- Linda D. Pershall, R.N., B.S.N. -

Elder abuse grabs headlines and is a topic of television documentaries. What elder abuse is and its prevalence in our society is often clouded by sensationalism then forgotten with little or no changes being implemented for the elderly victim. The abuse of the elderly is a real and serious problem. Elder rights and HIPAA are measures intended to decrease abuse as outlined in a previous newsletter (January 2005).

There is a flip side to the elderly person being the victim of abuse. That is when the elderly person is the abuser. The elderly person with dementia, delusional behavior, schizophrenia, depression, anger, confusion and frustration may express these problems/emotions as verbal and/or physical assault. The target of this assault is often the spouse, who is often frail and generally elderly.

Frequently the spouse endures this assault for years. It goes unreported for fear of loss of that person’s income should institutionalization occur or embarrassment of expressing the perceived "bad behavior" of the spouse. Frequently behavior is perceived as a social or moral failing, not as an illness. Untreated, these behaviors will continue to escalate. The spouse and family may be unable to distinguish these behaviors for an onset of increased depression, Alzheimer’s or other type of dementia. Violence and aggression may be a new onset for the elderly individual and signal the need for immediate medical evaluation and intervention. Also persons with a history of family violence, physical abuse, alcoholism or substance abuse will continue those behaviors as an elderly person. Acute or chronic changes indicate a need for medical intervention. Medication and psychological intervention is beneficial for the elderly as well as the younger population.

Not all aggressive, violent, elderly individuals have Alzheimer’s dementia, and Alzheimer’s dementia does not necessarily equate with aggressive and violent behavior. There are a growing number of Alzheimer’s special care, long-term care facilities or facilities with specific Alzheimer’s units. There are few long-term care facilities dedicated solely to elderly patients with psychological disorders. Frequently these patients in need of psychological therapy are placed in a general care facility. This may limit their therapeutic treatment as not all facilities have the staff with the specific skills needed to provide therapeutic psychological intervention.

The institutionalized elderly person with violent behavior may express that behavior toward caregivers and fellow patients. It is not uncommon for staff members to receive bites, bruises, cuts, torn clothing, verbal abuse, racial slurs, sexual advances, sexual groping and sometimes serious physical injury. It is not uncommon for a female staff member to be assaulted (grabbed) in a sexual manner while rendering routine care. Male staff members experience similar assaults. It is not uncommon for a fellow patient to be the recipient of a violent patient’s assault. The facility caring for these individuals has the responsibility for protecting staff and other patients while providing quality care for the aggressive or violent patient.

Dementia associated with physical and/or verbal violence is behavior difficult to medically manage. This behavior is emotionally draining for caregivers and family members. These individuals are among the most likely to be neglected and abused by caregivers or family members. Neglect may be subtle, i.e., not providing personal care as frequently, not having human interaction as frequently, etc. It may also be overt, with the demented patient being physically assaulted. Avoidance is a normal human response to this type of behavior. Staff and family tend to decrease interacting with these individuals for fear of starting an episode of aggression/violence. Medical staff members need to be educated to these individuals’ special needs and in turn need to educate family members.

Often aggression is an expression of a need for assurance and human interaction, yet the aggressive behavior tends to make meeting these needs difficult. The challenge for the medical caregiver is to provide the human need for comfort, contact and interaction to these difficult and needy patients and educate staff and family as to the patient’s needs. This requires more staff input and planning of care as well as detailed observations to determine what is the most beneficial approach for that patient. Planned regular one to one contact helps prevent the aggression born of isolation. A period of quiet time, when aggressive behavior starts, is often useful in defusing aggressive episodes. These individuals often respond to re-direction and a change of focus, a quiet, gentle approach and a loving tone.

Severe brain damage from injury (stroke) or progressive dementia may limit effective therapeutic psychological intervention, but it does not exclude the medical professional’s responsibility in attempting therapeutic intervention to evaluate potential benefits. Skilled intervention often has amazing benefit in even more damaged and delusional individuals. This intervention may be a less stimulating environment with more structure in daily routines and medication adjustments as opposed to traditional psychotherapy. It is a breach in care standards to not offer the aggressive and violent patient access to psychological assessment and intervention.

