Legal and Professional
Implications of Documentation
Issues
Implications of Documentation
Issues
Documentation issues have become more severe. According to the NSO/CNA Nurse Liability Claim Report (4th Ed.) failure to document or falsifying documentation cases rose from
$139,920 in 2015 to $210,513 in 2020.
The rounding schedule is
MHA Rounding: Every 15 minutes on acute units, every 30 minutes on non-acute units (24/7).
Nurse Rounding: Hourly on all units, independent of MHA rounding.
Constant Observation (CO, 1:1) and the ratio is
Used for patients exhibiting suicidal, homicidal, or destructive behavior. Staff Ratio: 1:1, or 2:1 for violent patients.
Licensed Practitioner Orders:
Full body assessment and search along with a urine toxicology
The Medication Administration Policy is:
TO PROMOTE QUALITY AND SAFETY ADMINISTRATION OF MEDICATIONS TO PATIENTS
Nearly half (49.6%) of license protection issues are due to
fraudulent or falsified records.
Record observations
in real time; do not copy from another form.
15-Minute Checks (Q15):
Admission level of precaution for Behavioral Health Services (BHS) inpatient units, excluding non-acute units.
Assign a room close to the nursing station and you must initiate
15-minute safety checks
IT IS A SAFE AND EFFECTIVE MECHANISM BY WHICH MEDICATIONS ARE:
ORDERED
ADMINISTERED
DOCUMENTED
CONTROLLED
Risk of Federal Penalties is
Deliberate falsification (e.g., false claims to Medicare) can lead to sanctions under the Federal False Claims Act (FCA).
Shift Change Protocol is.. and Bedtime Protocol is...
Nurses from both shifts perform joint rounds before shift reports. Charge Nurse assigns staff to rounds.
Leave room doors open at least 12 inches for auditory and visual access without compromising privacy. Staff should use flashlights carefully, avoiding direct light on patients’ faces.
30-Minute Checks (Q30):
Standard precaution level for Behavioral Health (BH) patients in non-acute units.
You must inform
Director of Nursing, ADN, security, patient’s family, and probation officer or caseworker
The nurse will validate the initial 5 Rights of prior to, at and post medication administration:
1. Right Patient
2. Right Medication
3. Right Dose
4. Right Route
5. Right Time
Federal False Claims Act is
Under the FCA, knowingly submitting false information for government payment is illegal.
Patient Safety and Proof of Life is
Check that all patients are breathing during each round and Confirm patient well-being by entering rooms and observing each patient’s condition directly. s
Patient Safety Watch (Safety Watch):
For patients at risk of falls; staff may monitor two patients in the same room.
Progress note detailing:
Time of return, behavior, body and belongings search, assessment findings, and elopement consequence.
Documentation must include the following additional rights:
6. Right Reason
7. Right Response
8. Right Documentation
It "Knowingly" includes
Actual knowledge.
Deliberate ignorance.
Reckless disregard of the truth.
Inconsistencies is
Any head count discrepancies are reported to the Charge Nurse or Nurse Manager immediately.
Hourly Rounding (Behavioral Health Division):
RNs/LPNs perform hourly rounds, documented on Head Count/Evacuation Form #971A (Days), #971B (Evenings), #971C (Nights).
Report elopement risk to
oncoming staff
How many rights are there in total
7