
E. Investigator 75
F. Medical expert 75
G. Team player 76
H. Strategist 76
I. Locating and working with expert witnesses 77
J. Preparer of demonstrative evidence 77
K. Deposition support 80
L. Presenter of damages at the settlement conference
or arbitration 82
M. Trial support person 83
5.5 Advantages of Using a Nurse Rather than a
Physician to Consult on Nursing Home Malpractice Cases 83
5.6 Limitations of the Legal Nurse Consultant's Role 84
5.7 The Independent Legal Nurse Consultant 85
A. Advantages of working with the independent
LNC 85
B. Locating an independent LNC 85
C. Interviewing the independent LNC 86
D. Compensation 86
E. Tips for establishing a strong relationship with
an LNC 91
F. Evaluation of the independent LNC 91
5.8 The Legal Nurse Consultant Employed by a Law Firm 92
A. Advantages of having an in-house LNC 92
B. Hiring the in-house LNC 93
C. The role of the in-house LNC 98
D. Performance evaluations 100
5.9 Summary 100
References 100
Appendix 5.1: Portions of a Case Summary 101
Appendix 5.3: Portions of an Elopement
Chronology 106
Appendix 5.4: Indepth Analysis of Negligence 107
Appendix 5.5: Plaintiff Nursing Expert Witness
Report 110
Part II
Liability: Settings and Healthcare Providers
Chapter 6: Inside the Nursing Home:
A Medico-legal Perspective 145
Julie A. Braun, JD, LLM, Mary L. Lubin, RN, MA, and Erane
Allen, MPA, RN, CDONA, CNHA
6.1 Introduction 147
6.2 Our Nation's Older Population 147
A. Future growth of the older population 149
B. Life expectancy increasing 149
6.3 Facility and Resident Characteristics 150
A. Types of facilities 150
B. Ownership and geographic location 151
C. Payment sources for nursing home care 151
D. Nursing home utilization 151
E. Resident characteristics 153
F. Resources 154
6.4 Role of the Facility Governing Body 157
A. State corporation laws 157
B. State facility licensure statutes 157
C. General duties of individual governing board
members 157
D. Select governing board functions 158
6.5 Key Players in a Nursing Home: The Basics 159
A. Nursing home administrator 159
B. Role of the medical director 160
C. Physician responsible for resident care 161
D. Director of nursing 163
E. Nursing staff 163
F. Administrative support services 165
6.6 Resident Assessment and Care Planning 167
A. Federal regulations direct resident assessment 167
B. Who conducts or coordinates the resident
assessment? 167
C. Role of resident's attending physician in the
assessment process 167
D. Minimum Data Set 167
E. Federal regulations governing care planning 168
F. Who prepares the resident's care plan? 168
G. Resident's right to participate in care planning
process 168
6.7 Resident Services 168
A. Subacute services 168
B. Rehabilitative services 168
C. Dietary services263 172
D. Psychosocial services 174
E. Vision and hearing services 175
F. Dental services 175
G. Social services 177
H. Activities programs 178
I. Pharmacy services 179
J. Laboratory services 180
K. Radiology and other diagnostic services 181
6.8 Documentation in a Nursing Home 181
A. Medical record audits and thinning 182
B. Resident Assessment Instrument documentation 182
C. Policy, procedure, and protocol 185
D. Staffing schedules and assignments 185
E. Lists and logs 186
F. Inservice records 186
G. Consultant reports 186
H. Survey documentation 186
I. Data Assessment and Verification Review
(DAVE) 188
J. Accreditation reports 188
K. Hospital discharge records and transfer forms 188
L. Face or cover sheet 188
M. Nursing home admission notes 188
N. Physician orders and progress notes 188
O. Nursing notes 189
P. Medication administration records 189
