LEGAL PERILS IN LONG-TERM CARE

1. LEGAL PERILS IN LONG-TERM CARE

2. Contact Information • Patricia Mullins-Freeman • Foland, Wickens, Eisfelder, Roper & Hofer, P.C. • 911 Main Street, Suite 3000 • Kansas City, Mo 64110 • pmullins@fwpclaw.com • 816-460-2833

3. The Perils • MALPRACTICE • COMMON LAW • OBRA • State Laws • EMPLOYMENT ACTIONS • FALSE CLAIMS ACT

4. 2/2004, $5,500,000 VERDICT • Arkansas woman dies of fatal septic shock after nursing home staff fails to alert treating physician of changes in bowel condition. Punitive damages awarded for failure of nurses to call physician, even though husband of deceased requested call. Nurse testified, “we cannot call the doctor every time someone gets a bellyache”.

5. 10/2004, $4,500,000 VERDICT • Malicious failure to treat injury. Continuing failure of nursing home staff to appropriately care for elderly man considered intentional act for which there was no insurance coverage.

6. New York 2009 • Hidden camera set up by family after management at the Fillmore Convalescent Center allegedly ignored their complaints that the elderly woman had unexplained bruises • Footage shows nursing home worker Monica Garcia pulling Arellano by the hair, slapping her, bending her wrists, fingers, and neck, and violently handling her while she is seated in a shower chair. • $7.75 million to the family

7. New Mexico 7/2008 • . Resident in nursing home for rehabilitation. She allegedly died in a puddle of blood, vomit and dirty sheets. The staff allegedly scrambled to clean up the scene of her death disposing of any evidence of how resident really died. The facility allegedly altered medical records to make it appear that resident was well cared for over the course of her stay. Facility insisted that understaffing was not an issue in resident’s case. The jury awarded $54,000,000 for resident’s pain and suffering.

8. WHAT WILL YOU GET SUED FOR?

9. GROUNDS FOR SUIT

10. OMNIBUS NURSINGHOME ACT

11. OBRA • Created a set of minimum national standards of care and rights for people living in certified nursing facilities. • Arkansas Code: 20-10-1001 et seq.

12. COMMONLAWNEGLIGENCE • Duty to resident • Breach of duty

13. DUTY = STANDARD OF CARE THAT DEGREE OF SKILL AND LEARNING ORDINARILY EXERCISED UNDER THE SAME OR SIMILAR CIRCUMSTANCES BY MEMBERS OF THE PROFESSION

14. BREACH OF DUTY = FAILING TO FOLLOW THE STANDARD OF CARE • Skin Breakdown • Falls • Failure to Respond to Change in Condition • Physical and Sexual Abuse • Dehydration/Malnutrition

15. Types of Claims Decubitus Ulcers • Failure to assess resident for risk of skin breakdown • Failure to provide intervention to address risk of skin breakdown • Failure to identify and treat skin breakdown • Failure to notify physician of skin breakdown or progression of wounds

16. Falls • Failure to assess risk of suffering a fall • Failure to provide intervention to address risk of falling

17. Failure to Respond to Change in Condition • Failure to assess resident for change in condition • Failure to monitor resident after identifying change in condition • Failure to provide interventions

18. Physical and Sexual Abuse • Resident on Resident • Staff on Resident • Failure to provide protection and oversight • Failure to take action after receiving notice of dangerous propensity • Failure to adequately respond to event

19. Dehydration/ Malnutrition • Failure to address risk • Failure to provide interventions • Failure to monitor intake/output

20. DEFEND YOURSELF • AGAINST LAWSUITS

21. EASY WAYS TO START DEFENDING YOUR LAWSUIT BEFORE YOU GET SUED START WITH THE ASSUMPTION THAT YOU WILL GET SUED • COMMON SENSE • EDUCATION • POLICIES • DOCUMENTATION • TRAINING • COMPLIANCE PROGRAM • EFFECTIVE INVESTIGATION

22. Common Sense Ways to Avoid Claims • Staff must not be seen idle or participating in non-work related activities. • Communication is vital • Avoid staff turnover • Show empathy • Be kind

23. EDUCATION • FROM DAY ONE – THE RESIDENT AND THE RESIDENT’S FAMILY MUST BE EDUCATED ABOUT LONG-TERM CARE AND WHAT TO EXPECT FROM YOUR FACILITY! • ADMISSIONS AGREEMENT IS YOUR NUMBER ONE TOOL • Mission Statement

24. EDUCATE THE FAMILY/ADMISSION AGREEMENT

25. WHAT IS IN THE ADMISSION AGREEMENT? IS YOUR ADMISSION AGREEMENT PROTECTING YOU? • DISCLAIMER: IT IS IMPORTANT THAT YOU ARE AWARE THAT WE WILL STRIVE TO ALWAYS PROVIDE QUALITY CARE TO THE RESIDENT. PLEASE UNDERSTAND THAT WE WILL NOT BE PROVIDING AROUND THE CLOCK ONE-ON-ONE CARE. RATHER, THERE WILL BE NURSING SERVICES AVAILABLE TO THE RESIDENT 24 HOURS A DAY.

