Risk management feature — Taking a gamble

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The task of risk management is becoming more complicated as the number of Alzheimer's and dementia residents rises.

Cell phones and nursing home residents with Alzheimer's disease once had something in common: Both were exceptions.
It was noteworthy when you knew somebody with either. But that was then and this is now. Cell phones have taken an overwhelming clutch on the public. The rise of Alzheimer's and dementia residents, while much more subtle, has been nearly just as remarkable.
According to experts, more than 40% of assisted living residents have some form of Alzheimer's or other dementia. The percentage for nursing homes is clearly much higher.
It's a trend providers are going to have to deal with more often. The tidal wave of baby boomers is crashing toward old age, and facility care.
Now that's risky business.
And it's a big reason risk managers need to get a better grip on operations, experts say.
"It's not just a suggestion any more," says Kymberlee Keefe, the leader of Aon Healthcare's long-term care arm.
With more dementia and memory-impaired residents to take care of, providers have to do more to safeguard their employees and residents from legal exposure.
"We need to make sure the employees taking care of the people on a day-to-day basis are aware and can understand them and have appropriate responses," Keefe said.
"It's day-to-day things that make it difficult for these residents to live. They get them more frustrated and that often makes them more angry and temperamental. That can cause other issues. That's what we're advising our clients to keep an eye on."
Besides falls and elopement, top risk management concerns are issues related to nutrition, weight loss, skin tears, bruises, burns, medication mismanagement, resident-to-resident altercations, and screenings for pain or depression.
Keefe says providers who don't hone their awareness of potential legal problems do so at their own peril. Lawsuits that gain any sort of traction are overwhelmingly settled at a big loss to providers.
"The juries are getting tremendously educated about what's going on, whether it's from their own personal experience or they're learning more through the media," Keefe warned.
The key becomes avoiding litigation altogether. And the key to that? "Good customer service," Keefe says without hesitation.
"It's often times not the one fall or one pressure sore, or the one bad outcome or unexpected outcome. It's a combination of things and lack of communication with family members," she says. "Many times, these facilities just don't communicate as well as they need to. The lack of communication is often what gets family members frustrated, so even though all these things might seem minor when they occur, they mount into litigation."
Undoubtedly, staff members are central to good risk management practices, especially with labor intensive Alzheimer's/dementia residents. Caregivers must be well-trained and taught procedures for a long list of possible behaviors.
In fact, experts recommend that all staff members receive special training with regard to Alzheimer's/dementia, and all employees should be aware of policies and procedures.
"The reality is you can't just have Alzheimer's wings any longer, because while that might be necessary for higher levels of the disease, we need to make sure it's being addressed at every level in our organization," Keefe said. "Even if somebody's coming in for rehab, they could have some form of dementia or memory impairment. You can't over train workers when it comes to that particular area."

Playing catch-up
Long-term care generally lags behind the acute-care sector when it comes to risk management proficiency, says Jay Schaffer, a Houston-based senior vice president with Marsh Risk Consulting. Larger providers are more likely to be up to speed, but smaller operations need more structure, he said.
"I don't believe the typical family member understands or has realistic expectations of dementia," Schaffer said. "I think the facility can do a great deal with sitting down with the family at the time of the first or second care planning meeting and explain the realities: It's a chronic condition, and it causes a range of cognitive and behavioral functional impairment that will cause some deficits.
"They need to understand that Mom is not necessarily going to be skipping out of the facility home some day," he added. "She's going to remain confused. It won't be a particularly pretty picture. But then you won't have, 'I didn't know. Nobody ever told me,' which has happened many times."
Providers should document that such discussions took place and indicate in a resident's medical record that the family has acknowledged understanding what they were told. Note anything salient that verifies their level of understanding. Also, provide family members with authoritative literature about Alzheimer's or other appropriate conditions. Note this in the record, too.
A facility's risk management process actually is a continuum that begins with pre-admission screening. Skilled professionals must check prospective residents thoroughly, in part to make sure a facility can handle any new admission, and to make sure family members are prepared.
"We've seen situations where the family felt putting Mom in a closed or secured unit is not dignified," Schaffer said. "That should probably result in an operator saying, 'This is probably not the facility for you.' The facility has to make that judgment: What's the revenue risk reward here?"
A very susceptible time for elopement occurs immediately after admission so providers must be especially watchful then. It's also a good time to test and re-check all wander- and fall-prevention systems.