Q. Flow sheets 189
6.9 Staffing Hours and Patterns 189
6.10 Committees 189
A. Quality assessment and assurance committee 189
B. Infection control committee 190
C. Institutional Review Board (IRB) reviews and
approves experimental research protocols 191
D. Residents' and families' groups 191
6.11 Relevant Law and Regulation 191
A. Federal Nursing Home Reform Law462 191
B. Federal long-term-care regulations464 192
C. Elder abuse reporting laws 192
D. Food and drug law and regulation 194
E. Patient Self-Determination Act 194
F. Privacy of Health Information 194
G. Life Safety Code (LSC)512 195
H. Americans with Disabilities Act 198
I. Rehabilitation Act, Section 504 198
J. Civil Rights Act 198
K. Civil Rights of Institutionalized Persons Act 198
L. Fair Housing Amendments Act 199
M. Federal False Claims Act580 199
N. State false claims acts 199
O. Consumer protection statutes 199
P. Federal racketeering laws 200
Q. Occupational health and safety law and
regulation 200
R. Workers' compensation acts 201
S. State law and regulation 201
6.12 Summary 201
Appendix 202
Endnotes 203
Chapter 7: Foundations of Nursing Practice 223
Gloria Blackmon, RN-BC, BSN, LNHA, Paricia W. Iyer, RN, MSN,
LNCC, and Jill Thomas, RN, CWOCN, LNHA, RNAC
7.1 Introduction 224
7.2 Long-Term-Care Diversity 224
A. Long-term-care hospitals 224
B. Assisted living 224
C. Intermediate/custodial care 224
D. Skilled care 224
7.3 Subacute Care 224
A. Definition 224
B. Standards of care for subacute-care units 225
7.4 Staffing Issues 226
7.5 The Nursing Process 227
A. The use of the nursing process in litigation 227
B. Steps of the nursing process 227
7.6 Errors in Carrying Out the Nursing Process 230
A. Incompetence 230
B. Lack of knowledge and experience 230
C. Chemical dependency 233
D. Improper delegation or failure to train 233
E. Stress and burnout 233
F. Impaired critical thinking 233
7.7 The Importance and Purpose of Documentation 236
7.8 Regulations Pertaining to Medical Records 236
7.9 Overview of the Components of the Long-Term-Care Record
237
A. Face sheet 237
B. Discharge summary 238
C. Physician's orders 238
D. History and physical 240
E. Physician's progress notes 240
F. Consultations 240
G. Graphic records 240
H. Nursing admission assessment 240
I. Minimum Data Set (MDS) 240
J. Care plan 240
K. Nurses' notes 240
L. Activities of daily living (ADL) 240
M. Medication records 240
N. Treatment records 240
O. Interdisciplinary care planning meetings 241
P. Laboratory results and diagnostic studies. 241
Q. Social services 241
R. Physical, recreational, speech, and occupational therapy
241
S. Respiratory therapy 241
T. Nutritionist's records 241
U. Consents 241
V. Transfer forms 241
7.10 Admission and Care Planning Documents 241
A. Admission assessment/documentation 241
B. Minimum Data Set 242
C. Additional assessments 244
D. Resident Assessment Protocol 244
E. Care planning 244
7.11 Nursing Notes 248
A. Format and frequency 248
B. Content 249
C. Progress toward care plan goals 249
7.12 Additional Nursing Documentation 249
A. Activities of daily living flow sheets 249
B. Medication administration records (MARs) 250
C. Treatment and wound care record (TARS) 250
D. Wound flow records 250
E. Meal intake 250
F. Behavior monitoring 250
G. Bowel movements 250
7.13 Physician Documentation 250
A. Progress notes 250
B. Orders 251
7.14 Medicare Documentation 251
7.15 Discharge Documentation 251
7.16 Careless Documentation 252
7.17 Summary 255
References 255
Additional Reading 256
Appendix 7.1: Common Nursing Home Phrases and Terminology
256
