Long-Term Care Survey Alert

The stereotypical idea of “charting parties,” where nurses with four different colored pens furiously fill in the blanks the night before a survey, is no doubt a figment of prosecutors’ imaginations in the vast majority of cases, say legal and survey experts.

But there are more subtle forms of charting parties that facilities should discourage, according to Beth Klitch, principal of Survey Solutions in Columbus, OH. “Staff can have an unspoken way of cutting corners and helping each other out.”

For example, Klitch recently reviewed a record of care for a short-stay orthopedic skilled nursing facility patient, an otherwise healthy woman who became dehydrated, went into renal failure and died. “And the intake and output sheet for one shift says the resident had 3,000 cc intake and 10,000 cc output,” Klitch reports. Not only is that level of output nearly impossible “but it’s hard to believe the resident had a round figure like that for the intake,” Klitch notes. And while that specific entry could be chalked up to an error or a caregiver in need of some oneon- one teaching, caregivers on several shifts recorded the same erroneous figures.

While that’s an egregious example of documentation that was probably worse than what really occurred with the resident, that kind of copying goes on all the time, because it’s hard for staff to chart everything, Klitch notes.

Medication administration records, flow sheets and therapy logs are easy for staff to fabricate — and that fabrication is just as easy for surveyors to detect, warns Harvey Tettlebaum, an attorney with Husch & Eppenberger in Jefferson City, MO. For example, federal prosecutor David Hoffman is currently working on a nursing home case in which the facility’s MARs indicate the residents received each and every medication as scheduled, Los Angeles attorney Mark Kleiman tells Eli. But the pharmacy returns for residents during that same time frame include blister packs that are a half to onethird full — a discrepancy that’s nearly impossible to explain to surveyors or a court.

Conduct Auditing Parties

To detect fabricated or “copy cat” charting before surveyors call you on the carpet, audit a sample of residents’ records on a regular basis for things that don’t jibe. The simple act of auditing will discourage staff from taking dangerous shortcuts when charting care, notes Tettlebaum. When auditing records, ask two questions:

• Does the chart provide an accurate picture of the resident, his care and outcomes?

To answer that question, “the director of nursing or another nurse manager who knows residents should read the chart,” suggests Annaliese Impink, an attorney with the Law Offices of Bianculli & Impink in Arlington, VA.

• Do the various records validate each other, such as nursing notes, therapy logs, flow sheets and medication administration records?

Use the audits to provide redacted examples of good and bad documentation to teach staff how to chart accurately, Klitch advises.

Finally, teach nursing staff to look over flow sheets each shift to catch glaring errors that busy staff might carry forward — or that surveyors may catch and ask why you didn’t. Examples include erroneous weights, vital signs, fluid intake and output or wound size assessments that stand out like sore thumbs. Catching such discrepancies allows nurses to make follow-up assessments and add notations to explain them in the record.