Was that documented? Was that care planned?

Administrators, as you conduct your clinical and stand-up meetings, I encourage you to reflect on the following:

Have you received updates on residents with changes in behavior and/or condition?

Examples:

• Changes in behavior: Agitation, withdrawal, changes in appetite, sleep disturbances, increased confusion, aggression, social isolation, changes in communication patterns.

• Changes in condition: Skin integrity issues (e.g., pressure ulcers, rashes), cognitive decline, changes in vital signs (e.g., heart rate, blood pressure, respiratory rate, temperature), weight loss or gain, falls, new onset of pain, changes in mobility, incontinence, difficulty swallowing.

Were all relevant actions taken?

Documentation:

• Were all observations and assessments documented accurately and timely in the medical record?

• Were any incident reports filed as required?

Interventions:

• Were necessary medical interventions ordered (e.g., medications, diagnostic tests, consultations)?

• Were interventions implemented effectively and as directed?

Team Involvement:

• Were appropriate team members involved (e.g., physician, psychiatrist, psychologist, nurse, social worker, therapist, dietician, physical therapist, occupational therapist, speech-language pathologist)?

• Was there effective communication and collaboration among all members of the care team?

Referrals:

• Were appropriate referrals made (e.g., specialist consultations, home health services, hospice)?

Family Communication:

• Were family members notified promptly and kept informed about the resident's condition and care plan?

• Were family concerns and preferences addressed?

Was the care plan updated to reflect these changes and interventions?

• Does the care plan accurately reflect the resident's current needs and condition?

• Are the goals and interventions in the care plan realistic, measurable, achievable, relevant, and time-bound (SMART goals)?

• Is the care plan reviewed and updated regularly (e.g., at least weekly or as needed)?

Was the incident reported according to facility policy?

• Were all relevant details of the incident accurately and completely documented in the incident report?

• Was the incident report submitted in a timely manner?

Did the team conduct a brief root cause analysis to identify any contributing factors and prevent future occurrences?

• What factors may have contributed to the change in the resident's condition or the occurrence of the incident?

• What steps can be taken to prevent similar occurrences in the future?

Thorough documentation and care plan updates are foundational to effective risk management. They ensure that all team members are aware of resident needs, that appropriate interventions are implemented, and that any potential risks are proactively addressed.

By consistently asking your team, "Was that documented? Was that care planned?" during team meetings, you can foster a culture of accountability, improve the quality of care, and enhance resident safety.