Appendix 7.2: Common Clinical Diagnosis
Abbreviations 259
Chapter 8: Nursing Home Liability and Its
Consequences 261
Patricia W. Iyer, MSN, RN, LNCC
8.1 Introduction 261
8.2 Scope of the Problem 262
8.3 Societal Consequences 262
8.4 Economic Consequences 263
8.5 Consequences for the Nursing Home 263
8.6 Consequences for Other Facilities 264
8.7 Legal Consequences: Settlement and Verdict Trends of
Nursing Home Cases 264
A. 1993-1995 264
B. 1996-1998 265
C. 2001-2003 267
8.8 Overview of Resident Consequences 269
A. Losses 270
B. Pain and suffering in dementia 270
8.9 Pressure Sores 271
A. Scope of the problem 272
B. Causes 272
C. Locations and prevention 272
D. Staging 273
E. Treatment 273
F. Debridement 274
G. Infection 274
H. Liability issues 274
I. Federal regulations 276
J. Pressure sore prevention recommendations 277
K. Cases related to pressure ulcers 278
L. Impact on the resident 278
8.10 Falls and Fractures 279
A. Types of falls 279
B. Scope of the problem 279
C. Causes 279
D. Liability issues 279
E. Federal regulations 281
F. Cases related to falls 281
G. Impact on the resident 281
8.11 Abuse of Residents 282
A. Types of abuse 282
B. Scope of the problem 282
C. Causes of assaultive behavior by residents 283
D. Liability issues associated with assaults by
residents 284
E. Federal regulations 284
F. Prevention of assaults 284
G. Abuse and assaults by the staff 285
H. Sexual assaults of residents 285
I. Detection and reporting of abuse 285
J. Screening a case for abuse 286
K. Case related to assaults 286
L. Impact on the resident 287
8.12 Neglect 288
A. Scope of the problem 288
B. Federal regulations 289
C. Cases involving neglect 289
D. Impact on the resident 289
8.13 Malnutrition and Dehydration 290
A. Scope of the problem 290
B. Causes 290
C. Liability issues 291
D. Federal regulations 291
E. Cases involving malnutrition 292
F. Impact on the resident 292
8.14 Medication Errors 292
A. Scope of the problem 292
B. Causes 293
C. Liability issues 293
D. Federal regulations 294
E. Cases of medication errors 294
F. Impact on the resident 294
8.15 Six Major Categories of Nursing Liability 295
A. Failure to follow standards of care 295
B. Failure to use equipment in a responsible
manner 295
C. Failure to communicate 296
D. Failure to document 296
E. Failure to assess and monitor 297
F. Failure to act as a patient advocate 297
8.16 Pain and Stress of Hospitalization 298
A. Perioperative risks 298
B. Injuries during the postoperative period 298
C. Pain and suffering from burns 299
D. Sources of suffering associated with the medical environment 299
E. Ongoing suffering caused by pain and emotional upheaval 300
8.17 Conclusion 301
References 303
Additional Reading 307
Chapter 9: Physician's Liability Issues 309
Kathryn L. Locatell, MD
9.1 Introduction 309
9.2 Overview of the Physician's Role in the Care of the Nursing
Home Patient 309
A. Evolution of practice patterns in the community 309
B. Disease-oriented physician training 310
C. Physician reimbursement issues 311
D. The growth of managed care 311
9.3 Regulatory Requirements in Nursing Home Care: Relationship
to the Physician's Role 311
9.4 Current Standards of Care and Potential for
Physician Liability 313
A. Initial history and physical 313
B. Changes in patient condition 314
C. The monthly or bimonthly visit 315
D. Coverage issues 315
E. Laboratory reports 315
F. Consultants 317
G. Pharmaceuticals 317
H. Informed consent 318
I. Advance directives 319
J. Common complications 319
9.5 Direct Physician Responsibility Issues 321
A. Diagnosis 321
B. Certification 321
C. Treatment 322