Standard of Care:

Specific care plans detailed to the individual needs of a specific patient is the standard of nursing care. This is especially necessary when behavior issues interfere with the patient’s activities of daily living (ADL). The standard of care is breached when care/care plans do not address aggressive behavior.
Routine maintenance medication is helpful to control depression or other underlying symptoms. Redirection of the patient’s focus to a quiet environment, providing human contact, etc., are the preferred first line of intervention when aggression is first evident before it escalates to the need for medications. The standard of care is breached when the only intervention for aggressive episodes is the administration of additional medication.
Safety is essential for all patients, especially those prone to impulsive and aggressive behavior. Some safety measures are beds in low position, pads on the floor to prevent injury from falls, quick release restraints, wheelchairs designed to prevent tipping and removal of injurious objects along with ongoing staff education. The standard of care is also breached when safety measures are not in place for injury prevention.
Restraining an impulsive or violent person should only be used in an extreme emergency situation. It should only be used for a few minutes and it requires a physician’s order. The routine use of restraints is still practiced, but it is rarely beneficial and it has been shown to increase serious injuries. The use of restraints for punishment or staff convenience is a violation of national standards and an illegal act.
Aggressive, impulsive and violent patients may sustain injury even under the best of situations considering the nature of their disorders, however caregivers must take all reasonable measures to protect these patients. These individuals are actually among the most vulnerable elderly patients.

These patients need more monitoring for injury (bruises, cuts), weight loss, symptoms of illness, etc., due to their inability to express their symptoms or needs. Lethargic behavior may be an indication of illness, stroke or in some situations overmedication. Failure to provide that additional monitoring and assessment is below nursing standards.

- Biography –

- Linda D. Pershall R.N., B.S.N.-

Linda Pershall is a registered nurse with a bachelor’s degree in nursing and 30 years of experience in working with elderly patients in long-term care facilities, community and home settings. She has a passion for quality elder care and an extensive knowledge of elder issues.

Her other passion is wound care, specifically treatment and prevention of pressure wounds or decubitus ulcers which are a frequent problem for the elderly individual.

She formed LDHP Medical Review Services Corp. in 1995 to support quality care standards and provide a resource to the public and medical or legal professional.

- Linda D. Pershall R.N., B.S.N.-

Elder abuse, what it is and its prevalence is often clouded by sensationalism. One definition of abuse is a violation of known rights. Two positive steps in prevention of abuse, including elder abuse, are the Patient’s Bill of Rights and the current HIPAA Regulations.

All patients, including the elderly, have rights to quality medical care .
The Patient's Bill of Rights was adopted by the U.S. Advisory Commission on Consumer Protection and Quality in the Health Care Industry in 1998. This bill of rights also pertains to the elderly patient. These rights are again emphasized by HIPAA to which all healthcare providers are currently responsible to adhere.

This is a partial list of the Patient’s Bill of Rights.
- Information Disclosure – The elderly person has the right to accurate and easily understood information pertaining to their health plan, health care professionals, and health care facilities. Allowances must be made for visual and hearing impairments as well as alternate languages.
- Choice of Health Care – The elderly person has the right to select medical practitioners and facilities.
- Access to Emergency Services – Long-term care facilities have the responsibility to provide access to emergency medical care/facilities.
- Participation in Treatment Decisions – The elderly person has the right to know treatment options and to participate in the decisions regarding care. Guardians, family members or designated person may be the decision maker under some circumstances.
- Respect and Nondiscrimination – The elderly person has the right to considerate, respectful and nondiscriminatory care from all of their healthcare providers.
- Confidentiality of Health Information - The elderly person has the right to talk in confidence with health care providers and to have their health care information protected. The elderly person has the same right to review and obtain a copy of their medical records, as do other patients.
- Complaints and Appeals –The elderly person has the right to a fair, fast, and objective review of any complaint they have against a health plan, doctors, hospitals or other health care personnel. This includes complaints about waiting times, operating hours, the conduct of health care personnel, and the adequacy of health care facilities.

HIPAA2 regulations are basically similar:
- Healthcare providers and facilities have the responsibility to notify patients about their privacy rights and how their information can be used.
- Healthcare providers and facilities are responsible for adopting and implementing privacy procedures for practitioners, private practices, hospitals, etc.
- Healthcare providers and facilities have the responsibility for training employees so that they understand the privacy procedures.
- Healthcare providers and facilities have the responsibility for securing patient records containing individually identifiable health information so that they are not readily available to those who do not need them.

