For Those Who Care:For Those Who Care:Heads-up on Providing Safer CareHeads-up on Providing Safer Care

Janna Bennett, CPHRMRisk Control Consultant, CNA

2015 Spring SCARCH ConferenceApril 15-16, 2015

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Disclaimer

The purpose of this presentation is to provide information, rather than advice or opinion. It is accurate to the best of the speaker’s knowledge as of the date of the presentation. Accordingly, this presentation should not be viewed as a substitute for the guidance and recommendations of a retained professional. In addition, CNA does not endorse any coverages, systems, processes or protocols addressed herein unless they are produced or created by CNA.

Any references to non-CNA Web sites are provided solely for convenience, and CNA disclaims any responsibility with respect to such Web sites. To the extent this presentation contains any examples, please note that they are for illustrative purposes only and any similarity to actual individuals, entities, places or situations is unintentional and purely coincidental. In addition, any examples are not intended to establish any standards of care, to serve as legal advice appropriate for any particular factual situations, or to provide an acknowledgement that any given factual situation is covered under any CNA insurance policy. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All CNA products and services may not be available in all states and may be subject to change without notice.

CNA is a registered trademark of CNA Financial Corporation. Copyright © 2015 CNA. All rights reserved.

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Learning Objectives

1. Identify the most frequent and severe resident care-related risks encountered in senior living communities.

2. Develop strategies and drive change in clinical practices based on the data.

3. Discuss risk exposures of the future for providers in senior living communities.

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Frequent and High Cost Frequent and High Cost Professional Liability ClaimsProfessional Liability Claims

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““Aging Services Claims Report 2014:Aging Services Claims Report 2014:Learning From the Past, Changing for the Future”Learning From the Past, Changing for the Future”

• Comparison of datasets for professional liability claims that closed between 2007 and 2011 (“2012 dataset”) with corresponding claims that closed between 2012 and 2013 (“2014 dataset”)

• Methodology

– Closed professional liability claims paid by CNA

– Indemnity payment between $5,000 and $1 million

– 2012 dataset: 1,558 closed claims

– 2014 dataset: 843 closed claims

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2014: Most Frequent Closed Claims: 2014: Most Frequent Closed Claims: Allegations at Assisted Living Facilities*Allegations at Assisted Living Facilities*

*Aging Services Claims Report 2014: Learning From the Past, Changing for the Future; 2014 dataset

Resident falls 46.3%

Improper care 13.7%

Pressure ulcers 10.5%

Elopement 9.5%

Abuse 9.5%

All other 10.5%

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2014: Highest Average Total Paid Closed Claims: 2014: Highest Average Total Paid Closed Claims: Allegations at Assisted Living Facilities*Allegations at Assisted Living Facilities*

$246,695

$271,931

$356,261

$360,221

$611,143

$0 $200,000 $400,000 $600,000 $800,000

Gross improper care

Failure to monitor

Elopement

Medication error

Delay in seekingmedical treatment

*Aging Services Claims Report 2014: Learning From the Past, Changing for the Future; 2014 dataset

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2014: Most Frequent Closed Claims:2014: Most Frequent Closed Claims:Allegations at Continuing Care Retirement Communities*Allegations at Continuing Care Retirement Communities*

Pressure ulcers14.3%

Abuse7.9%

Improper care6.3%

Failure to monitor

6.3%

All other14.3%

Resident falls

50.8%

*Aging Services Claims Report 2014: Learning From the Past, Changing for the Future; 2014 dataset

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2014: Highest Average Total Paid Closed Claims: 2014: Highest Average Total Paid Closed Claims: Allegations at Continuing Care Retirement Communities*Allegations at Continuing Care Retirement Communities*

$363,856

$446,170

$419,619

$0 $250,000 $500,000 $750,000 $1,000,000

Pressure ulcers

Elopement

Failure to monitor

Failure to followphysician’s order

Gross improper care

$984,749

$1,081,851

*Aging Services Claims Report 2014: Learning From the Past, Changing for the Future; 2014 dataset

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2014 Dataset: Short-term-stay Closed Claims2014 Dataset: Short-term-stay Closed Claims

• Admissions intended for short-term physical rehabilitation services and planned discharge

• Growing service niche for senior living communities

• Comprised 19.0 percent of the 2014 dataset

• On average, total cost is 10.4 percent more than long-term-stay closed claims

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Short-term-stay Closed Claims Summary DataShort-term-stay Closed Claims Summary Data

Data reflect trends seen in the aggregated data regarding

• Business segment

• Type of facility

• Allegations

• Resident falls: 40.5 percent were related to failure to monitor and 50.0 percent involved improper care; 68.9 percent of the falls occurred in the resident’s room.