D. Supervision of care plans 322
9.6 Indirect Physician Responsibility Issues 322
A. Billing 322
B. Aftercare 322
9.7 The Nursing Home Medical Director 323
A. Nursing home policy and procedure 323
B. Staff education and development 324
C. Conflicts 324
9.8 Defenses against Causes of Action against
Physicians 324
A. Negligence 324
B. Failure of oversight 325
9.9 Summary 325
References 327
Chapter 10: The Administrator and Nursing Home
Liability Issues 329
Byron S. Arbeit, MA, HFA, NFA
10.1 Introduction 329
10.2 Facility Licensure 329
10.3 Facility Certification 330
10.4 Essential Documents for the Attorney's Library 331
10.5 The Difference Between a "Skilled Nursing Facility" (SNF)
and a "Nursing Facility" (NF) 332
10.6 OBRA Citations and What Is Meant by
"Substandard Care" 332
10.7 Additional Sources of Information About an Individual
Nursing Home's OSCAR Reports 333
A. Mortality rates 334
B. Quality Assessment and Assurance Committee
minutes 334
C. Resident Council minutes 334
D. Family Council minutes 334
10.8 The Nursing Home Survey Process: A Brief Overview 335
A. Types of surveys 335
B. Use of surveys by counsel 338
10.9 Common Reasons Why Nursing Homes are Sued: Canvassing Federal OBRA 483.10-483.75
338
A. Federal OBRA § 483.10 338
B. Federal OBRA § 483.12 339
C. Federal OBRA § 483.13 340
D. Federal OBRA § 483.13(b) and (c) 340
E. Federal OBRA § 483.15 341
F. Federal OBRA § 483.20 341
G. Federal OBRA § 483.25 342
H. Federal OBRA § 483.30 343
I. Federal OBRA § 483.35 343
J. Federal OBRA § 483.40 343
K. Federal OBRA §§ 483.45 (Specialized Rehabilitative Services),
483.55 (Dental Services), 483.60
(Pharmacy Services) 343
L. Federal OBRA § 483.65 (Infection Control) 343
M. Federal OBRA § 483.70 (Physical
Environment) 343
N. Federal OBRA § 483.75 (Administration) 344
10.10 Administrator's Exposure as a Potential
Defendant 344
A. Pressure Ulcer Cases 345
B. Malnutrition cases 345
C. Fall prevention cases 346
D. Elopement cases 347
E. Other Types of Cases 347
10.11 Nursing Home Administrator's Role as an Expert Witness 347
A. Typical licensure provisions pertinent to the
administrator's duties 347
B. Testifying as to causation 349
C. Considerations for the use of an administrator
expert witness 349
10.12 Summary 350
References 350
Part III
Liability: Allegations
Chapter 11: Falls and Restraints Liability
Issues 355
Elizabeth Capezuti, PhD, RN, FAAN, William T. Lawson III,
JD, Michelle Hammer, MA, RN, and Jennifer Melone, MA
11.1 Falls in the Nursing Home 355
A. Prevalence of falls 355
B. Consequences of falls 355
11.2 Prevention of Falls 356
A. Standard of care as a dynamic concept 356
B. The current standard of care 357
C. Fall risk assessment 358
11.3 Interventions to Prevent Falls 361
A. Reducing risk factors 361
B. Addressing side effects of medications 361
C. Providing appropriate observation 362
D. Promoting safe mobility 363
E. Promoting safe transferring 364
F. Promoting comfortable, individualized seating 365
G. Preventing falls from bed 366
11.4 Post-fall Treatment 366
11.5 Physical Restraints and Side Rails 367
A. Definition 367
B. Restraint/siderail-related injuries, including
death 368
C. Recent research/clinical practice regarding the
relationship to falls/injuries 370
D. Standards related to use of physical restraints 370
E. Defense of falls and restraints cases 371
11.6 Damages 372
A. Proximate cause 372
B. Compensatory damages 373
C. Punitive damages 373
11.7 Summary 375
References 375
Additional Reading 382
Chapter 12: Skin Trauma 383
Kelly Jaszarowski, MSN, RN, CNS, ANP, CWOCN and Steven Castle,
MD
