ALN has participated in large scale analysis of cases of worthless care brought forth by the Department of Justice / Office of the Inspector General. Review of these case are approached differently from those of typical litigation. In reviewing cases of allegations of worthless care, ALN must take a broader approach, looking at the overall care provided, rather than looking at specific events, breaches from standard of care, or level of harm.
In this investigation, the ALN Reviewers scoured the medical records to ascertain the actual care provided, producing reports and demonstrative evidence to prove the provision of care. The reports proved, although care may not have been perfect, it was not worthless. One such case included a resident of a long-term care facility. We will call the resident Ms. Jones. DOJ/OIG lodged allegations of worthless care in regards to Ms. Jones related to poor hygiene, medication errors, and poor nutrition.
The allegation related to poor hygiene indicated Ms. Jones did not receive showers during her extended residency. In review, records revealed Ms. Jones’ need for assistance with ADLs was assessed and an appropriate care plan was developed to address the issue. ADL Sheets were presented as demonstrative evidence of daily provision of personal care and bathing. The records showed bathing was always in the form of bed baths, and the resident did not receive showers as she should have; however, the fact remained that bathing was received and personal hygiene maintained. Although this evidence was sufficient to prove the staff provided appropriate care and hygiene, the reviewer went a step further to prove proper hygiene. OT records were produced that showed assistance with provision of ADLs and provision of therapy to improve self-performance of ADLs. Psychiatric Consultation Notes and MD Progress Notes were also produced to show documentation of the resident being well-groomed. With the myriad of documentation from different sources, the reviewer was able to prove the care provided was not worthless, although no actual showers were received.
The allegation related to nutrition was completely proven false by the ALN Nurse Reviewer. The allegation cited failure to properly maintain a feeding tube resulting in altered nutrition. The OIG asserted the care plan indicated tube feeding was to be provided, but the TARs indicated it was not supplied. Upon review of the records, the ALN Reviewer presented evidence supporting staff routinely assessed Ms. Jones’ nutritional status and her feeding tube. A care plan was developed to address Ms. Jones’ nutritional status and feeding tube. Tube feedings were administered appropriately and speech therapy implemented to promote p.o. intake. Ms. Jones’ progressed to eating a p.o. diet and tube feeding was discontinued. Ms. Jones’ was subsequently able to have her feeding tube removed. Upon discontinuation of tube feeding, staff failed to update the care plan, therefore, the care plan continued to indicate provision of tube feeding, and the TARs revealed none was delivered. The reviewer admitted the nutritional care plan was not updated appropriately. Tube feeding was not being administered, as it was no longer ordered or warranted. Although failures in documentation existed, the resident’s nutritional and overall status improved showing the care provided was not worthless.
The DOJ/OIG also presented allegations related to medication errors, stating that medications were not always readily available, and thus omitted. The DOJ/OIG cited various medications over the course of the extended residency. The ALN Nurse Reviewer presented pages of MARs showing appropriate administration of 2700+ medication doses over the course of the extended residency. The ALN Nurse Reviewer could not refute the fact that 4 medications were omitted due to unavailability, but the big picture revealed a different story. Unfortunately, there was another issue to the medication errors, that of erroneous withholding of Coumadin. Review of the records indicated the MD stopped Coumadin pending a repeat PT/INR. Upon receipt of the subsequent PT/INR, the MD failed to write an order to resume the Coumadin, thus the medication was held for the subsequent 22 days. This error was to some degree the responsibility of the MD, who failed to write the order for resumption of the medication; however, nursing was responsible to follow-up on lab results and necessary medication adjustments, and thus the facility would also be responsible to some degree. Despite this erroneous withholding of medications, the overall medication error rate still did not exceed the 5% threshold for medication errors. All other medications were administered appropriately and her physical status improved, indicating the care provided was not worthless.
In the case of Ms. Jones, the ALN Nurse Reviewer investigated every allegation presented by the DOJ/OIG. Demonstrative evidence including power point presentations and reproduction of the actual resident’s chart were presented to prove the care provided by the facility. The ALN Nurse Reviewer took a holistic approach in presentation of evidence, not just presenting nursing documentation, but presenting documentation by therapists, psychiatric nurse consultants, and the physicians to prove the overall approach of care provided and the improved status of the resident. The records did show evidence of failures to appropriately update care plans, omissions of medication administration, and evidence of provision of bed baths instead of showers, but the overall records proved good and consistent care was provided. Although the care may not have been the most optimal on every occasion, the ALN Nurse Reviewer was able to prove the care provided resulted in improvement in the resident’s overall health status and quality of life, and clearly showed the care provided was not worthless.