Watch your language: Culture change for the medical record

Words used by long-term care professionals do far more than document observations, symptoms and events. They plant perceptions in the minds and hearts of care residents, caregivers, regulators and payers.

Words matter. Consider this one: “bedsore.” Say it aloud. Hear it. Write it. Instantly, bedsore defines a wound, creates an image, angers families, saddens guilt-ridden caregivers, motivates citation-seeking surveyors and may enable payers to reduce reimbursement.

Picture a bedsore. Stare at it. Now, focusing on that same image, re-label it “skin failure.” Suddenly, the identical wound no longer looks or ‘feels’ the same.

This article offers suggestions for modifying commonly used words and phrases to clarify what is communicated to residents, families and others. Think of it as culture change for the medical record.

A ‘FAILURE’ LIKE ANY OTHER

Clinicians should adopt the selective use of “skin failure” to communicate that the skin is an organ, and like other organs, it is prone to failure. Interestingly, our society accepts that as adults age, they may succumb to heart, kidney and other organ failures. When a 90-year-old patient at the end of life dies of heart failure, oversight agencies do not tag the cardiologist with multiple deficiencies. Should that same resident develop a “pressure ulcer,” however, surveyors will cite and raging relatives will sue.

The National Pressure Ulcer Advisory Panel recently recognized that “skin failure” exists. Skin failure is associated with hypoperfusion (diminished blood flow), particularly in residents at end-of-life and in those who demonstrate failure of vital organs.

Residents have a right to be fully informed of their total health status. “Fully informed” includes telling the resident (authorized representative) when an unwelcome outcome may reasonably be anticipated. As residents near the end of their lives, especially those who refuse food and beverages—a request that is often followed in accordance with advance directives—caregivers should fully inform families that organs might fail, including the skin. For such residents, adjusting the goal of the care plan to reflect the limited benefit of interventions that are otherwise intended to reduce the likelihood of skin failure may be appropriate. Professionals should document when, “Complete wound closure may not be realistic because….” and “Wounds may develop and may not heal due to….”

And not every wound over a bony area is a classic “pressure ulcer.” Some, especially foot wounds, have multiple causes. An ankle or heel ulcer may be symptomatic of severe peripheral atherosclerosis. “Skin ulceration or frank gangrene, particularly of the toes, heels, and lateral malleoli, suggests extensive disease….” (Merck Manual for Geriatrics, Section 11, Chapter 93)

Unfortunately, like its predecessor, the instructions for MDS 3.0 (Minimum Data Set) direct facilities to identify all skin ulcers as either pressure or non-pressure ulcers, including those that are due to mixed etiologies and/or end-of-life organ failures. However, Chapter 3, Section ‘M’ of the Resident Assessment Instrument (RAI) manual confirms that, “It is imperative to determine the etiology of all wounds and lesions.” To reduce liability, non-MDS records should document the multiple factors that caused each ulcer. In addition, nurses, wound care consultants and physicians should document when they educate the resident (family) to keep them fully informed about the multiple causes of skin ulcers, as well as the reasons why they may not heal.

Pressure ulcers are also commonly categorized by their “stage,” another example of the power our terms wield. However, the National and European Pressure Ulcer Advisory Panels recently suggested that clinicians consider replacing the term “stage” with “category” to better communicate the extent of tissue damage due to pressure ulcers. “Stage” implies that all pressure ulcers progress and resolve through stages: I, II, III and IV. They do not. “Category” is a less-hierarchical, more neutral term that avoids the mistaken belief of staged progression and resolution. Ulcers and wounds that are not caused by pressure, such as vascular ulcers and surgical wounds, should not be staged.

OTHER FACTORS TO RECONSIDER

Professionals should think about substituting “predictive factors” for “risk factors” when assessing residents for the possibility of skin breakdown and other unwelcome outcomes, such as falls with injury. Although subtle, this change in terms fully informs residents, families and staff that the resident’s underlying condition “predicts” that a pressure ulcer or a fall-related injury may occur. Appropriate care interventions help to reduce or delay the likelihood of predictable, unwelcome outcomes that are the consequence of advanced age, lifelong unhealthy habits, disease and impaired functional abilities.