12.1 Introduction 383
12.2 Wounds 383
A. Etiology 384
B. Assessment 385
C. Treatment options for wounds 387
D. Documentation 389
E. Case 391
12.3 Burns 391
A. Etiology 391
B. Assessment 392
C. Treatment 392
D. Documentation 394
E. Complications 395
F. Cases 396
12.4 Pressure Ulcers 396
A. Etiology 396
B. Assessment 397
C. Treatment 399
D. Documentation 401
E. Complications 402
F. Case 402
12.5 Standard of Care 402
A. The concept of standard of care in wound
management 402
B. Use of guidelines 403
C. Federal regulations 404
D. Natural progression of illness versus poor quality
care 405
E. Quality of the staff 405
12.6 Summary 406
References 406
Chapter 13: Infections in the Nursing Home 411
Jacqueline Vance, RN, C. CDONA/LTC
13.1 Introduction 411
13.2 Susceptibility Factors For Infection Among Nursing Homes
Residents 411
13.3 Barriers to the Optimal Management of Infections in
the Nursing Home 412
13.4 Common Types of Infections in Long-Term-Care Facilities
413
A. Urinary tract infections 413
B. Respiratory tract infections 414
C. Gastrointestinal infections 415
D. Skin infections 416
13.5 Infection Control 416
A. Elements of a comprehensive institutional infection
control program 417
B. An explanation of the federal regulations 417
C. Managing outbreaks 417
D. Immunization programs 419
13.6 The Importance of Following a Care Process in Infection Control 419
A. Recognition 420
B. Assessment 420
C. Treatment 421
D. Monitoring 422
13.7 Liability Associated with Transmittal of
Infections 422
A. Recommended precautions to prevent transmission
of the most common types of infections 422
B. Standard precautions versus contact
precautions 423
C. Employee health 423
D. Environmental decontamination 423
13.8 Liability Associated with the Delay in Recognition of Infections 423
13.9 Liability Associated with the Delay in Treatment or Transfer to the Hospital
426
A. To transfer or not to transfer 426
B. To treat or not to treat-palliative care 426
C. Neglect 426
13.10 Antibiotic Resistant Infections and Antibiotic
Use 426
A. Process for ensuring the prudent use of
antibiotics 427
B. A word about colonization 427
14.11 Summary 427
References 427
Appendix: Guidance to Surveyors-Long-Term-Care Facilities (from the State Operations
Manual) 429
Chapter 14: Wandering and Elopement 437
Margaret Chizek, RN, FNP, BSN, MBA, AAS, CLNC
14.1 Introduction 437
14.2 Wandering and Elopement Definitions 437
14.3 Wandering 438
14.4 Elopement 438
A. Elopement and suicide 439
B. Elopement and mental illness 439
14.5 Safety Duty 440
14.6 Residents at High Risk for Elopement 440
A. Having a plan 440
B. Aging in place 441
C. Death of a spouse or significant other 441
D. New admission or readmission 441
E. Resident moved to a new room in an existing
facility 441
F. Facility's physical change or new construction 441
G. History of elopement behavior 441
H. Inappropriate placement 442
14.7 Prevention Strategies 442
A. Departure alert systems 442
B. Photographs and identification 444
C. Secure dementia or memory support units 444
D. Sundowning behavior 444
E. Activities 444
F. One on one supervision 444
G. Time specific monitoring 444
H. Placement in building 445
I. Video cameras 445
J. Windows and screens 445
K. Window coverings 445
L. Trash and linen chutes 446
M. Elevators 446
N. Environmental modifications 446
O. Shared risk contracts 446
P. Elopement drills 447
14.8 Dealing with the Emergency 447
A. Pre-worn clothing 447
B. Policies and procedures 447
C. Responding to the elopement 448
D. Law enforcement and media involvement 448
14.9 Regulatory Impact of Elopement 448
