Compliance Corner, Clinical Care Documentation – Delivers Advanced, Resident-focused service


resident acuity levels increase, assisted living must keep close tabs on the services they provide to steer clear of litigious situations. Nursing is not what it used to be, it is not bad, but it does have to be diligent about how they understand the scope of their services. Party rising acuity levels, including the increase of its other diseases, chronic diseases, and behavioral challenges have caused the once widely accepted social model of nursing homes to develop a model that will give a greater amount of specialized clinical care.

With this development comes increased responsibility on the part of assisted living, to meet the medical and clinical needs of their populations. However, it also shows that more legal risks if they are not strategic and detail-oriented about the services they provide and how they provide services to residents.

assisted living communities, of course, there are rules in each state. But what the regulations require, it is clear that when armed with strategies to combat the negative results of resident associated with common clinical adverse events, assisted living providers can take the initiative, rather than reactive, approaches to residential care and this will help them to reduce litigious conditions. In that vein, there are two clinical issues assisted living communities will be paying close attention, in particular, fall prevention and medication management.

Double-Duty Documentation Whoever said, “nothing is certain but death and taxes,” put ‘t get it quite right. The quote should be, “nothing is certain but death, taxes and the fact that the population will fall.”

It is of course important to develop a system to prevent the collapse of the resident, but when it comes to staying out of litigious situations, it is equally important to a well-documented and detailed assessment of why the resident fell or dropped many times. Resides fall on the way to the bathroom in the night shift? Resides fall regularly at sunset? Resides fall near the kitchen in the afternoon? Resident seem to be over-medicated? This type of analysis helps not only to hone decent living-focused care, it also serves as verification of the assisted living community took the appropriate measures to take care of the resident and remedy any risky situations.

When it comes to medication management, a host of clinical issues center on administration errors, delegation and training, medication review (especially antipsychotics), and right resident is refusing medication. Community policy should be clear on medication management and the right of residence to refuse. Order physician for each product should be available and all necessary information on dosing and administration. Drugs administration training should be thorough and in accordance with state regulations.

Providers also consider random community-level review of medication administration records. This will help expose medication documentation defects such as medication error in reporting or omission and inaccurate or irrelevant data on medication administration has or refusal.

Nurses in charge of more and more nurses recruitment in assisted living companies managers, doctors, and officers, the second coming of care issue is a nurse delegation. These items usually sent around medication administration, but may also affect resident see where specific therapy involve. Nurse delegation is usually a creature of law and order of the state, but the key to successful implementation is the understanding of both nurse and delivered oversee what is entrusted with the mission, the appropriate level of monitoring and registration of the delegated tasks.

Again, thorough and detailed documentation is important not only to provide appropriate care, it is also important to respect the rules and legal issues. And here the old adage rings true nurse it is, “if it is not registered, it is not.” Advanced data keeps record, serves as a communication tool, and can insulate against regulatory and civil legal responsibility.

The current model of assisted living, find the key clinical issues affecting residents and take a proactive approach to these issues not only increase the quality of care and quality of life for residents, it gives providers the ability to better meet the needs of the population but reduce potential rules and their liability.


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