“Negative outcome” is a term that is commonly misused. “Negative outcome” should only be used to describe an unanticipated, poor result. For example, when a resident who has little to no risk or developing a pressure ulcer actually gets such an ulcer, the ulcer would be a negative outcome. However, clinicians can reasonably anticipate that older residents with non-modifiable peripheral vascular disease will develop vascular ulcers on the lower legs and feet. The development of ulcers such as these is an “unwelcome outcome.” The terms “adverse outcome” and “adverse consequence” may be used to describe unwelcome outcomes that are caused by an intervention that was intended to help the resident, such as when the use of a physical restraint (that is intended to promote safety) causes entrapment and injury.

When formulating plan of care goals, avoid the false promises of “prevention” and positive results. Reasonable and appropriate care does not assure a successful outcome. Words and phrases such as “postpone,” “delay the onset of…” and “reduce the likelihood of…” communicate that the goal is to increase the resident’s chances for a better outcome, even though the resident’s multiple comorbidities may be predictive of a decline in health status, medical complications and impending death.

For example, “Will not fall for 30 days” is often recorded as a care plan goal for residents who are deemed a “fall risk.” This, however, communicates the flawed expectation of a successful outcome, something that even the finest facility cannot assure. Why misinform residents and families by implying that the facility has the power to prevent every fall? It would be better to record the problem on the care plan using such phrasing as, “Likely to fall with injury,” with a realistic goal of, “Less likely to fall with less severe injury.” If the resident should fall, record the event on an “Occurrence Report,” not an “Accident Report.”

Nurses should avoid charting, “Will monitor.” It is a waste of time. The phrase is meaningless (unless you have residents whom you “will not monitor”). Often, for days following the “will monitor” nurses’ note, there is no documentation of who monitored what. Such apparent gaps in documentation may be interpreted as a failure to provide continuity of care.

NOT SOLELY A CLINICAL CONCERN

The opportunity to transform terms to better communicate what long-term care facilities do is not limited to clinical care conversation and documentation. Administrative management professionals are also cautioned to, “Watch your language.” When asked to describe their facilities, most administrators proudly proclaim the number of “beds.” Is long-term care an “industry” concerned with “beds,” or a “profession” caring for and about older adults?

The Occupational Safety and Health Administration calls certified nurses’ assistants (CNAs) “workers;” they are actually “caregivers.” “Policies, procedures and protocols” are not edicts; they are “guidelines” and they should be labeled as such. Home care is referred to as a “community-based” service, while long-term care is labeled an “institution,” not a “facility-based” residential preference. Perhaps MDS 3.0 should have been called the SDS (Standardized Data Set), because there is nothing “minimum” about it.

There is a need for new terms to describe the nature of what is currently mislabeled a “nursing home.” Most skilled nursing facilities have active short-term units. Some of these providers service only short-stay residents. Modern care centers provide complex, multidisciplinary healthcare and quality-of-life services to residents who are much sicker than the adults who lived in facilities in the 1970s; yet providers cling to the antiquated term, “nursing homes.”

Adults seeking facility-based health services would likely prefer a “health residence”—a warm, friendly place managed by sensitive leaders who understand that people count, not beds.

Providers who choose better words to define their business model, and encourage clinicians to amend how they describe conditions and expectations, will more accurately communicate the scope, nature and outcomes of care and services.

As Philip K. Dick, visionary science-fiction writer, noted, “The basic tool for the manipulation of reality is the manipulation of words. If you can control the meaning of words, you can control the people who must use the words.”

Dan Moles is a nursing facility owner, consultant, educator and expert witness. He is President of TRANSITION HealthCare Consultants and Nursing Home Expert Opinion Services. Moles can be reached at NHConsultant@Comcast.net.