Long-Term Care Survey Alert

Documentation holds the key to being deficiency free.

You know the old saw: If you don't document it, you didn't do it, at least in the eyes of surveyors and other government authorities.

So document every step of your investigation into abuse allegations or injuries of unknown source. "A bunch of sticky notes all over the DON's office" isn't going to suffice for surveyors, cautioned Janet Feldkamp, RN, JD, speaking at a February 2005 American Health Lawyers Association conference in San Diego. "Facilities need systematic documentation."

Attorney Adam Balick agrees, noting he recently represented a facility cited for failing to conduct a proper abuse investigation. Yet the person investigating the incident had actually done a thorough job looking into the incident - but lacked the documentation to prove it, says Balick in Wilmington, DE.