Long-Term Care Survey Alert

Here's how to protect residents and wow surveyors.

Your best bet for staying a step ahead of abuse and related F tags in your facility? Consider a plan that incorporates CMS-sanctioned best practices, as well as basic "CSI" techniques and legal know-how.

Start by implementing a protocol for when to notify the police about physical or sexual assaults, advises Daniel J. Sheridan, PhD, RN, FNE-A, FAAN, associate professor at Johns Hopkins University School of Nursing.

A recent Centers for Medicare & Medicaid Services' Web-based modular survey training course says that while a nursing facility administrator "would not be expected to know exact criminal laws, it's expected that the administration or his/her designee will immediately notify policy if any potential criminal act is committed against a resident."

Play it safe: "If you have a cognitively intact resident who hit someone in anger ... call the police and have them sort it out," advises Mark Guza, an attorney with Arnall Golden Gregory LLP in Atlanta. "You have victims' rights to consider and there's a tort action" if someone alleges the facility didn't report a crime, he says.

Bone Up on Injuries That Signal Abuse

Some injuries throw up a "red flag," says Nancy Shellhorse, an attorney with Thompson & Knight LLP in Austin. Examples include bruises on the wrists or inner thighs, she says.

Bruising to the head and face can indicate an undetected fall, which may actually indicate that a resident needs more supervision, says Shellhorse. But anytime someone has a black eye, do a thorough investigation, rather than attributing it to a fall, adds Pat Boyer, RN, NHA, principal of Boyer and Associates in Brookfield, WI. "You want to make sure no one caused the injury."

Forensic gems: Boyer has seen bruising on a ring finger that indicated someone had tried to steal a resident's ring. Look for bruising along the scalp line or bruising and tenderness of the scalp, suggests Gail Robison, RN, with Boyer &Associates. Finding a clump of hair on the pillow or in the patient's bedroom, etc., can be a sign of abuse, warns Sheridan. "If a staff person wants to control the resident's behavior, that person walks in, shuts the door, grabs the resident by the head, lifting him/her off the bed, and says 'If you push that call light again, I'm going to yank your head off.'" The hair pulling hurts, it invokes fear and causes very little trauma, he notes.

Don't jump to conclusions: Some serious-looking wounds that herald potential abuse may turn out to have a medical cause. For example, one patient's leg "turned very red and developed an area of eschar over the knee and hip areas," says Sheridan. "Initially we thought it was an abuse case but" discovered that the patient's severe atherosclerotic condition had caused the problem.

Document the Resident's Account

"Staff should ask every resident directly -- no matter the person's cognitive or verbal status -- how they got hurt," emphasizes Sheridan. "Many of them can communicate nonverbally" by writing notes or using a computer or pointing to letters to spell out answers -- or squeezing a finger once for "yes" and twice for "no," he says.

Documentation example: Sheridan might write: "Asked patient how he bruised his leg but he didn't respond which is consistent with his nonverbal status since his stroke in 1999. Established communication by writing notes ... ." Then document what the resident relayed about the injury.

Free resource: The CMS surveyor training provides actual scripts for staff to interview a resident about potential abuse. Go to www.cms.internet.streaming.com. Click on Web-based training and see the "abuse and neglect investigation" course.

Create a Timeline for the Injury

As part of an internal investigation of an injury of unknown source, talk to the person who found the injury. Then work your way backwards in time until you find a "credible witness" who can say the injury wasn't there at a certain time and date, suggests Sheridan. "In that way, you develop a window of opportunity."

Photodocument the injury when you discover it and to chronicle healing, advises Sheridan. He suggests  a Polaroid Spectra law enforcement camera for that purpose. You point the camera, "shoot, wait three minutes and see if you got the picture. It costs about a dollar per picture."


Take Steps to Preserve Evidence

wAlso implement a protocol for preserving evidence in suspected physical or sexual assaults. "The facility needs to make reasonable efforts to preserve evidence until the police arrive on the scene," says Sheridan. "Evidence might include bloody sheets or sheets with semen stains" or a broken object that one person hit another with, such as a chair. "Ideally, you leave the bloody pillow or object for the police to photograph and then they bag it." If you have to store evidence, use a paper bag rather than a plastic one. A paper bag allows the moisture in a piece of evidence to evaporate, thereby preserving it -- especially DNA evidence, explains Sheridan. Place each item in its own paper bag; then label and date it. "Seal the paper bag with tape of any kind but don't staple it," which can cause a needlestick injury, he says. "Place the bag in temporary locked storage in a file cabinet with holes punched in it to facilitate air flow,"says Sheridan.