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II. How to Self - Assess Your Facility for Risk Exposure

August 1, 2002
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By Richard J. Henry, JR., CNHA; and Christine A. Stevens, RN, MBA
II. How to Self-Assess Your Facility for Risk Exposure By Richard J. Henry, JR., CNHA; and Christine A. Stevens, RN, MBA The long-term care business model is a unique blend of healthcare and social services burdened by extensive federal and state regulations. By its very nature, this balancing act increases risk potential. Furthermore, changes in the survey process over the past few years have played a significant role in increasing risk exposure to litigation.

We know that risk, by definition, cannot be eliminated; however, we can manage the factors that contribute to the probability of risk and create a more defensible facility by implementing a risk-management protocol based on a team assessment process.

A Logical Approach

Major risk-exposure areas within your facility should have corresponding operational approaches to mitigate that exposure. The top five major risk areas in long-term care are:

1. Slip/fall exposures. Resident falls are one of the most frequent claims carriers receive.

2. Elopement/wandering. The percentage of our residents affected by various forms of dementia is approximately 44% nationally and represents a significantly "at-risk" population. Resident elopements in these cases can be the most costly type of claim, generating settlements and jury verdicts of staggering proportions.

3. Skin integrity. Some of the most notable litigation cases involve skin breakdown issues. Contributing inversely to the likelihood of litigation is the degree to which the facility adopts the most current technology to prevent wounds and provide and document wound care.

4. Resident rights/abuse/neglect issues. How often have operators been subjected to an allegation of abuse or neglect simply because a resident or family member had an unrealistic expectation of the level of service or care? Resident and family communication protocols, such as "shared-risk agreements," can be an effective preventative against abuse allegations. Moreover, there are occasions in which resident abuse/neglect claims are more a reflection of a facility's situation than of a true abusive event. For example, imagine an elderly resident who has been prescribed blood-thinning medication. We know that this resident will be prone to bruising, whether living at home or in a long-term care facility. Yet should this resident come to our facility, we could be subjected to an allegation of abuse with bruising as evidence! Unless we properly advise all parties of our expectations (in writing), we set ourselves up for an unfair allegation.

While it might feel unnatural for care-givers to share difficult scenarios such as this with customers, we must now begin to inform and educate the consuming public about the realities of our service model. These discussions could include frank language regarding falls, bruises and behavioral characteristics typical to our caregiving environment, for example: We do not restrain our residents with your mom's type of diagnosis and, as a result, in the normal course of living she might fall.... Dad might experience significant bruising as a result of the medication he is on.... Your uncle will steadily decline as the effects of Alzheimer's disease advance, and he will begin to exhibit the following behaviors.... We do not offer a staff ratio of one-on-one care; should you desire this level of care you might wish to employ a companion.... We will offer the following interventions to mitigate the effects of these undesirable outcomes.... Please sign here indicating that we have discussed these issues and that you understand our service level and approach to care. " Know thyself " Is a
long-standing motto for
success-and can be your
facility's best defense
against liability.
5. Medication and treatment errors/omissions. Facilities must monitor their training and staffing systems continuously to achieve the level of control necessary for risk reduction in clinical care. Although it is readily apparent that staff training and adequacy are critical elements in managing such risk exposure, all too often training systems and floor staffing are casualties of other pressing operational demands.

Elements of Self-Assessment

Facilities can employ specific strategies to create a culture that values ongoing and meaningful risk-reduction oversight. As an example, we have created the following assessment approach used by our team consultants to assess a facility's risk exposure level and defensibility posture.

Step one: Gather data and review potential areas of risk. Many of our clients have indicated that the process of collecting and organizing these data in preparation for an on-site review by our team has in itself initiated a meaningful risk-management process. It begins by gathering and organizing: 1. Survey results from the last four standard surveys and from any complaint surveys that have been conducted in the last six months
2. Quality Indicator Reports: Facility Characteristics, Facility Profile (QIs) and the Resident Summary
3.A current CMS Form 672-resident census and condition of residents
4.A current CMS Form 802-resident roster
5. Safety committee minutes from the last meeting
6. Family council minutes from the last meeting
7. Resident council minutes from the last meeting
8. Results of any resident and/or staff satisfaction surveys conducted with-in the last 12 months