Mar 21, 2023

Why Assisted Living Facility Documentation Matters

Your assisted living facility is being sued. The lawsuit alleges that you failed to take necessary precautions to keep a resident safe. You know that isn’t true – but can you prove it? Documentation will make or break your case. To prepare for scenarios like this, you need to train your team on assisted living facility documentation best practices.

Assisted Living Claims Are Rising

According to a report from CNA, the average cost of a liability claim in an assisted living setting was $267,174. This is higher than the average liability claim in skilled nursing facilities, which was only $245,559.

Adult residential care facilities cannot ignore liability risks. Seniors are vulnerable, and as the population ages, the risks will only increase. Facilities must show that they are fulfilling their duty to keep their residents safe.

Common Causes of Lawsuits

CNA says the most common causes of claims are resident falls and pressure injuries, and these two events alone account for nearly two-thirds of all claims. Dementia was a factor in 72.9% of all closed fall-related claims in assisted living settings.

Lawsuits often occur when family members say an assisted living facility was negligent in providing care or taking necessary safety precautions. When defending a claim a facility’s best defense is a written record of diligent conduct that corroborates the staff’s account of events. For instance, a log of nightly check-ins at regular intervals, medication logs or post-incident reports that reflect proper care, i.e. contacting a healthcare provider and family, following instructions, transfer to the hospital or periodic follow-up with the resident to assess any change in condition.

How Documentation Could Make or Break Your Case

If a resident is injured or dies, the resident’s family may blame the assisted living facility tasked with providing a safe home. This blame may or may not be warranted, and liability will often hinge on documentation.

When reviewing documentation after an incident, the following questions will be relevant:

  • Was adequate care given?
  • Were safety precautions taken?
  • Is the facility transferring residents who need additional care and support?

For example, let’s say that a resident falls and breaks a leg. The resident had fallen one month earlier, and even though that fall did not result in serious injuries, the assisted living facility should have documented an increase in the resident’s fall risk. A lawsuit might allege that the facility did not take proper precautions to prevent additional falls. If the assisted living facility can show through resident records and staff logs that the resident was assessed and proper precautions were put in place to the extent possible, the facility may be able to show that they were not at fault since all persons 65 and over have an increased risk of falls that worsens with age and number of falls.

Gaps in Documentation Could Cost You

According to a study from the American Health Care Association and the National Center for Assisted Living, only 4% of assisted living facilities say they are fully staffed, and 82% are experiencing moderate to high-level staffing shortages.

Employees may be overworked, and they may be tempted to cut corners. However, being lax about documentation can expose the facility to liability. For example, consider a resident who is showing signs of confusion. The staff realize that the resident is at risk of wandering and needs to be watched. This is put down in the records. Staff members also check on the resident regularly, but this is not always noted in the logs. One day, the resident wanders outside and falls. The family sues, and because the assisted living cannot show logs proving that they checked on the resident regularly, the facility could be found liable.

Documentation Best Practices

If your facility ever faces a lawsuit, you’ll need to have strong documentation on your side.

  • Select your system. Historically, staff used paper and pen to keep records, but modern electronic records systems can provide many advantages. When selecting a system, consider how it will impact the daily routine. You want the system to be as easy-to-use as possible. With the benefits of today’s technology, there are multiple options, including free mobile and web apps for easy medical dictation that is HIPAA compliant. Check out the latest options here.
  • Maintain your records. Follow state regulations regarding how long to keep records. For example, in Washington, assisted living facilities must store resident records on-site for six months after the resident leaves and on-site or off-site for five years after the resident leaves.
  • Train your workers. Educate your workers on how to fill out records completely, and explain why these records are so important. Review records for compliance on a regular basis and provide refresher training regularly. Even if your team is experienced, revisit the importance of record keeping at least monthly. When work gets busy, employees may perceive documentation as secondary or not important.

If a lawsuit is filed against you, you’ll be thankful that you have robust assisted living facility documentation. You’ll also be thankful that you have robust insurance coverage.

Ask us for information about tailored insurance for adult residential care facilities through the Personal Care & Assisted Living Insurance Center (PCALIC). Learn more.