“If it is not documented, it is not done” is a fundamental rule of healthcare. For those who work in long-term care (LTC) and skilled nursing, a relevant version of this rule is, “If a staff member communicates something to a resident’s family, but there is no documentation of it, did the communication really happen?”
As far as regulators and lawyers are concerned, the answer is “no.”
Clinical documentation, a record of residents’ treatments, medications, labs, safety requirements, physician notes, etc., is of primary importance for residents’ care, but there are other actions that also must be documented, including communication with residents’ families.
In many cases, there is regular communication between facilities and families, but it’s not always documented as well as required or as necessary for the benefit of both parties. LTC probably requires the most amount of documentation of any type of care, largely due to the rules of Medicare and Medicaid which provide most of the payment for residents.
A failure to properly document communications is one of the most common reasons why LTC facilities are written up in surveys. Poor communication is also a common subject of family complaints about resident care and can be damaging in lawsuits when facilities cannot prove they followed requirements and best practices.
Apart from those regulatory and clinical concerns, communicating regularly and clearly with residents’ families is a good way to keep them involved in their loved ones’ care.
According to the Centers for Medicare & Medicaid Services, a facility must immediately inform the resident and consult with the resident’s physician and representative in the following circumstances:
- An accident involving the resident which results in injury and has the potential to require physician intervention
- A significant change in the resident’s physical, mental or psychosocial status resulting in either life-threatening conditions or clinical complications
- A need to alter treatment significantly
- A decision to transfer or discharge the resident from the facility
- A change in room or roommate assignment
- A change in a resident’s rights under federal or state law or regulations
In addition to these requirements, there are other areas where it’s critical to document communications to residents and their families:
- Admission, discharge and transfer notifications
- Visitation rights, including any clinical or safety restrictions
- Ongoing communication of resident rights, as well as facility rules and regulations
- Advance care directives, including the facility’s policies to implement them. These must be regularly updated.
- Required regular assessments of a resident’s needs, strengths, goals, life history and preferences
- Discharge planning
- Hospice planning
Failure to properly communicate and document those communications in any of these instances can result in a facility being cited during an audit.
Of course, there are many reasons why communications can go undocumented.
LTC staff are busy; performing the actual tasks is a greater priority than documenting them. Sometimes, staff do not have time to record actions until the end of their shifts and items can be overlooked. Staffing shortages can also affect documentation. When employees are stretched to the limit, documentation can be neglected.
The processes for documenting communications are varied, manual and time-consuming, which contributes to lapses. The lack of a centralized system also makes it difficult during an audit to collect and sort all communications from emails, texts and phone messages kept by various staff members. Additionally, in some cases, staff have not been trained in documentation requirements and the procedures to do it correctly.
Another cause is that many of these communications are unscheduled and informal. A visiting family member stops a nurse in the hall to ask questions, or the front desk forwards a phone call to a busy nurse who answers a relative’s questions, but staff then returns to the tasks at hand and never documents the interaction. Many of these calls are made on staff’s personal cell phones which can make them difficult to record and document correctly.
The safest and easiest route is to centralize and automate communications and documentation rather than rely on an overworked staff to do it. New technology allows LTC facilities to route incoming and outgoing messaging with families through a single portal. The portal not only facilitates phone calls and messages but it also automatically records and documents them. The facility then has a record of what the family has been told, which prevents repetition and confusion. It also facilitates future communications with families and can easily be retrieved for surveys, audits, and other purposes.
Fortunately, LTC facilities can improve communications with families, ease the workload on their staff and remain in compliance with regulations if they take advantage of today’s accessible, easy-to-use technology.
Gary Hamilton is CEO and founder of InteliChart, an industry leader in patient engagement solutions.
Frances Carroll is principal and founder of Senior Care Support Services, a provider of nursing support and customer success programs for senior care operators.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
This article was originally published on McKnights Long-Term Care News on April 2, 2024. You can view the article here.
