All the King’s Horses and All the King’s Men

A few years ago, America lost two great men in a relatively brief period. The first was former President Ronald Reagan, stricken by Alzheimer's disease. The second was actor Christopher Reeve, well known as Superman, suffering from pressure ulcers related to his quadriplegia. This article asks how each man's tragic condition and subsequent death might have been judged had either been a skilled nursing facility resident, and the implications of the answer.

Similar, yet Different
Each man's medical circumstances varied. President Reagan was an elderly man living with a severe chronic disorder affecting first his cognitive functions and then his physical functioning. Reagan's chronic medical condition slowly robbed him and his family of his wonderful memories and cognitive function, and his ability to complete the simplest activities of daily living, such as bathing, walking, and eating. On the other hand, Christopher Reeve was a middle-aged man, completely disabled following an accident occurring at the prime of his life. His injury resulted in mass physical decline and deterioration, yet he remained cognitively intact. Even though the two men had completely different medical and psychosocial factors, there were commonalities experienced by both.

Each received healthcare services which, from all accounts, were extraordinary, readily described as "the best that money could buy." Both men had positive, optimistic outlooks on life before and during their illnesses. Both had incredible family support. However, neither could overcome his individual medical plight. Regardless of the significant financial resources that were aggressively directed to manage their medical conditions, care, and services, each experienced falls, fractures, alteration in skin integrity, and infections during their medical treatment course.

And that's with the best that money could buy!

Unfortunately, certain diseases and conditions cannot be reversed. Certainly this is no one person's or institution's fault. Often, these medical conditions and their related declines cause other comorbidities that result in unavoidable patient declines, anticipated negative outcomes and, ultimately, death.

Yet sadly, often family members and loved ones become bitter when a patient's outcome does not end the way they desired. When the result is pain and suffering or even death, the proverbial finger of guilt is frequently pointed at the healthcare provider, even when logic and medical information indicate otherwise. While death by natural causes can still be found on death certificates, many consider death someone's fault-something that could have been avoided. This is especially true when a patient resides in a skilled nursing facility. Family members often harbor unrealistic expectations of patient prognosis in a healthcare setting. Statements such as "they should have known" or "they should have prevented this" come forth, even when medical indications or a medical prognosis justifies the clinical care that was delivered and the patient's ultimate outcome.

"All the king's horses and all the king's men" could not put either Ronald Reagan or Christopher Reeve back together again. Had either of these men resided in a skilled nursing facility with the same medical conditions and outcomes, how would the care they received have been judged? The recently revised Centers for Medicare & Medicaid Services (CMS) Federal Interpretative Guidelines for Pressure Ulcers (F314) state that healthcare facilities, specifically skilled nursing facilities, may be cited for deficiencies when residents experience med-ical outcomes similar to those suffered by Reagan and Reeve. A conclusion from this might be that unrealistic expectations are placed on skilled nursing facilities through implementation of the new federal Interpretative Guidelines. As a result, facilities might be placing themselves at risk for deficiencies simply by accepting individuals for admission who have alteration in skin integrity or are at risk for this.

Perception Drives Litigation
Television, radio, newspaper, and billboard advertisements suggest that if a nursing facility resident's outcome did not end the way desired, then someone did something wrong and "they" should pay. The ongoing negative perception of care delivered in skilled nursing facilities, coupled with the maladies of chronic medical conditions experienced by patients, leads many to initiate professional liability or malpractice actions against skilled nursing facilities. Facility ownership, administrative staff, corporate staff, and even facility clinical staff are often named in such lawsuits.

Had either Reagan or Reeve been a skilled nursing facility resident, would the skilled nursing facility have been subject to litigation because of the maladies experienced by each of these men? Instead of the perception of care being "the best that money could buy," Reagan's or Reeve's hypothetical skilled nursing facility care would have been judged much more harshly, given public sentiment and the regulatory environment. Therefore, one must ask whether the threat of future license and certification citations and professional liability litigation subjects skilled nursing residents, with chronic conditions like Reagan and Reeve, to not being accepted to the facility of their choice because of the risks to the facility posed by their chronic ailments, clinical risk for skin alteration, or other maladies resulting from chronic medical conditions. Skilled nursing facilities dedicated to serving their local community and meeting the needs of their residents must obviously find a way to cope with these factors and still accept such chronically ill individuals.

Steps to Consider
A skilled nursing facility's first priority is to provide the level of care and services required by its residents. But how does the skilled nursing facility protect itself from the above noted threats while focusing on healthcare delivery for all appropriate residents? Suggestions include:

  • Document any anticipated negative outcome(s). It is often known that a patient's disease process or condition may result in a particular negative outcome, or even death. The patient may be declared terminal. "Terminal" is a condition and diagnosis that declares that the patient's anticipated negative outcome is death. Health practitioners should follow state statutes for proper terminal declaration. Although sometimes unpleasant, declaring a patient terminal does not mean a facility does not provide care, nor does it imply that the patient or family approve the terminal status.
  • Consider documentation revisions for the patient's treatment plan indicating that plans are in place to help counter potential negative outcomes and the patient's response to that treatment. Once the potential negative outcomes are identified, even if only palliative approaches are desired by the patient, plans may be implemented to reduce negative outcomes.
  • Ensure that attending physicians and physician extenders are involved in treatment planning activities for anticipated negative outcomes. Physician documentation should include statements that anticipated negative outcomes, when they do occur, are not facility-related or "under the facility's control." Physicians might consider documenting that the negative outcome occurred despite the appropriate care and services provided.

Patients, regardless of where they reside, may encounter conditions, diseases, and circumstances that result in negative outcomes. These conditions must be assessed and addressed. Skilled nursing facilities should continue accepting such patients for admission. If appropriate care is delivered and documented, skilled nursing facilities should not fear citations and litigation.

The lesson learned from the examples of Reagan and Reeve is that even the best care that money can buy often results in negative outcomes anyway. Skilled nursing facilities can help counter the negative perception of the industry and its regulatory ramifications by following appropriate care coupled with defensive documentation by the facility's interdisciplinary team (nurse, social worker, physician, therapist, dietitian, physician extender, and other professionals). This can help to ensure that patient maladies will not be attributed to "poor care and treatment" and thus reduce improper citations and unfair litigation.

Money and services alone cannot alter the outcome of disease processes, but improved and targeted documentation may be the best defense against allegations stemming from those outcomes. This includes creating a record that outlines what might be anticipated, including potential negative outcomes. Skilled nursing facilities will find it far easier and less costly to develop such a system, as opposed to fighting devastating survey deficiencies and protracted medical litigation for something they weren't responsible for.

Robin A. Bleier, RN, LHRM-FACDONA, is Principal of RB Health Partners, Inc., in Palm Harbor, Florida. Her company provides LTC clinical and risk-management education and consultation. She can be reached at (727) 786-3032. Rob J. Becht, Esq., CNHA, CHE, is a practicing healthcare attorney with Snell & Wilmer, LLP, in Phoenix. He is a licensed nursing home administrator, certified fellow of the American College of Health Care Administrators, and certified healthcare executive in the American College of Healthcare Executives. He can be reached at (602) 382-6505. To send your comments to the authors and editors, e-mail .

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