Compliance Corner, Clinical Care Documentation - Delivering Detailed, Resident-Focused Services

As resident acuity levels increase, assisted livingWhen it comes to medication management, a host
providers must keep close tabs on the services theyof clinical issues center around administration errors,
provide to steer clear of litigious situations. Assisteddelegation and training, medication review (especially
living isn't what it used to be-and that's not a badpsychotropic medication), and a resident's right to
thing-but it does mean that providers must be morerefuse medication. Community policies should be clear
diligent about how they deliver their scope ofon medication management and the resident's right
services. Residents' rising acuity levels, includingto refuse. A physician's order for every medication
increases in their co-morbidities, chronic diseases, andshould be readily available and include all the required
behavioral challenges, have caused the onceinformation regarding dosing and administration.
universally accepted social model of residential care toMedication administration training should be thorough
evolve into a model that must provide higher levelsand in accordance with the state's regulatory
of specialized clinical care.guidelines.
With this evolution comes an increased responsibilityProviders also should consider random
on the part of assisted living providers to meet thecommunity-level audits of medication administration
medical and clinical needs of their residents. However,records. This will help expose medication
it also exposes them to more legal risk if they aredocumentation shortcomings, such as medication
not strategic and detail-oriented about the servicesdocumentation errors or omissions and inaccurate or
they provide and how they provide those servicesinappropriate documentation of medication
to residents.administration holds or refusals.
Assisted living communities, of course, are regulatedNurses in Charge With more and more nurses being
in every state. But whatever the regulations require,hired into assisted living companies as managers,
it's clear that when armed with strategies to combatclinicians, and supervisors, another emerging care
negative resident outcomes associated with commonissue is nurse delegation. These issues usually center
adverse clinical events, assisted living providers canaround medication administration, but can also impact
take proactive, rather than a reactive, approaches toresident care where a particular treatment is
resident care-and this will help them minimize litigiousdelegated. Nurse delegation is generally a creature of
situations. In that vein, there are two clinical issuesstate statute and regulation, but key to its successful
assisted living communities must pay close attentionimplementation are an understanding by both the
to in particular-fall prevention and medicationnurse and the delegated caregiver of what the
management.delegated task is, an appropriate level of supervision
Double-Duty Documentation Whoever said, "nothingand monitoring, and documentation of the delegated
is certain but death and taxes," didn't get it quitetask.
right. The quote should be, "nothing is certain butAgain, thorough and detailed documentation is critical
death, taxes, and the fact the residents will fall."to not only providing appropriate care, it also is
It is of course important to develop a system forimportant as it pertains to regulatory and legal issues.
preventing resident falls, but when it comes toAnd here the old nurse's adage rings true and that is,
staying out of litigious situations, it is equally as"if it's not documented, it's not done." Detailed
important to thoroughly document detaileddocumentation preserves the record, serves as a
assessments about why the resident fell or has fallencommunication tool, and can insulate against
multiple times. Is the resident falling on the way toregulatory and civil legal liability.
the bathroom during the night shift? Is the residentIn the current model of assisted living, identifying key
falling routinely at sunset? Is the resident falling nearclinical issues affecting residents and taking proactive
the kitchen in the afternoons? Does the residentapproaches to those issues not only enhances the
appear to be over-medicated? This kind of analysisquality of care and quality of life for residents, it
not only helps hone appropriate resident-focusedgives providers the ability to better meet the needs
care, it also serves as verification that the assistedof those residents while reducing their potential
living community took the appropriate steps to careregulatory and civil liability.
for the resident and remedy any risky situations.