Long Term Care Primer – Specialty Documents

Long term care is a highly litigated area of health care. As a legal nurse consultant (LNC) without a clinical background in long term care, I had to educate myself on this specialty. The nursing tasks were familiar but the chart was not.

As I worked on more of these cases, I came to rely upon a uniform set of documents that provided a good starting point for LTC case analysis: Minimum Data Set (MDS), Resident Assessment Protocols (RAPs) and the Care Plan.

Starting my analysis with these documents gave me information on baseline function, skin condition, cognition and more. From there, I could wade through the piles of nurses’ notes, nursing assistant checklists and medication administration records looking for the details I needed to provide my clients with the meaningful tool they required to litigate the case.

Long term Care History

In 1987, Congress passed the Omnibus Budget Reconciliation Act (OBRA). This legislation set specific standards for all Medicare certified skilled nursing facilities including a detailed assessment of the patient that was linked to their plan of care. What came out of this legislation was the Resident Assessment Instrument (RAI).

Don’t let all the acronyms confuse you. The RAI standardizes communication regarding the person’s medical problems and conditions both within the LTC facility and to outside healthcare providers.

The RAI enables the nursing home to track changes in a patient’s status and evaluate their individualized plan of care. So, you can see how the RAI is a great place to start a medicolegal analysis

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Specific Documents of the RAI

• Minimum Data Set (MDS) provides a detailed assessment of the patient that is linked to that person’s individualized plan of care. The MDS includes information on people’s cognitive and functional abilities along with their physical condition. The MDS is a goldmine for a LNC.

One of the best things about the MDS is consistency throughout all facilities in the United States. Of course, there is a twist to this. A revision of MDS – MDS 3.0 – was rolled out in late 2010 with an expanded section on skin conditions. It is critical to analyze cases according to the standard of care in place at the time of the alleged negligence.

If the events took place in 2010, the new MDS 3.0 would not be applicable. Please refer to Angie Duke Haynes’ article devoted specifically to this new version of MDS.

• Resident Assessment Protocols (RAP) are the next steps in the RAI. Based on the MDS, certain protocols are triggered. Think of these as “problems”. Included in these protocols are risk factors that prompt care planning. A RAP summary is part of the MDS. It is a checklist and includes which RAPs are triggered, date of assessment documentation and where that document is located in the record, i.e. speech therapy note. Again, this form is consistent among all facilities in the U.S.

• Care Plan – There is nothing new or different about a long term care care plan. Nurses in all specialty areas assess, diagnose, plan, implement and evaluate based on the individual patient’s needs. The key in long-term care is to review the care plan to ensure it is consistent with the MDS and RAP. As with all case analysis, the care plan is reviewed to ensure the nursing staff identified issues and appropriately provided interventions and evaluated those interventions.

Practice Pearls

• Educate yourself if this is a new area of nursing for you. Utilize resources such as National Pressure Ulcer Advisory Panel (NPUAP), Agency for Healthcare Research and Quality (AHRQ) Clinical Practice Guidelines, RAI User’s Manual and The Long Term Care Survey. Be careful to use resources during the time for which the alleged negligence took place.
• Compare the MDS to the RAPs and the care plan. Is the information consistent? Then compare the clinician progress notes including therapy notes. Note relevant inconsistencies in your analysis.
• Were changes in function or cognitive status identified appropriately? Was the plan of care adjusted based on the change in status? Where is the evidence to support or refute the standard of care being met?

Dana Jolly, BSN, RN, LNCC, is Principal of Jolly Consulting, LLC.

To learn more about these specialty documents and to create your own long term care case analysis, please sign up for a digital download of a multimedia course presented by Angie Duke Haynes, Pat Iyer and me on writing skills and long term care case analysis.