MDS Alert

Hint: Eliminate bias, focus on theories of causation.

Who doesn't like putting on their CSI hat to figure out "whodunit" on TV mysteries? But when it's the real deal, forget the fiction and perform a solid investigation that will hold up with surveyors and in court.

Forensic specialist Daniel Sheridan, RN, PhD, provided that key advice in a presentation at the September 2007 American Association of Nurse Assessment Coordinators conference in
Las Vegas.

"Nurse assessment coordinators may end up in a position where they help investigate suspected abuse and neglect," said Sheridan, a nursing professor at Johns Hopkins. He suggested a number of strategies for keeping investigations fair and on target.

1. Develop an investigative protocol and use it consistently. "A haphazard one that differs each time doesn't look good to surveyors," Sheridan cautioned AANAC conferees.

2. Investigate allegations of abuse or complaints timely. That means right after you discover potential abuse or neglect or hear about a complaint, Sheridan said. Getting the investigation going quickly is important because "memories fade and evidence gets lost" otherwise. And you don't want to give staff time to collude in order to cover up facts.

Smart forensic move: Review and immediately secure the clinical records so you don't give staff time to doctor or add something to them, he advised. The clinical records and MDSs may also provide information for the investigation (see p. 17).

To expedite investigations, the facility needs a designated team that's on call, advises Gail Robison, RN, clinical reimbursement and operations consultant for Boyer and Associates in Brookfield, WI. If there is an injury of unknown origin or allegation of abuse, staff needs to know whom to call immediately to get the investigation going, she tells Eli.

3. Discover bias before the fact. To avoid bias or allegations of bias, make sure whoever is doing the investigation doesn't have a non-work-related relationship (friend, enemy, former spouse, dating partner, or business associate) with anyone who could be a potential target or witness in the investigation. That can be tougher to do in smaller facilities where people wear multiple hats, Sheridan conceded.

As a solution to the bias issue, some facilities have an outside team come in and do the investigation.

4. Use strategic, fair interview techniques. Start by interviewing staff who found or witnessed an injury or event, such as a fall. "Falls are very common, but they can be [caused by] abuse and neglect," Sheridan said. So document all the names of people who witnessed a fall or found a person "down." If someone discovered the resident down rather than observed him falling, then document that. There's a "world of difference" between the two, Sheridan said. It doesn't mean the person was abused and fell. Maybe she sat down and couldn't get back up, he pointed out.

After you talk to the person who found the resident injured or noticed a problem, work your way back to the last person who saw the resident before the incident, Sheridan advised. That doesn't mean that the person who discovered the problem inflicted the injury or allowed it to happen, he added. The goal is to identify the window of time during which the incident or injury could have occurred.

Also, take care to talk to people separately. Sheridan noted that interviewing people is very effective in terms of getting information if you do so within one to two hours of the event. Use your Nursing 101 communication techniques, Sheridan advised. Ask open-ended questions such as "tell me what happened" and "then what?" Get more specific as the person reveals more information.

Avoid any trick questions, he emphasized. Don't play "good cop, bad cop."

5. Identify and explore theories of causation. For example, if staff found someone "down," look at the surface and the person's clothing and any wounds. If the person tripped and fell on the grass, as opposed to concrete, you'd expect to find different things in his clothing and wounds, Sheridan said. "Ask yourself what you'd expect to find if he fell at a certain location."

Ask staff to share their ideas about what might have happened in a particular scenario where a patient has a bruise, for example. Document those theories, ponder and explore them, Sheridan counseled.

Key example: A resident with dementia who walks at a fast pace has a horizontal bruise on the front of her thigh. She can't tell you how it happened. One theory would be that the person walked quickly into an object. So measure the height of the bruise. You might find a table in a dining room that's the same height as the bruise, Sheridan noted.

But if a resident has a huge horizontal bruise on the back of the leg, you'd realize that the person probably could not have walked that fast backwards into furniture, he said.

Investigation tip: When investigating injuries of unknown origin, observe the resident in his daily activities to see what might have caused the injury, Robison advises. "Even when someone wears padded arm protectors, you'll sometimes see him bang his arms along the wall railings, leading to bruising. Or if the person has a skin tear, look for a jagged edge somewhere -- on the wheelchair, a chair the person uses, the bedrail, etc."

As you observe the person in his daily routine, including the rehab therapy gym, you will also identify more people who may have seen something or know something about the injury and how it could have occurred, Robison adds.

6. Document, document, document. The record should include each step of the investigation. Include the theories of causation and how staff investigated each one, Sheridan advised.