Long-Term Care Survey Alert

These common terms can signal staff doesn't like a resident.

You may not always like a resident's behavior or personality traits, but allowing those sentiments to creep into your charting can come back to haunt you or the facility.

"Surveyors can tell within 30 seconds in reading a chart if staff likes a resident," cautioned forensic nurse Daniel Sheridan, RN, PhD, in a presentation at the recent fall National Association of Subacute and Post Acute Care conference in Washington, D.C. And you can bet if a resident suffers abuse, neglect or a wound of unknown origin, surveyors or other authorities will be combing through documentation to see how staff appeared to relate to and describe the person.

Solution: Avoid use of certain terms that you may not even realize conveys bias, suggested Sheridan. For example, writing "resident claims abuse" may subtly convey you don't believe the person, Sheridan said. Instead limit your attributions to neutral terms such as, "the resident says, states or reports," he suggested.

Another tip: Don't chart  "resident refuses care." Simply write, if accurate: "The resident chose not to receive a treatment," Sheridan relayed.

Follow up: Document what steps you took to educate the resident and family about the benefits and risks of the treatment, including the consequences of foregoing it, suggest risk- management experts. Document how you care planned the issue, as well--for example, obtaining an order for an alternative treatment.

Jettison This Description

How often does nursing or other caregiving staff write: "Resident uncooperative all shift"? Sheridan said he has seen instances where staff on one shift documents that assessment. Then the second shift picks up the theme and writes: "Resident continues to be uncooperative." And the third shift chimes in: "Resident uncooperative all shift. Finally fell asleep."

That kind of documentation can indicate on a subtle level that the staff feels frustrated with the resident. And it does nothing to explain what staff mean by "uncooperative" or what's going on with the person. As an alternative, state the resident's behaviors and your assessment, suggested Sheridan.

If you draw and document a conclusion based on your assessment, support it by writing, "as evidenced by," Sheridan advised.

Example: You might write, "Resident appeared agitated, as evidenced by" and then list the specific behaviors you observed. Also document your assessment of potential underlying causes of the behavior and any interventions.