• Injuries

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Short-term-stay Resident Unique Risk FactorsShort-term-stay Resident Unique Risk Factors

• Higher expectations for achieving or surpassing the prior level of functioning

• Significant change in functional level following an acute event or surgical procedure

• May be more likely to initiate a claim against the community

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Summary of Findings (2014 Data All Levels of Care)*Summary of Findings (2014 Data All Levels of Care)*

Most Frequent Allegations

• Resident fall

• Pressure ulcer

• Improper care

Highest Average Total Paid Allegations

• Gross improper care

• Elopement

• Failure to follow physician’s order

*Aging Services Claims Report 2014: Learning From the Past, Changing for the Future; 2014 dataset

Summary of Closed Claims > $1 million

• Failure to Monitor: Resident died as a result of burns sustained while smoking without appropriate supervision. (Assisted Living)

• Gross Improper care: Citations by state regulatory agency for several areas of non-compliance including administrator’s lack of proper licensing. Resident eloped and died due to exposure. (Assisted Living)

• Gross Improper Care: Resident suffered fracture of unknown origin. Jury accepted assertions that facility staff had dropped resident and concealed the fact. (CCRC – Skilled area)

• Gross Improper Care: Delayed diagnosis and treatment of hip fracture resulted in an infected and ultimately fatal hematoma. Hematoma not reported to facility leadership for 8 days, despite family complaints of resident pain. Missing documentation rendered claim indefensible. (CCRC – Skilled area)

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Summary of Closed Claims > $1 million

• Elopement: Resident not seen during 4 am rounds on Alzheimer’s unit, but not reported as missing. Resident later found on grounds severely injured, and subsequently died. Investigation also revealed administrator not properly licensed. (CCRC – Assisted Living area)

• Elopement: Resident with known confusion left unit unescorted. She subsequently fell down an easily accessible stairwell in her wheelchair and died from her injuries. Resident had been administered a sedative that family had previously requested not be given. Expert testimony said sedative contributed to fall. (CCRC – Skilled area)

• Elopement: Resident with no prior history of wandering was transferred from assisted living area of CCRC to skilled area for rehab after hip surgery. She eloped from skilled unit for an undetermined period of time and died of hypothermia. (CCRC – Skilled area)

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Risk Minimization and AvoidanceRisk Minimization and Avoidance

Risk Management Recommendations

• Obtain pre-admission assessments and information; include in record

• Complete and document nursing and multi-disciplinary team assessments immediately upon admission, repeat per facility policy

• Ensure initial and revised care or service plans clearly reflect multi-disciplinary team assessments

• Perform follow-up assessments at regular intervals and following any adverse event or change in condition

• Update care and service plans based upon follow-up assessments

• Include family and primary care providers in the resident assessment process, and instruct staff to regularly communicate any change in the care or service plan, or following adverse event or change in condition

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Employee Retention and Accountability

• Reinforce importance of earning employee loyalty among supervisory staff

• Provide a regularly scheduled, objective system for communicating with employees regarding their performance

• Demonstrate appreciation for staff who provide quality resident care on a daily basis and for those who “go the extra mile.”

• Continuously emphasize the need to follow resident care/service plans and organizational policies and procedures

• Identify successful quality improvement efforts

• Implement innovative ideas suitable to the organization, and demonstrating support for employees who take initiative in improving resident care

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Details Related to Resident Falls*Details Related to Resident Falls*

Allegation Related to FallAll other

5.0%

Failure to monitor 45.6%

Improper care 38.3%

Unsafe EOC 11.0%

Location of Fall

Bathroom18.0%

Bedroom15.6%

Hallway/stairs9.9%

Other indoors9.9%

All other14.2%

Bed32.4%

*Aging Services Claims Report 2014: Learning From the Past, Changing for the Future

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Resident Falls: Suggested ActionsResident Falls: Suggested Actions

• Identify barriers to decreasing resident falls.

• Monitor resident service/care plans on each unit that require one-on-one attention.

• Plan ahead regarding how the team will provide one-to-one assistance to residents.

• Consider communication options staff can use to request immediate assistance.

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Resident Falls: Suggested Actions (continued)Resident Falls: Suggested Actions (continued)

• Review fall data for short-term residents.

• Expand the role of certified nursing assistants.

• Actively manage key aspects of the physical environment including:

– Layout of resident rooms.

– Floor surfaces and cleaning solutions.

• Provide focused training and follow-up based on your findings.

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Pressure Ulcers: Suggested Actions Pressure Ulcers: Suggested Actions

• Identify barriers to decreasing pressure ulcers.

• Perform root cause analysis if pressure ulcers worsen and become Stage IV.

• Increase the role of certified nursing assistants.*

*http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/ontimeqimanual/ontimeqimanual.pdf; last accessed 9/7/2014.

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• Provide learning opportunities on specifics relevant to your experience.

• Continually monitor and document interventions and outcomes.

• Update data, information and actions until the target for improvement is sustained.

Pressure Ulcers: Suggested Actions (continuedPressure Ulcers: Suggested Actions (continued)

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Improper Care/Gross Improper Care: Improper Care/Gross Improper Care: Systems Failures in Quality of CareSystems Failures in Quality of Care

• Leadership style and stability

• Culture

• Employee Retention

• Accountability

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Improper Care/Gross Improper Care: Improper Care/Gross Improper Care: Suggested ActionsSuggested Actions

• Provide focused educational and growth opportunities for staff.

