Medical-Legal Aspects of Long-Term Care PDF eBook

• Editor: Jeffrey M. Levine; Contributors: Faerella Boczko, Victoria Hammer Castellanos, Nancy Collins, Fred Feinsod, Carlos Rojas-Fernandez, Thomas Haas, Karen Josephson, Marshall B. Kapp, Samuel W. Kidder, Jeffery M. Levine, Jill Loeb, Duncan S. MacLean, Vincent Marchello, Steven Miles, Lorraine C. Mion, Laurence Z. Rubenstein, Andrew Weinberg, Ruth West
• ISBN 10: 1-930056-23-0
• ISBN 13: 978-1-930056-23-7
• Copyright Date Ed: May 1, 2003
• Pages: 376 pages
• PDF eBook

There are currently over 1.7 million elderly persons in nursing homes in America. Because of their medical complexity, this group is prone to poor outcomes such as falls, accidents, pressure ulcers, infections and death. In recent years, damage awards by juries in negligence cases involving elderly persons have soared.

This book is designed as a reference source for attorney and lay persons interested in the topic of neglect and abuse in nursing homes. Its goal is to provide a framework for understanding when a poor outcome is a result of negligence on the part of the caregiving facility and its personnel. It provides a source of information on basic medical aspects of nursing home care, with an emphasis on topics of medical-legal importance.

TOPICS INCLUDE

• Introduction to the nursing home industry
• The survey process and the minimum data set
• Understaffing in nursing homes: Causes, consequences and cures
• Dementia and dysphagia
• Pain management; adverse drug events
• Nutrition and hydration
• Wound care
• Psychopharmacolgic medication
• Falls and fall-related injuries
• Bed safety and physical restraints
• Physical abuse and neglect
• Effective risk management
• The role of private accreditation

• Table of Contents

  Acknowledgments
  Conventions Regarding Medications
  Foreword
  Marshall B. Kapp, JD, MPH, FCLM

  Chapter 1: Introduction to the Nursing Home Industry
  Jeffrey M. Levine, MD
  1.1 Introduction and Scope of This Book
  1.2 Historical Considerations
  1.3 Demographic Issues
  1.4 The Spectrum of Long-Term Care
  1.5 The Nursing Home Resident
  1.6 Services Provided by the Nursing Home
  1.7 Certification and Ownership
  1.8 Economic Issues
  1.9 An Industry in Crisis
  1.10 Conclusions
  Endnotes

  Chapter 2: The Survey Process
  Ruth West, RN, BS
  2.1 The Federal Survey Process
  2.2 Types of Surveys
  2.3 Survey Tasks
  2.4 The Statement of Deficiencies
  2.5 The Plan of Correction
  A. Immediate corrective action
  B. Identification of other residents who may have been affected by the deficient practice
  C. Systemic changes
  D. Quality assurance monitoring
  2.6 Enforcement Actions
  A. Category one remedies
  B. Category two remedies
  C. Category three remedies
  Endnotes

  Chapter 3: Resident Assessment and Care Planning
  Duncan S. MacLean, MD, CMD and Jeffrey M. Levine, MD
  3.1 Overview of the Resident Assessment Instrument (RAI)
  A. In general
  B. Historical origins
  C. Conceptual models
  D. Statutory basis for the RAI in nursing facilities
  E. Participants in the assessment process and sources of information
  3.2 Content of the RAI for Nursing Facilities
  A. Minimum Data Set (MDS) Version 2.0
  B. Resident Assessment Protocols (RAPs)
  C. Utilization Guidelines
  3.3 The Assessment Schedule for the RAI
  A. Regular assessment schedule
  B. Significant change in status assessment (SCSA)
  3.4 Linking the Assessment to the Care Plan
  3.5 Additional Uses of the Minimum Data Set
  A. Medicare and Medicaid payment systems
  B. Monitoring the quality of care
  Endnotes

  Chapter 4: Understaffing in Nursing Homes: Causes, Consequences and Cures
  Jeffrey M. Levine, MD
  4.1 Introduction
  4.2 Institutional Policies to Keep Costs Down
  4.3 Understaffing of the Nursing Department
  A. In general
  B. The effect of understaffing on basic care
  C. The effect of understaffing on complex care
  4.4 Understaffing of Other Clinical Personnel
  4.5 The Effect of Understaffed Support Personnel
  4.6 Approaches to Improve Staffing
  A. Legislation of minimum nurse staffing standards
  B. The view of consumer advocacy organizations
  C. Industry initiatives
  4.7 Summary and Conclusions
  Endnotes

