Tag Archives: Documentation

Incident Reports: Proceed With Caution

Long term care facilities often question whether documentation of falls or other resident accidents at their facilities is necessary.  The answer really depends on the type of facility and the state of licensure. Federal public health regulations require skilled nursing facilities to notify family and the responsible party if there is an accident involving the resident that requires physician intervention.  42 C.F.R. §483.10(11)(i)(A).  These regulations also require skilled nursing facilities and intermediate care facilities serving intellectually disabled individuals to report any instances of mistreatment, neglect or abuse, including injuries of an unknown source, to the proper agencies in accord with …

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Tactics Skilled Nursing Facilities Can Use to Prevail in Discharge Appeal Hearings Before the New York Department of Health

Federal Law and the laws of most states, including New York, provide that facilities are permitted to discharge residents in the following circumstances: when the discharge is necessary for the resident’s welfare; the discharge is appropriate because the resident’s health improved such that facility services are not required; the health and safety of other individuals is threatened if the resident remains at the facility; the resident has failed to pay for the stay at the facility; and the facility discontinues its operation.  This article focuses on the discharge procedure for residents no longer requiring services of the facility due to …

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When a Resident or Family Requests a Chart

Every facility with which I have worked has had family members or residents request copies of their charts.  The request may be as the result of an incident, may be simply to keep medical providers updated or may be for transfer purposes.  Regardless of the stated reason, it is not an over-reaction to be concerned. When a chart request is made, an appropriate response is for the administrator or a designee to speak with staff providing care to find out if there are any issues with either the resident or the family.  If the family members have raised concerns, it …

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