The HIPAA Privacy Rules for the first time creates national standards to protect the individual’s medical records and other personal health information. It gives the patient more control over and access to their health information. It sets boundaries on the use/release of health records. It establishes appropriate safeguards to protect the privacy of health information. It holds violators accountable, with civil and criminal penalties that can be imposed if a patient’s privacy is violated. And it strikes a balance when public responsibility supports disclosure of some forms of data – for example, to protect public health and the patient’s right to privacy.

For the elderly, and all patients, it means being able to make informed choices when seeking care and expecting to be provided pertinent healthcare information. It enables patients to find out how their information may be used and about certain disclosures of their information that have been made. Limits are placed on the release of information and disclosure as to when and how information is released. It generally gives patients the right to examine and obtain a copy of their own health records and request corrections. HIPAA is basically the legal enforcement for the prior Patient’s Bill of Rights.

All patients, especially the elderly, have the right to quality care that maintains their dignity and reflects their wishes. Yet these are exactly the areas most often violated for the elderly person.

Violations of the Patient’s Bill Of Rights.

The most common violation of the elderly person’s rights is when they are addressed in a condescending manner rather than as the adult they are. This sets the tone for not permitting them to participate in multiple elements of their own care. With the universal implementation of HIPAA2 regulations, healthcare providers who violate patients’ rights are generally in violation of HIPAA regulations as well. This now carries legal ramifications.

- Not respecting the elderly person’s right to decision making. If no alternative decision maker is designated, then the elderly person is their own decision maker. The decision to seek another physician, emergency care or treatment alternatives is not always offered to the elderly person with the same frequency as the younger person. The assumption is made that due to their age the elderly person is not able to make an informed decision when in fact the elderly person is able to do so and just needs allowances made for their physical impairments.
- Privacy issues are often violated. Medical information is discussed in front of other patients, often in a loud tone to accommodate for the elderly person’s hearing impairment. Due to embarrassment, the elderly person may not fully explore the medical information/options. This is a violation of their rights and a breach in standard of care (HIPAA standards).
- The reverse of omitted care also occurs for the elderly patient. Namely the elderly person is coerced into signing a consent for invasive and dangerous procedures without a clear understanding of the risks of the procedure or its expected benefits. Family and medical caregivers are often guilty of pressuring the elderly person to have a painful/dangerous procedure when the best of all expected outcome would be a few months of life, often with no alteration in their pain level. This violates the elderly person’s wish for not prolonging their life with a minimum of pain. Sometimes these procedures are performed with the permission of the family when the elderly person has not been declared incompetent thus violating their right to make their own medical decisions, a clear violation of HIPAA standards.
- Another element of poor informed consent is not providing information in a form the elderly person can understand. An example is providing verbal information in English when the patient is non-English speaking and hearing impaired. Again this is in violation of HIPAA standards.
- If the elderly person is not allowed to handle their own finances, then their rights are violated. This occurs in the community as well as in institutional healthcare settings. Family members and occasionally caregivers compel the elderly person into giving them their funds. Adult Protective Services needs to be notified as well as law enforcement agencies as this may create a criminal situation and at the least the vulnerable elderly person needs protection.

It must be remembered that the majority of elderly people continue to live in their own homes with their own families and are never institutionalized. Any time an elderly person is not offered full civil and personal rights it is a potentially abusive situation, be it medical or civil. Preventing elderly abuse is synonymous with providing elders with respect. Any time a patient is offered lesser care due to their age it is a breach in standards of practice. Failure to provide respect and dignity is a short step to abuse and neglect.

Elderly persons are usually quite capable of making informed decisions if information is presented in an appropriate manner. I am reminded of the 100-year-old woman who injured her leg while operating her electric wheelchair. Emergency care was provided, and this person was offered the choice of remaining in the long-term care facility or seeking more diagnostic tests in an emergency room. She made the decision to seek additional care and selected the local hospital to which to be transferred. Her dignity was respected, as was her right to choice. All that was needed to allow her to make these decisions was a willing staff, a little time and written/verbal communication to allow for her physical impairments. This was an actual occurrence. Having fully recovered from her injury she continues to make her own decisions at age 101.