*See the National Nursing Home Quality Care Collaborative Change Package, March 2013 v 1.2, page 9, “1.c Change Concept: Plant Now – Harvest Later: Nurture Professional Growth and Foster Innovation in Others” and page 11, “2. Strategy: Recruit and Retain Quality Staff.” Available at the date of publication at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/NNHQCC-Package.pdf.

• Identify areas that need improvement or refining.

• Examine staff’s perception of the organization’s culture.

• Convey and require transparency, fairness and accountability.

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Details Related to Elopements – Mental Status*Details Related to Elopements – Mental Status*

Anger2.0%

Cognitive impairment

87.8%

Psychiatric condition

10.2%

*Aging Services Claims Report 2014: Learning From the Past, Changing for the Future

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Details Related to Elopements – Timing of Elopement*Details Related to Elopements – Timing of Elopement*

0

5

10

15

20

25

Less than1 month

1-2 Months 3-5 Months 6-11Months

12 Or moremonths

Nu

mb

er o

f cl

ose

d c

laim

s

*Aging Services Claims Report 2014: Learning From the Past, Changing for the Future

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Elopement: Suggested Actions Elopement: Suggested Actions • Monitor residents closely during the

first month.

• Establish a process to account for every resident by name.

• Consider investing in new technology designed for more effective and less intrusive surveillance of residents who tend to wander.*

• Provide education for staff.

*See Rajecki, R. “Newer Tech for Elopement Prevention, Wander Management Keeps Residents Safe, Provides Sense of Freedom.” Long-Term Living, posted June 2, 2014. Available at http://www.ltlmagazine.com/article/safe-and-sound.

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Stories from Organizations with Successful OutcomesStories from Organizations with Successful Outcomes

• Leaders maintain high visibility and active participation.

• Leaders and managers show appreciation.

• Leaders model, demand and reward accountability.

• Leaders sustain focus on mission and vision.

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Stories from Organizations with Successful Outcomes Stories from Organizations with Successful Outcomes (continued)(continued)

• Leaders are consistent and fair in policies and procedures.

• Everyone is passionate about resident care

• They have created a family for staff and residents and a home for residents.

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At The End of the Day . . . It is All About People At The End of the Day . . . It is All About People

If you take good care of employeesIf you take good care of employees, they will take , they will take better care of residents and better care of residents and everyone will flourish.everyone will flourish.

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Additional ResourcesAdditional Resources

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PublicationsResident Falls

CNA Publications

• Aging Services Claims Report 2014: Learning from the Past, Changing for the Future; Published 10/14

• Aging Services 2012 Data Analysis Supporting the Need for Change; Published 10/12; see page 22. https://www.cna.com/web/wcm/myconnect/9ae9b9a3-9f3e-49e5-afe3-8e96676d6e97/RC_Med_Claim_AgingServices2012DataAnalysis102012_CNA.pdf?MOD=AJPERES&CONVERT_TO=url&CACHEID=9ae9b9a3-9f3e-49e5-afe3-8e96676d6e97

• Protecting Residents, Reducing Liability Exposure; Published 4/10. Available upon request.

Agency for Healthcare Research and Quality

• The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities

http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/index.html

• Appendix B2: Tracking Record for Improving Patient Safety (TRIPS); The Falls Management Program Manual http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/fallspxmanapb2.html

Pressure Ulcers

CNA Publications

• "Wound Care: Common Deficiencies and Effective Countermeasures;“ published 10/13. Available upon request.

• Aging Services 2012 Data Analysis Supporting the Need for Change; Published 10/12; see page 22. https://www.cna.com/web/wcm/myconnect/9ae9b9a3-9f3e-49e5-afe3-8e96676d6e97/RC_Med_Claim_AgingServices2012DataAnalysis102012_CNA.pdf?MOD=AJPERES&CONVERT_TO=url&CACHEID=9ae9b9a3-9f3e-49e5-afe3-8e96676d6e97

• Protecting Residents, Reducing Liability Exposure; Published 4/10. Available upon request.

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Publications (continued)Pressure Ulcers continued

Agency for Healthcare Research and Quality

• Guideline for prevention and management of pressure ulcers. http://www.guideline.gov/content.aspx?id=23868

• The National Pressure Ulcer Advisory Panel - NPUAP » Resources » Educational and Clinical Resources » http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-prevention-points/

• “Are We ready for This Change? Preventing Pressure Ulcers in Hospitals: A Toolkit For Improving Quality of Care;” Agency for Healthcare Research and Quality, Rockville, MD.

• http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/index.html;

• http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/putoolkit.pdf

Wound, Ostomy and Continence Nurses Society™ (WOCN®) www.wocn.org/

Association For The Advancement of Wound Care www.aawconline.org