14.10 Reviewing and Preparing the Elopement Case 449
14.11 Identifying the Defenses: Resident Rights 451
14.12 Discovery Strategies 452
A. Did the resident elope? 452
B. Labeling the incident 452
C. Facility policy and procedures 452
D. Engineering and preventive maintenance (PM) 452
E. Documentation 452
F. Risk identification 453
14.13 Summary 453
References 453
Chapter 15: Pharmacology and the Elderly 455
Steven Zlotnick, BSc, PharmD, CCP, FASCP
15.1 Introduction 455
15.2 Qualifications of the Consultant Pharmacist 455
15.3 Roles of the Consultant Pharmacist 456
A. Educating 456
B. Medication dispensing 456
C. Preventing medication errors 456
D. Performing drug regimen review (DRR) 457
15.4 Inappropriate Medications 458
15.5 Chemical Restraints 458
A. Definition of chemical restraints 458
B. Psychoactive medications 459
15.6 Off-Label Agents 463
15.7 Unnecessary Drugs 464
A. Intent of OBRA restrictions on chemical
restraints 464
B. Review of the medical record 465
C. Ongoing monitoring 466
15.8 Implications of Drug Therapy for the Elderly 466
A. Dose and duration of use of a medication 466
B. Polypharmacy 466
C. Adverse drug reactions (ADR) 466
15.9 Guidelines and Medical Practice 466
Resources 467
Additional Reading 467
Chapter 16: Pain (Mis)Management Litigation 469
Julie A. Braun, JD, LLM
16.1 Introduction 471
16.2 Pain (Mis)Management: An Emerging Care
Issue 472
A. Landmark case: liability for inadequate treatment
of pain 472
B. Decade of pain control and research 472
C. Pain as a fifth vital sign 472
D. Federal legislation targets pain and symptom
management 472
E. CMS creates Medicare specialty code for pain
management 473
F. Pain: A Nursing Home Quality Initiative Program
measure 473
16.3 Pain Incidence and Prevalence 476
16.4 What is Pain? 477
A. Defining pain 477
B. Self-reports of pain 477
C. Classification of pain 477
D. Causes of pain in the elderly 478
E. Consequences of unrelieved geriatric pain115 481
16.5 Pain Recognition In Long-Term Care:
Misconceptions And Barriers 481
A. A laundry list of misconceptions 481
B. Barriers to pain recognition 481
16.6 Assessing Residents' Pain 482
A. Federal regulations direct resident assessment 482
B. Who conducts or coordinates the resident
assessment? 483
C. Role of resident's attending physician in the
assessment process 483
D. Resident Assessment Instrument (RAI) 483
E. Did the nursing home conduct a pain
assessment? 486
F. Did the nursing home use a standardized pain
assessment instrument? 490
G. Assessing pain in the confused or cognitively
impaired nursing home resident 492
H. Staff attitudes toward pain assessment 494
I. Assessment/care plan among ombudsman
complaint categories with largest growth 494
J. Inaccurate assessment produces an inappropriate
care plan 495
16.7 Resident Care Plan and Pain Management 495
A. Federal regulations governing care planning 495
B. Who prepares the resident's care plan? 495
C. Resident's right to participate in care planning
process 495
D. Resident's right to be fully informed of change in
care or treatment 496
E. Comprehensive care plan content 496
F. Services provided must meet professional standards
of quality 501
G. Resident education forms cover pain
management 501
H. Establish realistic goals: manage resident pain
relief expectation 501
I. Timely communication of pain: resident-to-nurse
and nurse-to-clinician 502
J. Care plan demonstrates facility knowledge of
resident's pain management needs and foreseeability of negative outcome 502
16.8 Does Pain Management Result in Chemical Restraint? 502
