by Nicola Gray, Esq., Managing Attorney,
Midwest & Medical Legal
Smith Clinesmith, LLP
If it was not documented, it was not done.
Many of us have heard the above phrase before, but why is this phrase so important for our loved ones receiving care in a nursing home?
It matters because effective communication among nursing home staff plays a significant role in positive resident outcomes. Nursing homes are not staffed by the same employees across every single shift. Given that, there needs to be an effective system to transmit information about what occurred from one shift to the next—and from day to day—regarding residents. Nursing scope of practice dictates that communication is an essential and fundamental component used during the nursing process. Communication is key in the care of our loved ones in nursing homes.
Documentation provides a road map through the nursing process mentioned in the preceding paragraph. Let’s take a look at the nursing process of a new resident in a nursing home. The resident is admitted into the facility, and a nursing assessment is done. Nursing staff are unfamiliar with a new resident until they have performed an assessment. Essentially writing down everything that nurses note regarding each body system allows nurses to establish a baseline for the resident and for the nurses themselves to be able to identify anything that is not that resident’s normal. An example of this is simply documenting vital signs. Keeping a record of vital signs allows the nursing home to determine whether the low heart rate noted in a resident file is normal for them, or whether a low heart rate represents a change in condition that warrants a call to action.
Tracking changes in condition are among the main reasons why documentation is important. Having established a baseline, it is important for nurses to track anything that deviates from that baseline. This, in theory, should allow for a resident who is experiencing a medical emergency to be transported to a higher level of care.
In the setting of an injury such as pressure wounds, documentation of skin status on admission is important in order to communicate the need to oncoming staff to put treatment in place. In the unfortunate event that a pressure wound is acquired in the facility, the nursing standard of care requires nurses to measure the wound, document dimensions and document wound appearances and locations. This way, it allows oncoming nurses to determine whether the wound is increasing or decreasing in size, deteriorating or improving in terms of wound appearance (drainage, granulation etc.).
A medication administration record (MAR) documents what medications a resident has received. Imagine the consequence of a medication being administered and not documented as given. Without a record of the medication, a nurse may readminister the medication, with possible fatal consequences. Because of this, documentation serves the purpose of keeping the resident safe – and keeping the license of the nurse safe.
A large population of residents in nursing homes are recipients of Medicare and/ or Medicaid. In order to participate in these programs, federal regulations require nursing homes to maintain complete and accurately documented records on their residents.
Remember, you don’t have to be a nurse in a nursing home to maintain documentation on your loved one. Visit often and keep your own diary/journal of what is going on with your loved one that day. Doing this allows you to identify any changes your loved one is experiencing and allows you to alert nursing staff as well. Document it. Because it matters.