Biography

Linda D. Pershall R.N., B.S.N.

Linda Pershall is a registered nurse with a bachelor’s degree in nursing and 30 years of experience in working with elderly patients in long-term care facilities, community and home settings. She has a passion for quality elder care and an extensive knowledge of elder issues.

Her other passion is wound care, specifically treatment and prevention of pressure wounds or decubitus ulcers which are a frequent problem for the elderly individual.

She formed LDHP Medical Review Services Corp. in 1995 to support quality care standards and provide a resource to the public and medical or legal professional.

MALNUTRITION AND THE DIETITIAN: TWO IMPORTANT ROLES OFTEN
OVERLOOKED IN HEALTH CARE FACILITIES

- Stephanie Copeland, Registered Dietitian /Licensed Dietitian -
Malnutrition (the state produced by excess or deficient energy (calorie) or nutrient intake or by an imbalance of nutrients) of many types is common in nursing home residents, with a prevalence ranging from 17% to 65% (1), while studies of hospitalized patients have shown 30%-50% to have protein calorie malnutrition (PCM) (2). In some cases, diseases related to malnutrition are the major reason for admission. Nutritional problems may also result in readmission to the hospital either directly (for example, dehydration) or indirectly (for example, infection).
Even with such a high rate documented, nutritional elements are often overlooked by medical professionals and may be a key element in a plaintiff’s claim or defense of a client.
Risks and Complications of Poor Nutritional Status
• Inadequate fluid intake, which is extremely common, leads to dehydration and other complications.
• Severe malnutrition puts patients at higher risk for death, sepsis, infections, and increased length of hospital stay.
• Severe Protein Calorie Malnutrition (PCM) alters tissue regeneration, inflammatory reaction, and immune function.
• PCM has been associated with decubitus ulcers, cognitive problems, orthostatic hypotension, infections, and anemia (3).
• Low levels of vitamin C have been associated with decubitus ulcers (4), while PCM and vitamin D deficiency are important factors associated with hip fractures, a frequent cause of morbidity and mortality in residents (5).
• Zinc and selenium deficiency can aggravate immune deficiency and delay wound healing (3).
• A 1991 study revealed that about half of the people over age 65 who are hospitalized with illnesses accompanied by dehydration die within one year of admission.
• Malnourished patients are more likely to have postoperative complications than well-nourished patients.
• Diabetic complications have a direct correlation to nutritional status and patient nutritional education.
Most physicians and nursing staff have had inadequate training in nutrition, and studies have shown that they fail to treat patients with poor nutrition. The signs and symptoms of nutritional deficiencies or toxicities can be similar to those of other medical conditions, and nutrition related diagnoses are often not made by physicians or suspected by nursing staff. The cost-cutting environment of healthcare which is most readily seen in reduced head counts is a short-sighted approach when applied to nutrition intervention and the role of the Dietitian.

Dehydration alone is probably one of the most common and most cost-efficient nutrition related conditions to treat or avoid if interventions and care plans are in place and followed. If left untreated, it is one of the most common and most costly problems identified in the elderly population, especially those in long term care (LTC) settings. Because of this, HCFA surveys now include detailed monitoring of hydration standards and implementation procedures in LTC facilities (6). The Hydration Management Program from Novartis Nutrition reports that 12-25% of LTC residents are affected by dehydration, and that over 50% of dehydrated residents with other medical problems die. Clinical signs and symptoms of dehydration include decreased blood pressure, increased heart rate, decreased cardiac output, decreased weight, electrolyte abnormalities, fever, confusion/change in mental status, constipation, and poor skin turgor. Increases in lab values (due to decreased blood volume) such as hemoglobin/hematocrit, BUN/creatinine, and albumin may also mask other potential deficiencies.

The Surgeon General has stated, "If you are among the two out of three Americans who do not smoke or drink excessively, your choice of diet can influence your long-term health prospects more than any other action you might take." The Surgeon General's Report on Nutrition and Health has also stated that eight of the ten leading causes of death, including coronary heart disease, stroke, some types of cancer, and diabetes mellitus, are related to diet and alcohol.

