Thursday, May 3, 2012

Continuation of Common Alleged Deviations in the Standard of Care

As we continue to review the most common allegations in deviations to the standard of care, we come across §483.25 which address nursing home quality of care.  Under this regulation, the expert witness is asked to review adherence or deviation to the following sections:
§ 483.25(a)- This section would be commonly alleged in cases where a plaintiff attorney perceived that residents were not adequately kept clean, brought to the toilet, ambulated or provided assistance with activities of daily living.  These deviations would naturally compromise a resident's ability to attain or maintain their “highest practicable well being".
§ 483.25(c) - This regulation is used with any allegations regarding pressure ulcers. Central to correctly ascertaining if a facility deviated from the standard of care in the prevention and treatment of pressure ulcers, one must determine whether a resident's pressure sore was clinically unavoidable. To deem an ulcer unavoidable, a facility must demonstrate preventative interventions were applied.  Licensed Administrators are governed by the understanding that pressure ulcers cannot be deemed clinically unavoidable without routine preventative care, such as,
  • Frequent turning and repositioning;
  • Promptly providing incontinent care;
  • The provision of adequate nutrition and hydration;
  • Providing adequate pressure reduction or pressure relief supplies;
  • Assuring staff are trained in techniques to avoid friction and shear; 
  • Assuring staff follow the resident’s care plan and timely revise it as the resident’s needs dictate;
  • Assuring staff notify the resident’s physician immediately after significant changes in a resident’s skin condition.
§ 483.25(c) - This section would typically be used if efforts were not made to restore or maintain continence control through a bowel and bladder maintenance program.
§ 483.25(h) - A nursing facility " must ensure that the resident environment remains as free of accident hazards as possible, and each receives adequate supervision and assistive devices to prevent accidents." This section commonly applies with a resident care practice that results in allegations of:
  • Falls with injuries;
  • Patient care equipment not adequately maintained or functioning;
  • Inadequate supervision of a resident whose actions represent a danger to themselves or to others;
  • Residents who aspirate based on a failure to provide food consistent with their swallowing ability. 
  • Resident elopements;
  • Physical restraints that were applied inconsistent with physician orders or inconsistent with prevailing nursing home practices.
§ 483.25(i) - This section would be cited for deviations to the standard of care regarding weight loss that is clinically avoidable.  The federal interpretive guidelines identify associated risk factors and the amount of weight with respective time periods that constitutes  "significant" weight loss.    Meal consumption sheets and their consistency with nursing staff entries into the medical chart are critical factors in the support of adherence or deviation to avoidable weight loss claims.  
§ 483.25(l) - This section is used for medications that are deemed to be unnecessary or be of an excessive dose.     Working under the resident’s physicians, the facility is required to show systematic efforts to minimize chemical restraints and have practices that demonstrate appropriate dose reduction efforts with the goal that a chemical restraint are minimized or possibly eliminated.