Does Your Facility Have a Legal "Safety Net" For Wound Care Documentation?

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By Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC

Substandard documentation tops the list of mistakes for long-term care facilities. It involves "all hands in the chart" so to speak. This encompasses all disciplines, from the nursing assistant to the physician. Discrepancies and gaps in documentation put your facility at risk of litigation. Impeccable documentation is essential in defending any case. Your facility must have a "safety net" in place. This "safety net" consists of educating staff about the importance of timely and detailed documentation not only for the facility, but for their license. Often times, clinicians are not aware of the legal repercussions of their actions. Surveyors will also consider other related Federal Tags (F-Tags) during investigations for compliance.

Demonstrating Consistent Processes for Wound Prevention

F-Tag 314 (§483.25 Quality of Care) states that each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

Facilities that have failed to establish consistent processes regarding wound prevention and quality care may tussle with regulatory issues, litigation, impression of poor care, and substantial fines. In spite of the fact, those that have established such processes are better off, but not completely in the clear.

Educational Resources for Clinicians in Wound Management

There are now several seminars and webinars offered through Healthcare & Legal Resource Group, LLC, a group of educators, legal consultants, published authors, and attorneys who have joined forces to create an educational program benefiting health care professionals from multiple disciplines. One such program they offer, Legal Concepts in Wound Management, is for licensed clinicians. The course curriculum consists of ethical issues in wound care, wound related litigation, wound specific issues – breaches of duty, standards of care, communication, medical record, documentation, HIPAA, social media, internet, avoiding litigation, and more.

There is no specific certification, licensure, or credentials required to participate in the program. Their course prepares the participant for the Certified Legal Wound Care Professional (CLWCP) exam. The exam is provided by the National Organization of Healthcare and Legal Professionals.

You can visit their website for further course information and exam eligibility requirements.

About the Author
Cheryl Carver is an independent wound educator and consultant. Carver's experience includes over a decade of hospital wound care and hyperbaric medicine. Carver single-handedly developed a comprehensive educational training manual for onboarding physicians and is the star of disease-specific educational video sessions accessible to employee providers and colleagues. Carver educates onboarding providers, in addition to bedside nurses in the numerous nursing homes across the country. Carver serves as a wound care certification committee member for the National Alliance of Wound Care and Ostomy, and is a board member of the Undersea Hyperbaric Medical Society Mid-West Chapter.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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