Risk Management Tips Archive

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Risk Management Tips - Minimizing Risk

2009 Legal Tips
Minimize The Risk!

We are pleased that Constance Watkins, RN, CLNC has agreed to another year of offering advice for our readers. Her topics have been so timely and relevant to the current state of health care delivery.  We welcome Rose Clifford, RN, LNCC who has graciously agreed to also lend guidance on issues pertinent to patient care.  Please email your suggestions for topics or questions to:
educate@hru.net

     Constance Watkins, RN, CLNC
     www.cmc-llc.net
     cgwatkins@sc.rr.com

     Rose Clifford, RN, LNCC
     www.MedAnalysisResources.com
     CliffordRZ@aol.com

 

January 2009
Recovery Audit Contractor (RAC) and What It Means To You
Constance Watkins, RN, CLNC

     RAC 's are reviewing old Medicare claims to disccover overpayments and demand their repayment from providers and hospitals. The RACs review claims and are paid on the basis of a percentage of the overpayments they recover. If they recover a fraction of what Medicare estimates it overpays each year, the impact upon providers will be huge.

 

     How huge? How does ~$700 Million over 3 years for just six states sound? How much did it cost to recover the money? About 20 cents per dollar, and $187.2 million was paid to the auditors.  This is a serious financial impact for health care organizations and nursing can be expect to see more emphasis on documentation and accountability.

 

     What can nurses do to cut down on RAC  recoupments?  Nurses have many opportunities to make sure the facilities in which they work are Medicare compliant. Here are a few of the areas in which nurses can improve:

 

  • Make sure there is a complete order on the chart. There must be an order that reads:  Admit to floor A for observation/inpatient/outpatient for diagnosis of chest pain (or other diagnosis). The order must include what kind of admission, where the patient is to be admitted, the diagnosis and the physician signature. Without an order, there is no legal admission and the nurse could be held liable for the fraudulent admission. The RAC can and will take back any money received by the hospital if there are incomplete orders.
  • Make sure there is a complication or reason that the patient is kept in the hospital, not just for convenience or other non-medical reason. What kept the patient observation or what complications made and kept the patient in inpatient status? InterQual criteria and Milliman Guidelines are two programs that are used to establish medical necessity.

 

     Medicare compliance is using basic nursing skills, critical thinking, good documentation, and a lot of common sense.  Nurses are responsible for many patient-related concerns with RAC now one more added responsibility.

 

      For additional reading:

      www.cms.hhs.gov

          www.medicalnewstoday.com

 

 

February 2009
PERSISTENT ISSUES CHALLENGING ED STAFF
Rose Clifford RN, LNCC

     The lack of and inconsistent medical record documentation continues to exist in the delivery of emergency department care. Whether the emergency department is busy or not, there seems to be a high number of emergency department records reviewed from a medical legal standpoint either for standard of care issues, personal injury descriptions, justification of payment or evidence of criminal injuries.

 

     In analyzing medical records for more than 20 years, it is often apparent that both emergency department doctors and nurses are challenged to document care delivered in more complete and concise detail. Realizing by the very nature of the specialty area where time is of the essence, it is not surprising to see the continued lack of legible handwritten notes or the sketchy legible clear electronic notes. Either forms of documentation hinder retrospective audits of the emergency department medical record that would help support the evidence that appropriate comprehensive care was in fact delivered or that injuries were related to out-of-facility events.

 

     This becomes a real issue in cases that are evaluated for medical and nursing malpractice or where a personal injury occurred such as in a motor vehicle accident or a work related injury resulting in the loss of a limb that will later need to be explained. Consistent points in issue that make it hard to defend or explain the extent of the injury are:

 

·         Lack of documentation 

·         Lack of consistent legible documentation

·         Failure to document the time care was delivered

·         Lack of legible signatures of healthcare providers

·         Failing to intervene

·         Lack of documenting when consultants are called in

·         Rewriting entire entries

·         Delays in evaluation, diagnosis, treatment

·         Failing to confirm the accurate placement of peripheral intravenous catheters in a vein instead of in an artery

·         Failure to confirm accurate placement of central venous catheters prior to use or administration of medications

·         Errors in IV administration of medications dosage, dilution, rate

·         Lack of communication

 

     Remember the medical record is a tool that all healthcare providers use to communicate any and all care provided to the patient. Its fundamental purpose is to facilitate the continuity of healthcare, but its use lives well beyond the immediate emergency department visit.

