Is Your Patient Frail?
November 11, 2009
Nothing is ever simple! A year ago, I would have never thought that a standard definition of frailty would come in useful. Isn’t the word, ‘frail’ self explanatory? As it turns out, it is not. The OASIS-C asks for frailty indicators giving weight loss as an example.
A colleague found a great article from The Journal of Gerontology Sciences which uses the symptoms of weakness, poor endurance, weight loss, low physical activity, and slow gait speed to assess frailty. The article states that more than one symptom is generally present. Conditions associated with frailty are those we see every day in home health. They are: undernutrition, functional dependence, prolonged bed rest, pressure sores, gait disorders, generalized weakness, aged .90 years, weight loss, anorexia, fear of falling, dementia, hip fracture, delirium, confusion, going outdoors infrequently, and polypharmacy.
If you are thinking that many of your patients meet this criteria for frailty, you are likely correct. Using the definition stated above, about seven percent of the population over age 65 is frail and a full 30% of persons over 80 are frail. Consider that our patients are the ‘active adults’ targeted by Florida’s condominium industry looking for a place to play golf and Mah Jong and it is easy to believe that our percentage of frail patients is much higher.
To assess your patient, look for some of the associated symptoms. Check your diagnoses for those that might contribute to frailty. Most importantly, assess your patient always being leery of those stoic patients who report being stronger and more capable than they actually are. Collaboration with home health aides and physical therapy may paint a much clearer assessment.
We always welcome your comments below and you are always welcome to email us at haydelconsulting@haydelconsulting.com.
Thanks to Lavonne for sharing the link with me.
Clinical Record Review
November 6, 2009
If you are like most agencies, your nurses are wearing more than one hat, as a favorite DON used to say. Nurses in the office performing duties as QA nurses will also pick up the phone and take orders or go admit a patient when the agency is running short of nurses. A host of different staff members may take part in QA activities when survey is drawing near. No QA at all may get done when the agency is extremely short staffed or dealing with another project such as an audit.
The flexibility demonstrated by most nurses in home health is amazing. We wouldn’t make it without this heroic ability to change gears and move seamlessly between assignments. And yet, this familiar pattern of staffing does have its drawbacks.
Nurses who work the floor in the hospital are almost never called to review charts. QA is kept separate from the staff for a very valid reason. First of all, once a nurse has participated in the care of a patient, QA of the clinical record becomes challenging. It is too easy to read between the lines. An order that was taken from a physician but never transcribed may be overlooked when reviewing the chart because the nurse reviewer remembers writing the order! Big gaps in the clinical record such as no therapy for patient in need may not stand out to a nurse who knows that the patient had therapy on a prior admission or has refused.
These sorts of errors are most easily found by a person who has no prior experience with the patient. Ideally, you would want to hire a consultant, preferably me, to review your clinical records periodically but even we understand that an agency’s budget doesn’t always allow for it. Don’t worry, you are not doomed!
If your agency has more than one location such as a parent or a branch or a sister location, the answer is easy. Trade out a nurse a few times a year and have someone who is relatively unfamiliar with the patients review the records. Most agencies hire PRN nurses for admissions and visits when the agency is very short staffed. By looking for QA experience in these nurses prior to hiring them or signing a contract will ensure that you have a fresh set of eyes to go over your clinical records.
When these reviews do occur in anticipation of a survey, remember that there is precious little that can be done to correct some errors. By reviewing records 90 days prior to a survey and identifying trends, the problematic areas will ‘wash out’ of the clinical records before survey. Your regular staff will then know what to monitor and how to correct the issues.
Finally, would you rather answer to me or a state surveyor? By enlisting the help of someone who is only privy to the same information as a surveyor, you can identify problems long before the surveyor is asking for documentation that you don’t have!
Protecting Your Staff from Violence
November 3, 2009
The following is shared with us by Elizabeth Hogue who provides insight into the legal responsibilities of post-acute providers for protecting staff from dangerous situations. We would be very interested to know if any of our readers include the potential for violent crime in their home safety evaluations and what precautions you take to ensure the safety of your staff. Please leave comments below.