16.9 Proving Adherence to or Deviation from the Standard of Care in a Pain
(Mis)Management Case 502
A. Violation of federal Controlled Substances Act 503
B. Federal statutory or regulatory
(non)compliance 503
C. State law and regulation 507
D. Voluntary accreditation standards 507
E. Clinical practice guidelines (CPGs) on pain
management 508
F. Usual and customary professional or industry
practice 513
G. Consensus statements and position papers created by professional and specialty
organizations 514
H. Institutional policy and procedure 515
I. Survey and enforcement documentation 515
J. Establishing the standard of care through expert
testimony 516
K. Courts recognize distinction between negligence
and professional error of judgment 520
16.10 Litigation and Pain (Mis)Management 521
A. Current threat of pain (mis)management
litigation 521
B. Recognition of legal right to pain and symptom
relief 521
C. Case illustration: imposing a duty to treat pain 521
D. Case illustration: pain medication prescribed,
never administered 521
E. Landmark pain (mis)management case uses state
elder abuse law 521
F. Doctrine of negligent infliction of emotional
distress may apply to pain (mis)management
cases 524
G. Proving pain as damages 524
H. Impact of emerging liability for pain
(mis)management 527
16.11 Documentation of Pain Management 529
A. Purpose of pain management documentation 529
B. Relationship between document review and pain
(mis)management case viability 529
C. Learn the jargon 529
D. "If care was not documented, it was not given" 529
E. Documentation practices 529
F. Role of discovery in evaluating a pain
(mis)management case 530
G. Long-term-care record content 530
16.12 Conclusion 534
Endnotes 534
Chapter 17: Investigation of Billing Fraud 571
Rose Clifford, RN, and Mary K. Leverock, BSN, RN
17.1 Introduction 571
17.2 Government Agencies Involved in Fraud and Abuse Investigations
572
17.3 Overview of Federal Fraud and Abuse Laws 575
A. Federal statutes 575
B. State laws affecting fraud and abuse 579
C. Provider manuals 579
17.4 Fraud and Abuse 579
A. Elements of a false claim in Medicare or
Medicaid 579
B. Abuse 580
C. Fraud alerts and advisories 581
17.5 Public Payor Programs 583
A. Medicare 584
B. Medicaid 587
17.6 Nature of Nursing Home Reimbursement 588
17.7 Reimbursement Issues 589
A. Coding resources 589
B. Cost reports 590
C. Consolidated billing 592
D. Billing aspects of MDS 593
17.8 Quality-of-Care Issues Related to Fraud and
Abuse 594
17.9 Other Fraud and Abuse Cases in the Nursing
Home 594
17.10 Attorney-Client Privilege 595
17.11 The Future of Billing Fraud Investigations 595
17.12 Summary 596
Glossary 596
References 600
Websites 602
Chapter 18: Tampering with Medical Records 605
Patricia W. Iyer, RN, MSN, LNCC
18.1 Introduction 605
18.2 Definitions of Spoliation 605
18.3 Spoliation Inference 605
18.4 Implications of Spoliation 606
18.5 Remedies for the Person Harmed By Spoliation 606
18.6 Organizing and Analyzing Medical Records 608
A. Use of interrogatories 614
B. The incident report 614
C. Obtaining the incident report 615
18.7 Techniques for Tampering With Medical
Records 615
A. Adding to an existing record at a later date 615
B. Placing inaccurate information into the record 616
C. Omitting significant information 617
D. Rewriting the record 617
E. Destroying records 619
F. Adding to someone else's notes 619
18.8 Tampering with Records Relating to Common Liability
Issues 619
A. Pressure ulcers 619
B. Malnutrition and dehydration 625
C. Physical and sexual assault 625
D. Falls and fractures 626
E. Wandering and elopement 626
18.9 Documents Examiners 627