 

March 2009
The Admission Process: The choice between outpatient (OP), observation status (OBS) and inpatient (INPT admissions
Constance Watkins, RN, CLNC

     It is every nurse’s responsibility to make sure admission orders are complete and correct. 
If an admission is incorrect or needs to be changed, it is the nurse who must ensure that the
physician is aware and corrects the admission status. Hospital reimbursement funds depend
on accurate admission orders and inaccuracies may result in overpayment, underpayment, or perception of fraud.

      The admission process begins when the physician writes the admission order. This order must include:

§         Level of care (OP, OBS or INPT)

§         Physician’s signature and date signed

§         Admitting diagnosis

     Some examples of Outpatient Services are:

§         X-rays or scans

§         Laboratory tests

§         Other procedures performed

§         Patient is discharged to home the same day

 

     The Inpatient Admission is determined by:

Severity of signs/symptoms

Medical history

Need for inpatient diagnostic studies or tests

Medical predictability of an adverse event

 

     Observation Status can be an unplanned event or an evaluation period to determine if

an inpatient admission is necessary. Examples:

1.    An unplanned event occurs in the patient’s post-op recovery period that

requires the need for periodic monitoring and assessment by the clinical staff.         

2.    The order is written in the post-op period and signals the beginning of the

OBS period.

3.    An evaluation period occurs as the result of an outpatient condition needing

additional evaluation; most commonly 24 hours or less.   

 

     Observation status is appropriate if a serious condition can probably be ruled out in < 24

hours or if that identified medical condition is likely to abate within < 24 hours of therapy.

Nurses must keep the physician actively involved in the status of the initial order being met

or if the patient needs inpatient admission, then a new order must be written.

 

     Inpatient vs. Observation is ongoing but doesn’t have to be a problem if the nurse/physician

remembers the following:

 

R/O Rule Out = R/O Remember Observation

 

Additional information can be found in the Medicare Benefit Policy Manual,

Chapter 1:  Inpatient Hospital Services Covered Under Part A, pages 6-7. 

 www.cms.hhs.gov/Manuals/downloads/bp102c15.pdf

 

 

 

April 2009
Three goofs in one: Poor charting, failure to name all defendants, and slack citing to medical records
Rose Clifford RN, LNCC

 

 

In a recent Wisconsin medical malpractice case, a hospital staff nurse could not defend herself with her own charting to prove that she had timely paged a neurosurgeon concerning a patient.

 

A jury found her 60% at fault under a $1 million award and the trial court found her negligent as a matter of law. However, the plaintiffs’ attorney did not name her in the suit. The plaintiffs were then in the strange position, on an appeal alleging procedural blunders by the trial court, of trying to exonerate the negligent nurse so as to shift all blame to the named parties and thus fatten the award. On top of this, the plaintiffs’ attorney angered the appeals court by sloppy citations to medical records.

 

In Skrzypchak v. Jensen, 2009 WL 130130 (Wis.App.), plaintiff Dale Skrzypchak showed up at an ER with cauda equina syndrome. CES is a neurosurgical emergency where time is of the essence. The longer surgery is delayed, the more nerve damage can occur.

 

Poor charting

 

Skrzypchak was admitted to Wausau Hospital complaining of lower back pain, tingling and trouble urinating. A staff nurse was found negligent “as a matter of law” by the trial court for a failure to report an abnormal medical condition, which is a breach in the standard of care.

 

The appeals court said, “The undisputed evidence was that… [the nurse]… did not report the abnormal neurological signs she discovered at 4:50 and 8:30 p.m. Experts testified that her failure to contact a physician constituted a breach of the standard of care.”

 

The nurse insisted that she made proper and timely pages about Skrzypchak to a neurosurgeon as she had been ordered to do, and electronic phone records showed that some pages were made on the hospital floor by someone, but the nurse’s charting did not reflect that she herself made the pages. Thus, the nurse’s lack of charting notes were weighed more heavily than electronic phone records, and the trial court told the jury not to speculate on who made the pages based only on phone records.

 

Skrzypchak suffered medical complications that were exacerbated by a delay in his eventual surgery, the delay was attributed to a lack of communication by the nurse and, for want of charting, the lack of communication could not be rebutted.

 

Poor trial strategy?

 

The appeals court noted that “The issue of negligence is rarely decided as a matter of law.”

 

But here, a nurse was found negligent by a directed verdict on uncontested facts and held 60% liable by a jury. However, she luckily was not sued and thus was a nonparty to the action — the plaintiff attorneys had sued only two subcontractor doctors and not the nurse or her hospital employer.

