Long-Term Care Survey Alert

Cover these essential bases.

Documentation can save the day when surveyors are hot on the written trail to see how you investigated suspected abuse. The record should include these key elements, according to a recent Centers for Medicare & Medicaid Services' Web-based training on abuse and neglect.

• Chief complaint/history of injury

• Complete medical and relevant social history

• A detailed description of every injury, including its type, number, size, location, stages of healing and color

• A body map or accurate drawing

• Color photographs and imaging studies

• Results of all pertinent laboratory and diagnostic procedures

• An opinion about whether the injuries match the history (Aravanis et al, 1982).

Consider These Additional Tips

Document each step of the investigation into suspected abuse, advises Mark Guza, an attorney in Atlanta. For example, make sure the record includes information about who discovered the injury and when -- and who reported to whom and when.

Example: The DON should document the time she observed the injury if she didn't discover it and "when she notified the administrator and other people or places, such as the emergency room or attending physician and family," advises Guza.

Maintain a separate investigation file that shows the facility's active involvement all the way through the investigation, advises Guza. If the facility is focusing on a "certain individual" as someone who caused the injury, the file should show that the facility has removed that person from patient care -- and when, he adds.