  Chapter 5: Dementia Care
  Vincent Marchello, MD
  5.1 Introduction
  5.2 Evaluation of Dementia
  5.3 Specific Dementing Diseases
  A. Alzheimer's disease (AD)
  B. Multi-infarct dementia (MID)
  C. Frontotemporal dementias (FTD)
  D. Metabolic and toxic dementias
  E. Other dementias
  5.4 Treatment of Dementia
  A. Medications
  B. Behavior management
  C. Alzheimer's special care units (SCU)
  5.5 Staging and Survival
  Endnotes

  Chapter 6: Pain Management
  Jill L. Loeb, BSN, RN
  6.1 Introduction
  6.2 An Emerging Standard
  6.3 Pain Assessment Is Key
  6.4 Pharmacologic Interventions
  A. Non-opioid analgesics
  B. Opioid analgesics
  C. Adjuvant analgesics
  D. The analgesic ladder
  E. Potentially inappropriate medications
  6.5 Nonpharmacologic Interventions
  6.6 Key Concepts in Pain Management
  6.7 Regulatory Environment and Accreditation
  6.8 Conclusions
  Endnote

  Chapter 7: Nutrition and Hydration
  Nancy Collins, PhD, RD, LD/N and Victoria Castellanos PhD, RD
  7.1 Introduction
  7.2 Nutrition Care Professionals
  A. Registered dietitian (RD)
  B. Dietetic technician, registered (DTR)
  C. Certified dietary manager (CDM)
  D. Licensed nurses and certified nursing assistants
  E. Speech pathologist
  7.3 Timeline for Nutritional Assessment
  7.4 Assessment and Provision of Nutrition
  A. Determining calorie and protein needs
  B. Meeting calorie and protein needs
  7.5 Assessment and Provision of Fluids
  A. Determining fluid needs
  B. Meeting fluid needs
  7.6 Documentation of Food and Fluid Intake
  7.7 Involuntary Weight Loss (IWL)
  A. Increasing food intake
  B. Pharmacologic interventions for weight gain
  7.8 Tube Feedings
  Endnotes

  Chapter 8: Dysphagia
  Faerella Boczko, MS, CCC/SLP
  8.1 Introduction
  8.2 The Normal Swallowing Process
  8.3 Causes of Swallowing Disorders
  8.4 Medication Affecting Swallowing
  8.5 Signs and Symptoms of Dysphagia
  8.6 The Clinical Bedside Examination
  8.7 Diagnostic Studies
  8.8 Speech and Language Pathology Interventions
  8.9 Adaptive Equipment
  8.10 Swallowing and Dementia
  8.11 Tube Feeding and Ethical Issues
  Endnotes

  Chapter 9: Wound Care
  Jeffrey M. Levine, MD
  9.1 Introduction
  9.2 Pressure Ulcers
  A. In general
  B. Pressure ulcer prevention
  C. Complications of pressure ulcers
  9.3 Other Types of Wounds
  A. Peripheral vascular disease (PVD) ulcers
  B. Diabetic ulcers
  C. Surgical wounds
  D. Cancer-related wounds
  E. Other wounds
  9.4 Wound Care in the Nursing Home
  9.5 Avoidable versus Unavoidable Ulcers
  9.6 Determination of Neglect
  A. Wound documentation
  B. Nutritional assessments
  C. Wound-care orders
  D. Treatment records
  E. Minimum Data Sets (MDS) and care plans
  9.7 Summary
  Endnotes

  Chapter 10: Adverse Drug Events
  Carlos Rojas-Fernandez, PharmD
  10.1 Introduction
  10.2 Epidemiology of Adverse Drug Events in the Nursing Home
  10.3 Sequence of Events in Prescribing Medications
  10.4 Side Effects and Allergies
  10.5 Drug Interactions
  10.6 Adverse Events Associated with Drug Withdrawal
  10.7 Establishing Causality
  10.8 Factors that Predispose Residents to Adverse Drug Events
  A. Polypharmacy
  B. Metabolic changes associated with aging
  C. Medication errors
  D. Inappropriate prescribing of medication
  E. Special considerations in the nursing home
  10.9 OBRA Regulations Relevant to Adverse Drug Events
  10.10 Conclusions
  Endnotes

  Chapter 11: Psychopharmacologic Medications
  Samuel W. Kidder, PharmD, MPH
  11.1 Introduction
  11.2 Federal Regulation of Psychopharmacologics: The OBRA '87 Provision
  A. Use of the term ∏chemical restraint∑
  B. Antipsychotic drugs: Indications for use
  C. Antipsychotic drugs: Gradual dose reductions
  D. Unnecessary drugs
  11.3 Specific Psychopharmacologic Medications
  A. Antipsychotic medications
  1. ∏Conventional∑ antipsychotic medications
  2. Common ADEs of conventional antipsychotic medications
  3. ∏Atypical∑ antipsychotic medications
  B. Antidepressant medications
  C. Antianxiety medications (also called anxiolytic medications)
  D. Hypnotic medications
  11.4 Implications for the Future
  Endnotes

