Documentation as Ally
By Mary lynn curran
In the world of senior living, the requirements for documentation vary widely from state to state. And adhering to the state standard of
documentation is often not sufficient to provide a
maximum level of care or to defend against allegations of negligence or abuse.
Today’s economic climate means individuals
have delayed moves into senior living residences
as they wait to sell their homes. The senior living prospect is living longer but not necessarily
better due to chronic ailments requiring medications and treatments. Actually, today’s typical
assisted living residents are often more frail and
require more services than the same residents a
Documentation is required to provide:
• Proof that state requirements have been
•Evidence of compliance with federal requirements, such as OSHA;
• Substantiation that services were provided
in accordance with the resident agreement
(many organizations have learned that item-
ized checklist statements of specific person-
al services can go a long way in reducing
private reimbursement cycles); and
• A defense of an organization from allega-
tions of negligence or breach of contract.
In some senior living organizations, documentation has been reduced to a checklist with
little narration required. In some states, surveyors will accept a checklist noting completed actions, but it’s difficult to piece together a story
merely from a checklist.
Some state surveyors find lack of documen-
tation often leads to deficiencies and violations,
• Failure to substantiate how the residence
meets the needs of a resident as detailed in
the care plan or evidenced by the circum-
• Failure to conduct a nursing assessment to
identify functional needs prior to service
•Failure to properly document services
agreed upon at move-in;
• Failure to review and change service plans
after a resident’s condition changes; and
• Failure to ensure services were rendered as
agreed upon by the service plan.
Where documentation is limited or inadequate, there is virtually no way to determine if
actual care or service has been provided; the assumption is, therefore, that nothing was done.
cases in Point
By improving documentation in your residences, you’re able to conduct your own internal
quality assurance efforts and support and enable
a defense should your company be accused of
in some states, surveyors
will accept a checklist
noting completed actions,
but it’s difficult to piece
together a story merely
from a checklist.
negligence or abuse.
Consider these real-life examples requiring
1. Following an injury such as a fall or skin
tear: It’s sound practice to have a policy and
procedure requiring staff to document specific assessments and observations following an injury, especially when the resident’s
head is or is thought to be involved, or for
a possible hip injury. Many organizations
send any resident with a suspected head injury to the emergency room. A specific protocol for monitoring an injured resident is
also sensible practice.
2. Following a change in condition: Every organization needs to define “a change in
condition.” For most, falls and medication
regimen alterations constitute a change in
condition. Following such a change, staff
should reassess and review physician orders
against the medication record and docu-