As more and more lawyers focus their attention on bringing claims against Skilled Nursing Facilities in the State of New York, we cannot underestimate the importance of ensuring best practices in clinical record keeping. Because most claims against Skilled Nursing Facilities focus on the formation or care of pressure ulcers and/or patient accidents/falls within the facility, the most critical of medical records for defending many of these claims is more often than not the Certified Nursing Accountability Record. Certified Nursing Assistants, who are primarily responsible for transferring patients and assisting patients in their activities of daily living, fill out this Medical Record to account for and to substantiate that they performed their care obligations in conformance with the established Care Plan for the particular patient.
If the Accountability Record is not filled out properly or carefully done, the lawyer on the other side will be able to argue effectively that the patient’s care plan, designed to prevent harm to patients, was not followed or adhered to. Unfortunately, this type of finding can often result in an adverse finding against the Facility in the legal arena.
The most obvious example involves the process of turning and repositioning a patient every two hours and as needed for the prevention of developing pressure ulcers. This represents the standard of care and is typically found in most care plans designed for long term patients in a nursing home setting. If the Accountability record does not substantiate that this extremely important nursing intervention was not followed and a patient thereafter sustains a pressure ulcer, the pursuing attorney will pounce on that failure even if the care was actually provided or the ulceration can be traced and/or connected to a patient’s underlying co-morbidities. Conversely, if the Accountability Record properly and carefully documents that the standard of care was met, the defense can effectively point to the patient’s underlying co-morbidities as a coherent cause for the development of the pressure wound.
In addition, most attorneys will also bring claims against a Skilled Nursing Facility asserting a violation of New York State’s Public Health Law. Section 415.12 of this law defines certain minimal standards of care for skilled nursing homes in establishing a patient’s quality of care. With regard to pressure ulcers, section 10 NYCRR 415.12(c) provides that residential facilities “must ensure that patients who enter without bed sores do not develop them unless, because of the patient’s clinical condition, the bed sores were unavoidable and the facility made every reasonable effort to prevent them.” Without a coherent and viable accountability record, how is the Facility going to demonstrate that it made every reasonable effort to prevent the ulcer from forming.
With the advent of electronic record keeping and new software programs used at Skilled Nursing Facilities, it is critical that all Certified Nursing Assistants understand the import of their documentation efforts. If properly implemented, electronic record keeping and software programs permit the Certified Nursing Assistants to effectively document when, where and how the care was provided. This would include training in the use of the computerized record because without proper training, any added effectiveness gained in the added use of the technological advancement will be lost if the personnel do not know how to effectively use the software program to document their efforts.
In the end, it is extremely important that skilled nursing facilities have a coherent method for documenting the care provided by Certified Nursing Assistants. This must include training and a simple process that all certified nursing assistants can follow to document their hard work and avoid the pitfalls of litigation that are fairly easy to avoid.