Deeper knowledge
Dementia affects up to 7% of adults above age 65, but the number soars to at least 40% of those over 85, according to research by the American Psychological Association.
Researchers say the number of people with Alzheimer's is expected to triple, to more than 13 million, over the next two generations if a preventive treatment isn't found.
"It's only been in the last several years that researchers have begun to understand how many seniors are impacted by dementia and Alzheimer's," explains Allen A. Lynch II, partner, Nixon Peabody LLP, and an executive education fellow at the Erickson School of Aging Studies at the University of Baltimore.
"We in the industry need to recognize that almost one of every two assisted living residents either presently has some form of dementia or early Alzheimer's, or will develop it. Care planning and programming need to be responsive to that reality."
Operators also must be responsive to staff and their needs, not just residents'.
When there isn't enough staff support, "quasi-resident abuse types of issues can erupt," Lynch said. In short, Alzheimer's and dementia residents can be some of the most labor intensive, and work schedules need to reflect that, Lynch said. Otherwise, without proper supervision and a supportive culture in place, caregivers won't be prepared to deal appropriately with problems.
And that could lead to lawsuits not only from residents, but also from disgruntled employees or ex-employees, Lynch pointed out.
"The dementia and Alzheimer's resident caregiver is the most vulnerable so providers need to acknowledge that," Lynch said. "The implication is they need the most, and most frequent, training. And it needs to be 'best practice' training, not just internal, as in 'Here's what works for us.'"
Lynch said paying more attention to workloads and breaks is vital.
"It doesn't necessarily mean more staff," he said. "It just means making sure these folks in particular are well cared for, have respite breaks, and have strategies for best practices."
Alzheimer's and dementia care demand high standards.
"If you're a provider and want to go into the Alzheimer's-dementia care business, you better be sure you understand what 'state of the art' is because that's the standard you'll be held to," Lynch explained. That goes for the facility and infrastructure, and care processes.
"You need to 'keep up with the Joneses' in this area."
An attorney, Lynch also returned to the "managing expectations" theme.
"There's a lot of ignorance about the trajectory of Alzheimer's disease," he said. "Families need to be educated about the progression, and they need to be educated about proxies and advance directives. If providers do those things, in a sensitive way, they will significantly lessen the potential for a claim by a family member."

Doing your homework
Providers must continue to learn what their vulnerabilities are and put monitors in pace to make sure they're addressed. This means taking responsibility for reviewing the literature and understanding what happens in areas other than their own.
"Learn from other people's mistakes and the things they have encountered," advises Bet Ellis, a Charlotte, NC-based senior clinical consultant for LarsonAllen.
In the realm of design and remodeling, for example, she recommends using thermostatic mixing valves on sinks to prevent scalding, and color-coding faucet handles (blue for cold, red for hot) for consistency. Using motion sensors to turn on lights, especially for night wanderers, also can be helpful. Putting contrasting color plates on wall light switches is a way to help Alzheimer's residents locate a switch quicker.
Ellis also recommends handrails with splinter-proof, smooth edges and carpeting that does not have dark borders.
"I've actually seen a resident walk up to that, think about it and then jump over the perceived barrier. It's not something an elderly person needs to do," Ellis said.
When residents have a cognitive loss, they are also less likely to use call bells, she noted. They are more liable to get up and search for help, bringing up another need for motion sensors in rooms.
Because reading is one of the first skills to go for many dementia residents, signs and labeling should become more picture- and symbol-oriented, Ellis said. Instead of a sign saying "Joe's room," for example, a photo of Joe might be better. Photos should be updated frequently so staff members have an up-to-date reference to give authorities should an elopement search become necessary.
A better focus on managing risk for Alzheimer's and dementia residents now will reap benefits in the long run, Ellis believes.
"We'll have a more informed, better-educated workforce," she said. "I think some people will probably seek this out as a specialty. Some will thrive in cognitive loss and taking care of those people who have it."

Loss per occupied bed
The countrywide cost per occupied long-term care bed for general liability/professional liability losses
Year $ per occupied bed
1993 430
1994 700
1995 560
1996 820
1997 1,160
1998 1,660
1999 1,670
2000 2,070
2001 2,290
2002 2,230
2003 2,270
2004 2,310

Source: Aon Risk Consultants, 2005

Severity per liability claim
The countrywide average general liability/professional liability claim size has remained stable since 1997.
Year $ claim size
1993 72,000
1995 97,000
1997 171,000
1998 203,000
1999 165,000
2001 186,000
2003 180,000
2004 176,000

Source: Aon Risk Consultants, 2005