The appeals court said, “At the outset, it is worth noting that the Skrzypchaks’ grievance with the judgment stems from the jury allocating 60% of the causal negligence to [the nurse], an employee of Wausau Hospital. The Skrzypchaks did not sue [the nurse] or Wausau Hospital, and therefore 60% of their damages were uncollectable.”

 

Cite it right

 

The plaintiffs’ attorney in the case also was fined $500 for violating the rules of appellate procedure.

 

The appeals court said: “We note that our task in writing this decision was unnecessarily complicated by the failure of the Skrzypchaks’ attorney… to provide appropriate citations to the record, as required by the rules of appellate procedure.”

 

“For example, [the attorney] repeatedly cites to trial exhibits 1 through 3, each of which is a binder of medical records. He does not, however, cite to page numbers within those exhibits, even though exhibit 2, for instance, is nearly 600 pages.”

 

“Failure to follow the rules of appellate procedure is grounds for dismissal of the appeal, summary reversal, striking of a paper, imposition of a penalty or costs on a party or counsel or other action as the court considers appropriate. Here, we deem a sanction of $500 against [the attorney] to be an appropriate penalty for these rule violations….”

 

Reprinted with permission of The Medical-Legal News. For more information or subscription information please go to www.medical-legalnews.com or call 859-234-2345.

 

 

June/July 2009

HINN Letter

Constance Watkins, RN, CLNC

 

 

   You enter your patient’s room and notice he looks confused and hands you a letter given to him by a case manager.  Apparently, his admission is no longer covered by Medicare- how can this be?

 

    HINN letters are hospital issued notices of non-coverage (also known as HABN-hospital advance beneficiary notice) for a hospital stay or admission to the hospital.  If the hospital believes that Medicare will not pay for a hospital admission or stay, a letter stating these facts must be presented to the patient and signed by the patient.  Just because the patient has Medicare does not imply it covers their current needs being provided by your organization.

 

     The official letter will be on hospital letter head, and is required under the Medicare rules. HINNs can be presented prior to admission, after admission or during the hospital stay when a patient is believed to no longer need acute inpatient hospital care. The continued stay type of HINN must be issued in agreement with the patient’s physician.  As with any type of hospital denial, HINN letters can be questioned or appealed by the patient or their family.

 

     Why do nurses need to know about HINN letters?  Many nurses serve as case managers and are responsible for delivering/explaining HINN to a Medicare patient if the admission or inpatient stay is in question. Also, the issuer of the HINN letter must be knowledgeable as to how the HINN appeals process works, the timeframe involved, and when the patient will need to start paying for the hospital stay out of pocket.

 

    The HINN letter can often be overwhelming to a patient.  A courteous, caring attitude must be used when one is issued along with a knowledge base to understand the process.

 

For additional reading: 

 

 http://www.cms.hhs.gov/Transmittals/Downloads/R982CP.pdf

 

 http://www.gmcf.org/medicare_beneficiaries/media/hinn_flyer.pdf

 

 

October/November 2009

Healthcare Road Rage

Constance Watkins, RN, CLNC

 

Healthcare Road Rage is the medical equivalent of road rage, sometimes it is passive-aggressive behavior and at other times extremely offensive. Most hospital workers have experienced the behavior of physicians or other professionals who throw instruments, refuse to answer pagers, swear and make belittling remarks. Such behavior can cause medical errors   patient harm and even increase the cost of healthcare.

 

     Frequently, physicians are the aggressors and nurses are the targets. In fact, a Joint Commission survey found that 50% of nurses had been targets of this kind of intimidation, and 90% of nurses reported having witnessed it. Many of these nurses or healthcare workers felt frustrated and feared retribution if they reported the aggression.

 

     Shortly after a very high profile legal case was decided (a perfusionist sued a heart surgeon for his swearing, yelling and belittling remarks, and won) The Joint Commission on Accreditation of Healthcare Organizations issued a safety alert, requiring hospitals to adopt a zero-tolerance policy toward workplace bullying.

 

By January 2009, hospitals must have complied with the new disruptive behavior standard (LD.3.15).  Hospitals are required to establish a code of conduct that defines unacceptable behavior, sets up a mechanism for workers to report inappropriate outbursts and establishes consequences for misconduct. But even with these standards in place, it could take years to establish behavior concurrent with treating colleagues with civility and respect; unless disciplinary actions are in place and enforced.

 

 

For additional reading: 

www.workplacebullying.org:  Trends: Putting a Stop to Medical Road Rage by Melissa Knopper Clinician Reviews January 17, 2009

www.boston.com/news/local/massachusetts/articles/2008/08/10

       
     

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