Common Problems Encountered in Subacute and Long-Term Care Facilities
Posted by: Sanford Goldberg M.D. and Philip Robbins M.D.
Co-Chief Medical Officers for EmPRO Insurance Company
Many malpractice cases result from allegations concerning the care of residents and long-term care patients in sub-acute and nursing home facilities. To better understand the risks identified in these cases, EmPRO conducted an in-depth review of 184 long-term care malpractice cases reported between 2008 and 20201. Our goal is to provide you with some awareness of the inherent risks identified in these cases.
It is important to recognize that there is shared liability for both the facility and the physician caring for the sub-acute and long-term care patient when an adverse outcome occurs. When caring for nursing home and rehabilitation patients it is important to be aware of the risks of litigation.
In 84% of the cases, staff providing nursing services at the facility were determined to be primarily responsible for deviations in the administration of care, which led to the injury that precipitated the lawsuit. In 13% of the cases, the physicians managing care for the patient were determined to be primarily responsible for errors that resulted in the injury to the patient.
Forty-four percent of the cases involved the prevention of chronic pressure ulcers. In 98% of those cases, it was determined that there was a lapse in the focused monitoring of the integument of the patient (e.g. failure to recognize and/or manage skin breakdown leading to a debilitating skin pressure ulceration). In 23% of the cases, there was insufficient or inadequate documentation of clinical findings. Although the average indemnity on these cases is relatively low the frequency with which these cases occur, and the costs involved in defending them, it warrants attention to reduce the risk of these suits.
An important risk reduction strategy when caring for potential pressure ulcer patients is to ensure that skin integrity is assessed, monitored and documented frequently. If a nascent pressure ulcer is identified, further monitoring and treatment should be managed by a wound care team. The defense of these cases is compromised when the physicians caring for the skin impaired patient do not evaluate the wound(s) during their visits with the nursing home or sub-acute inpatient. Notes from nursing and the wound care team should be referenced in the physician’s notes as well. This documentation will provide evidence that the physician was aware of the patient’s status and the treatment being provided.
Nineteen percent of the cases studied involved fractures typically associated with falls such as a hip fracture and/or other fracture of the lower limb. The average indemnity payment for these cases was under $100,000. In 86% of the fracture cases, there was a failure to adequately monitor and ensure the patient’s safety (e.g. toileting supervision, bed monitors/alarms). In 24% of the fractures, there was a failure to follow the fall reduction protocols of the facility. Physicians should routinely order the active use of fall precautions for all at-risk patients. An important emergency response to a fall is to obtain immediate x-rays to evaluate the regions where pain is felt by the sub-acute inpatient or nursing home resident. Transfer to the hospital should not be delayed and it is essential to ensure that a patient with a head injury obtains a timely CT scan.
1EmPRO is a member of the prestigious CRICO Strategies Comparative Benchmarking System (CBS). The CBS database contains over 450,000 medical malpractice cases and includes the in-depth coding and analysis of member companies’ claims. This allows member companies from across the country to better understand and analyze the causes and costs of medical malpractice cases and to compare their cases with similar companies that insure healthcare providers and facilities.
EmPRO believes it is important to share this valuable information with our Insureds to help you understand the common causes of malpractice claims and help you to mitigate your exposure to such events.
We welcome your comments and feedback.
Sanford Goldberg M.D. S.Goldberg@medmal.com
Philip Robbins M.D. P.Robbins@medmal.com