  Chapter 12: Falls and Fall-Related Injuries
  Laurence Z. Rubenstein, MD, MPH, and Karen R. Josephson, MPH
  12.1 Introduction
  12.2 Epidemiology
  A. Incidence of falls
  B. Fall-related injuries and mortality
  12.3 Causes and Risk Factors for Falls
  12.4 Fall Prevention in the Nursing Home
  A. Assessment
  B. Fall prevention interventions
  C. Muscle weakness and impaired function
  D. Gait and balance impairments
  E. Dizziness syndromes
  F. Postural hypotension
  G. Polypharmacy and inappropriate medications
  12.5 Institution-Wide Fall Prevention
  A. Environmental assessment
  B. Nursing interventions
  C. Fall- and injury-prevention devices
  12.6 Conclusion
  Endnotes

  Chapter 13: Physical Restraints
  Lorraine C. Mion, PhD, RN
  13.1 Introduction
  13.2 Regulatory Definitions
  13.3 Types of Physical Restraint
  13.4 Rationale for Physical Restraint Use
  13.5 Adverse Effects of Restraint Use
  13.6 Regulatory Requirements for Physical Restraints
  13.7 Risks of Liability
  13.8 The Process of Restraint Minimization
  A. General considerations
  B. Interventions to manage wandering
  C. Interventions for agitation and disruptive behavior
  D. Interventions for maintaining therapeutic devices
  13.9 Summary
  Endnotes

  Chapter 14: Bed Safety
  Fred M. Feinsod, MD, MPH, CMD and Steven H. Miles, MD
  14.1 Introduction
  14.2 The Decline of Using Bedrails for Safety
  14.3 Bed Safety without Restraints
  14.4 Alternatives to Bedrails
  14.5 Limited Uses for Bedrails
  14.6 Conclusions
  Endnotes

  Chapter 15: Physical Abuse and Neglect
  Duncan S. MacLean, MD, CMD
  15.1 Introduction
  15.2 Definitions and Classification of Mistreatment
  15.3 Comparison between Domestic and Institutional Mistreatment
  15.4 Epidemiology of Abuse and Neglect
  15.5 Clinical Features
  15.6 Natural and Accidental Causes of Bad Outcomes
  A. Spontaneous osteoporotic fractures
  B. Dementia-associated weight loss
  C. Dementia-associated functional decline
  D. Contractures from severe spasticity or dementia
  E. Immobility from advanced heart, lung or arthritic disease
  F. Fall-related injuries despite adequate fall-prevention care plans
  G. Resident-to-resident accidents
  H. Unavoidable pressure ulcers
  I. Senile purpura
  J. Adverse drug events
  K. Death
  L. Post hoc ergo propter hoc
  15.7 Dynamics of Institutional Abuse and Neglect
  A. Physical abuse
  B. Neglect
  15.8 Prevention and Risk Management
  A. Anti-abuse policies
  1. Prevention policies and procedures
  2. Screening of potential hires
  3. Training of employees
  4. Identification of possible incidents or allegations that need investigation
  5. Investigation of incidents and allegations
  6. Protection of residents during investigations
  7. Reporting of incidents, investigations, and the facility's response to the results of their investigations
  B. Additional administrative measures
  1. Monitoring indicator trends
  2. Reviewing indicator trends with the medical director
  3. Reporting the medical director's analysis to the owner
  4. Advance directives and end-of-life care
  5. Restraint management
  6. Behavior management
  7. Attending physician documentation
  C. Corporate compliance programs
  15.9 Documentation and Reporting
  A. Documentation
  B. Reporting
  C. Special considerations
  15.10 Summary
  Endnotes

  Chapter 16: Effective Risk Management
  Andrew D. Weinberg, MD, FACP
  16.1 Introduction
  16.2 Risk Management for Physicians and Medical Directors
  16.3 Risk Management for Nurses
  16.4 Documentation and Charting
  16.5 Recommendations for Nursing Homes
  16.6 Sample Issue: Elopement
  16.7 Summary
  Endnotes

  Chapter 17: The Role of Private Accreditation
  Thomas Haas, MS, RNC, LNHA
  17.1 Private Accreditation Organizations
  17.2 The Accreditation Process
  17.3 State Survey and JCAHO Survey Compared
  17.4 Continuous Updating of Standards
  17.5 JCAHO Accreditation Decision Categories
  17.6 Conclusions

  References
  About the Editor
  About the Contributors
  Index