26. MISSIONSTATEMENT These nursing policies have been drafted and implemented in an effort to assist the nursing staff in providing exceptional care to our residents. The policies are not intended to create the standard of care. These policies are not intended to replace nursing judgment, but should be used in conjunction with nursing judgment.

27. SHIFT RESPONSIBILITY • SOME THINGS A NURSE CANNOT DECIDE: MAKE THE DOCTOR DO IT! • MAKE THE FAMILY TAKE ON THE RESPONSIBILITY • Off-grounds privileges; • Driving privileges • Searches • Resident activities • Resident socializing • Resident on grounds, but outside (no supervision)

28. ADMISSION AGREEMENT: I HEREBY ACKNOWLEDGE • FALLS HAPPEN • PRESSURE SORES HAPPEN • RESIDENT WILL BE BATHED 2X A WEEK • RESIDENT WILL BE CONFUSED ABOUT HER ENVIRONMENT • RESIDENT WILL NOT LIKELY LEAVE THE FACILITY BETTER THAN SHE ARRIVED

29. RESIDENT FAMILY OBLIGATIONS • Special Food • Smoking Privileges • Complaints • Pets • End of Life Planning

30. STANDARD OF CARE IS NOT: • BEST CARE • POLICIES

31. POLICIES

32. POLICIES • WHAT ARE THEY • WHAT IS THEIR PURPOSE • STATE THEIR PURPOSE • POLICIES SHOULD NOT REQUIRE MORE THAN FACILITY CAN OFFER • MUST V. SHOULD • OUTSIDE REVIEW OF THEM • LEGAL TRAINING SESSIONS

33. DEFENSIVE DOCUMENTATION WILL WHAT YOU ARE WRITING TODAY HELP OR HURT YOU IN THREE YEARS?

34. DO NOT CHART EXCESSIVELY

35. IF CHART BY EXCEPTION

36. PLEASE DO NOT CHART THE UNEXCEPTIONAL!

37. WHEN ITS EXCEPTIONAL, INCLUDE: • ALL OF YOUR ASSESSMENTS • EVALUATIONS OF HOW TREATMENTS OR INTERVENTIONS WORKED • RESIDENT NON-COMPLIANCE!!!!! • DISCUSSION WITH M.D. ESPECIALLY WITH REGARD TO PATIENT SYMPTOMS • DOCUMENT ALL WITNESSES TO CARE OR CONVERSATIONS! • ALL RESIDENT REFUSALS

38. NOTHING NEGATIVE PLEASE • NEVER ENTER INTO THE RECORD NEGATIVE OPINIONS ABOUT THE RESIDENT (E.G. ODOR, WEIGHT, PERSONALITY) • PLAINTIFF’S COUNSEL WILL SAY YOU GAVE POOR CARE BECAUSE YOU DID NOT LIKE HIM. • ALWAYS DOCUMENT NON-COMPLIANCE

39. TRAINING FOR DEFENSE • LEGAL TRAINING • KNOW WHAT THE STANDARD OF CARE IS AND GROUNDS FOR SUIT • DEFENSIVE DOCUMENTATION • POLICIES • FORMS • COMPLIANCE PROGRAMS • EEOC • OBRA/NURSE PRACTICES ACT

40. Compliance Programs

41. CCP’S ALLOW INSTITUTION TO: • Identify weaknesses in internal system • Demonstrate hospital’s commitment to honest and responsible corporate conduct • Provide more accurate review of employee fraud and abuse • Identify and prevent criminal unethical conduct

42. Elements of Compliance Plans • Compliance standards • High level oversight • Employee screening • Education • Monitoring systems • Discipline • Responses

43. Functions: • Education of staff • Policy review • Grievance review • Case Review • Discussion of clinical and organizational ethics

44. Members: • Doctors • Administrators • Social Services • Lawyer • Business Office Manager • Resident Representatives • Director of Nursing

45. Response to claims and incidents: Investigation

46. NEVER FAIL TO INVESTIGATE • If you know about significant misconduct or a dangerous condition and do not do anything about it – you are exposing your company to tremendous legal risk. • Any harm that comes to your employees or residents as result of a known dangerous condition will result in liability. • Sometimes – just investigating a potential bad outcome saves you from liability

47. WHAT TO DO WHEN YOU SUSPECT A CLAIM OR LAWSUIT HOW TO CONDUCT A SUCCESSFUL WORKPLACE INVESTIGATION WHAT MISTAKES IN INVESTIGATION TO AVOID

48. WHEN YOU SUSPECT A RESIDENT/FAMILY CLAIM • INVESTIGATIVE PROTOCOLS SHOULD BE CLEARLY STATED AND FOLLOWED

49. RESPONSE TO INCIDENTS DOS & DON’TS

50. DO HAVE A POLICY IN PLACE REGARDING A RESPONSE TO A CLAIM OR LAWSUIT DO CONTACT THE COMPANY RISK MANAGER OR DEFENSE ATTORNEY IMMEDIATELY