Education requirements for physicians and nursing staff usually consist of no more than a one semester course in nutrition. Because of this, the registered dietitian (RD) is a key member of the interdisciplinary team. Registered dietitians are the experts in nutrition and dietetics. A common misconception among the public and those in healthcare is that dietitians do little more than plan menus or counsel patients on weight loss or diabetes. Clinical RD's have extensive knowledge in medical nutrition therapy specific to almost any disease or condition, parenteral and enteral nutrition formulas and requirements, supplemental drinks, e.g., Ensure (there are multiple supplements with specific indications for different conditions), nutritional treatment of decubitus ulcers, and drug/nutrient interactions, to name a few. The education required for a degree in nutrition and dietetics is based primarily on science courses including medical nutrition therapy, metabolism, biology, chemistry, physiology and anatomy. The American Dietetics Association defines a Registered Dietitian as one who has "completed a baccalaureate degree in dietetics or a related area at a regionally accredited US college or university, completed a supervised clinical experience, and passed a national examination administered by the Commission on Dietetic Registration, which is recognized by the National Commission for Certifying Agencies. To retain registered dietitian status, continuing education activities are required. Registered dietitians are qualified to perform nutrition screening, assessment, and treatment."

Due in part to limited reimbursable services, dietitians are often underutilized, and this can lead to a lack of recognition of their importance as a member of health care teams. In recent years, however, Medicare and JCAHO surveys have greatly increased their focus on nutrition related issues, and new health care reform is leading health care providers and payers to implement new approaches that will meet demands for cost containment and quality care. Dietitians and medical nutrition therapy play key roles in identifying those at risk and improving patient outcomes resulting in improved quality of life and cost savings. Medical nutrition therapy and proper documentation of dietetic services and outcomes are also proving to be essential in protecting against litigation.
References
1. Drinka, P.J, Goodwin, J.S. Prevalence and Consequences of Vitamin Deficiency in the Nursing Home: a Critical Review”. Journal of American Geriatric Society. 1991;39:1008-17.(Medline)
2. Morley, J..E., Silver, A.J. “Nutritional Issues in Nursing Home Care”. Annals of Internal Medicine 1995; 123:850–9.
3. Konstantinides,F. “Nutritional Assessment of Hospitalized Patients: A Long Overlooked Area of Lab Testing”. Clinical Lab News. Feb 1998.
4. Morley, J.E. “Nutritional Status of the Elderly”. American Journal of Medicine. 1986;81:679-95.
5. Goode, H.F., Burns, E., Walker, B.E., “Vitamin C Depletion and Pressure Sores in Elderly Patients with Femoral Neck Fracture”. British Medical Journal. 1992;305:925-7.(Medline)
6. Pierron, R.L., Perry. H.M., III, Grossberg, G, Morley, J.E, Mahon, G, Stewart, T. “The Aging Hip”. Journal of American Geriatric Society. 1990;38:1339-52.(Medline)
7. Instructor's Handbook to In-service Training, Hydration Management Program. Copyright 1999 Novartis Nutrition Corporation.

Biography - Stephanie Copeland, R. D., L. D.

Ms. Copeland provides direct patient care for inpatient and outpatient settings in hospitals, nursing homes, physical rehabilitation facilities, Hospice, home health, and private consultation. She provides education to patients/family on specific therapeutic diets and food/drug interactions.
She serves as a member of the Wound Care Team; developed protocol for nutrition therapy with respect to all stages of wounds/decubitus ulcers.
She has implemented education programs for diabetic, pulmonary and cardiac patients. Ms. Copeland has also completed a legal assistant program.
She has extensive knowledge of medical nutrition therapy, patient nutritional assessments with regard to dietary, clinical, biochemical and anthropometric parameters.
She has participation in several surveys with the JCAHO Quality Assurance Team.
She has served as a consultant for nursing homes during Medicare surveys.

by Cheryl Nelson-Conley, M.S.N., R.N. (C.N.S.), C.N.O.R.

Electronic medical database charting is setting the gold standard for patient care documentation by incorporating best practice standards, organization and legibility in an easily retrievable database. The use of computer documentation of patient care is increasing in our technology oriented world. The purpose of this article is to discuss the electronic documentation of patient care using a database application. The use of this technology increases the possibility that an attorney has encountered or will encounter a case that has been documented using an electronic based or computerized method of charting.