Post-Acute Providers Must Protect Staff from Violence/Threatened Violence
Elizabeth E. Hogue, Esq.
Office: 877-871-4062
Fax: 877-871-9739
E-mail: ElizabethHogue@ElizabethHogue.net
Post-acute providers owe their employees a duty of reasonable care. That is, they are responsible to take reasonable precautions to protect their employees from harm. This obligation is becoming far easier to talk about than to fulfill in increasingly threatening environments for personnel who provide care in patients’ homes. Providers must, for example, deal with the potential for violence. The murder of a home care nurse in Maryland, along with the patient and the patient’s mother, received national attention from the media. Managers of providers in more rural areas often worry about the well-being of staff members in areas that are geographically isolated.
Of course, a key question regarding this obligation on the part of post-acute providers is: What is reasonable? Reasonableness is determined by what other providers are doing across the country. In other words, whether providers take reasonable precautions to protect workers will be judged by comparison to what other providers throughout the country would have done under the same or similar circumstances. This definition of reasonableness poses particular difficulty for post-acute providers. There is a lack of data or even anecdotal information about how other providers are dealing with a number of key issues in home care, including the protection of workers from harm.
Failure of providers to fulfill their obligation of reasonable care can take several forms: (1) acts or errors, and (2) omissions. In other words, providers must show that nothing happened to harm workers because of something that the provider did or should have done.
First, providers’ obligations to employees include a requirement to avoid doing anything that causes injury or damage to them. Providers may be found to have caused injury to employees, if the damage to employees would not have occurred “but for” an act or omission by their employers.
Second, the primary obligation is to avoid errors or omissions that cause physical injury or damage to employees. Courts generally require proof that employees were injured physically, as opposed to only emotionally, in order to compensate them for their injuries.
Post-acute providers that fail to meet their obligations in this regard may be the target of suits for negligence by employees and/or workers’ compensation claims. Since occupational health and safety requirements include a general mandate to employers to provide a safe working environment for their employees, providers may also face OSHA violations when workers allege that conditions are unsafe.
From a practical point of view, therefore, it is important to ask what home care providers can do legally to protect their employees from harm. The most important answer to this question is that managers must carefully evaluate patients referred with regard to the potential for violence. Managers must also listen and take action when workers complain about possible violence from patients already admitted.
One of the strengths of the home care industry has always been that staff is willing to go the extra mile to care for patients. The perception of many who know the industry well is that workers tend to put up with safety hazards that others would not hesitate to avoid. So, it becomes essential for coordinators and supervisors to gather information after receiving referrals and to listen carefully to staff members who complain about safety hazards. The assessment of most staff members that they regard a situation as unsafe can usually be taken at face value, since their natural inclination is to stay in unsafe situations, as opposed to terminating services to patients whose care involves exposure to risk.
It is also extremely important for managers to take action in response to complaints by personnel. There is an old legal adage that “every dog is entitled to one bite.” This means that, as soon as the dog has bitten one person, those responsible for the animal are on notice that the dog is dangerous and they must take reasonable precautions to prevent further injury or damage. Appropriate action may include refusal to readmit patients following their discharge from hospitals and various types of facilities.
Once employees have registered even a single complaint regarding dangers associated with the care of particular patients, the employer is on notice that further care may involve harm to workers. In view of this “first bite,” so to speak, providers must take appropriate action or face almost certain liability for injuries to their personnel.
Termination of services to patients is also an appropriate response to concerns regarding the safety of post-acute providers even when the only alternative may be hospitalization.
Post-acute providers knock on the doors of thousands of patients each day unaware of what may be inside the patients’ homes. They regularly encounter unfamiliar terrain and unknown risks. These risks are likely to become even greater as the use of post-acute services continues to expand. Staff must be prepared to deal with a constant potential for compromised safety that may force them to refuse referrals, to decline to readmit patients and to terminate services to patients.
©Copyright, 2009. Elizabeth E. Hogue, Esq.
All rights reserved. No portion of these materials may be reproduced in any form without the advance written permission of the author.
