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Medical-Legal Aspects of Long-Term Care PDF eBook - Lawyers & Judges Publishing Company, Inc.

Medical-Legal Aspects of Long-Term Care PDF eBook

$ 95.00

  • 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.


    • 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

    Conventions Regarding Medications
    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

    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

    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

    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

    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

    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

    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

    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

    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

    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

    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

    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

    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

    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

    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

    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

    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

    About the Editor
    About the Contributors

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