18.10 Email is Discoverable 627
18.11 Summary 627
References 627
Additional Reading 628
Part IV
Defense Perspectives
Chapter 19: Defending Long-Term-Care Facilities: Unraveling
Clinical Outcomes from the Natural History of Aging 633
Fred M. Feinsod, MD, DSc, CMD and Ann Riggs, MD
19.1 Introduction 633
A. The National Nursing Home Reform Act-
OBRA '87 634
B. Chapter purpose 635
C. Chapter organization 635
19.2 Keeping Frail, Elderly Residents Safe: Facility Responsibility 636
A. Reducing risk of falls 636
B. Reducing risk of pressure sores and expediting
healing 637
C. Reducing risk of weight loss and inadequate fluid
intake 638
D. Systems and process, integrating care plans, and
communicating with staff 639
19.3 The Aging Process 640
A. Loss of functional and physiological reserve 640
B. Frailty 641
C. The dying process 641
19.4 Basic Geriatric Principles 641
19.5 Clinical Outcomes of the Aging Process 642
A. Delayed diagnosis and treatment during
infection 642
B. Risk for fractures 643
D. Risk for falls 644
D. Involuntary weight loss 645
E. Risk for skin breakdown 647
F. Hypovolemia, dehydration, and electrolyte
imbalance 648
G. Over-diagnosis of "dehydration" 648
19.5 Refusal of Care and the Ethics of Informed Consent 650
19.7 Summary 651
References 651
Chapter 20: Defense Attorney's Perspective 655
J. Scott Myers, Esq.
20.1 Introduction 655
20.2 Preliminary Considerations 655
A. Early action is important 655
B. Identifying the client 656
C. Standard of care 656
20.3 Documentation Issues 657
A. Assembling the documents 657
B. Control of the medical record 658
C. Examination of the medical record 658
20.4 Additional Documents to be Obtained 658
20.5 Cooperation of Nursing Home Personnel 660
A. Interviewing key witnesses 660
B. Risk manager and administrator 660
20.6 Common Defense Strategies 660
A. Injuries will occur and conditions will worsen
absent negligence 660
B. The resident's preexisting condition predisposed
him to the injury 662
C. It did not happen the way plaintiff said it did 662
D. The resident contributed to his injuries 662
E. Errors in paperwork do not constitute
negligence 663
20.7 Responding to the Pleadings 663
20.8 Preparation for Deposition 663
20.9 Experts 664
20.10 Common Types of Cases 664
A. Falls 664
B. Pressure ulcers 664
C. Malnutrition and dehydration 664
D. Failure to follow physician orders 665
E. Abuse and neglect 665
F. Failure to observe changes and communicate with physicians 665
20.11 Summary 665
References 666
Additional Reading 666
Chapter 21: Claims Adjuster's Perspective on Nursing Home
Cases 667
Steven I. Adler, BS, Licensed Adjuster and Jaclyn S. Adler,
BS, RN, Licensed Health Care Risk Manager
21.1 Introduction 667
21.2 Reporting Potential and Asserted Claims 667
A. Incident reports 667
B. Resident/family complaints 668
C. Medical record requests 668
D. Attorney letter of representation/Notice of intent 668
E. Lawsuits 668
21.3 Investigative Process 669
A. Medical record review 669
B. Department of Health survey reports 675
C. Interviews 675
D. Administrative issues 675
E. Experts 675
F. Plaintiff's counsel 676
G. Venue 676
H. Plaintiff 676
I. Payment source 676
21.4 Investigative Report 676
21.5 Insurance Coverage 679
21.6 Defense Counsel 679
21.7 Suit/Budget Report 679
21.8 Tools of Assistance 682
A. Mock trials and focus groups 682
B. Claim committees 682
21.9 Reserving 682
21.10 Mediation and Alternative Dispute Resolution 682
21.11 Trial 684
21.12 Summary 684
About the Editor 685
About the Authors 687
Index 695
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