Patient charting on paper has become a time-consuming and tedious task. Handwritten charts can lead to problems, including but not limited to the following:

- Documentation may contain gaps in patient care documentation due to low staffing level and high/acute patient census.

- Documentation may not be compliant with hospital or national standards.

- Documentation may be difficult to read due to poor handwriting.

The healthcare providers and medical institutions of today face a seemingly impossible challenge in managing paper patient records. Consider the following statistics located on the Internet at “http://www.infonition.com/medical.shtml#HIPAA”:

- The average document may be copied 19 times.

- 7.5% of all documents are lost, 3% of the remaining get misfiled.

A database application can assist documentation of healthcare by providing a wide range of processes to address the issues of documentation of care by physicians, nurses and ancillary staff by providing the following:

- Legible documentation.

- Consistency in documenting to meet national standards of care (mandatory parameters can be established which must be answered in order to complete/close the record).

- Flexibility in documentation by including free text options for the user.

-‘Real-time’ data when medical monitoring equipment is being used as in the OR (Operating Room) or ICU (Intensive Care Unit).

- Easy retrieval of data through reports that can be generated from the system to provide timely feedback to providers.

- Quality Management tracking to identify sentinel events and patient outcomes can be monitored within the database.

- Access to information can be limited to protect patient confidentiality.

Drawbacks of electronic based or computerized charting include:

- Applications which are difficult to use resulting in providers and hospitals ‘migrating’ to paper charting or a combination in which some information is electronically charted and some is handwritten.

- Providers who have difficulty with the use of technology and/or that have difficulty with typing.

What does this mean to the attorney defending a healthcare provider or healthcare facility accused of a breach in standards of practice or patient care? What does this mean to an attorney who is reviewing a case for a client that believes he/she or a loved one has been harmed by the healthcare provider or system? It is important that the attorney be aware of the relevant pieces of documentation that may exist in a database application and where to find them. Specifically, documentation can include the patient record (who documented what, when and where), quality management reports of incidences that may have occurred while caring for the patient, and an audit trail that might indicate any changes/alterations in documentation such as what data was changed, who changed the record and when that change was made. An electronic database may also contain information about hospital, as well as national and professional, standards of care that are accessible by the healthcare provider while documenting care.

When an electronic database is used to document care, several considerations are important in obtaining and reviewing patient documentation. First, there are many types of electronic systems in use, including electronic medical records that may or may not be a database. An expert in the professional field is knowledgeable about the electronic systems in the industry and which ones are a database and not just a documentation system. This can be important in understanding the process of how to obtain the requested information. Second, an expert can determine the existence of additional documentation components such as adverse incident tracking and an audit trail of data entry. Finally, an expert can then assist in reviewing the patient record and additional documents to provide feedback, to the attorney, as to whether or not care of the patient has met a reasonable standard.

The documentation of patient care and the record keeping of a patient’s treatment is one of the most important tasks and challenges that today’s healthcare provider must face. Quality documentation is critical to the delivery of quality medical care in a safe and competent manner. Accurate medical records are important in determining the effectiveness of treatment(s) and in determining the quality of care provided. Specifically, accurate, complete and timely documentation can assist a healthcare practitioner, as well as the healthcare facility, in determining ‘best practice’ standards of care. Documentation must be correct, legible, comprehensive and timely in order to be useful. The use of a database application to document patient care can address all the components of care and provide timely and accurate reporting to assist in benchmarking and determination of standards of care.
Electronic based or computerized charting can be confusing to someone who is not familiar with this type of record keeping, leading to incomplete assessment regarding the presence or absence of critical documents. An expert familiar with electronic based or computerized charting can identify key elements within the medical record, recognize the existence of an audit trail and provide an opinion regarding the likelihood that the record has been changed.
Biography

Ms. Nelson-Conley has practiced as a Registered Nurse for twenty years in the operating room. She has an Associate Degree in Nursing, Bachelor's Degree in Nursing and Master's Degree in Perioperative Nursing. She has published in peer review journals, taught nursing at the undergraduate and graduate level and is licensed as an advanced practice nurse. In addition, she has a national certification in operating room nursing.

Ms. Nelson-Conley is an implementation consultant for a software company.