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6th AnnualForumonLongTermCareLitigation&RiskManagementStrategies

FRANKRUSSOSENIOR VICE PRESIDENTRISK AND LEGAL AFFAIRSSILVERADO CARE HOME OFFICE

CONFLICTS BETWEENRESIDENTS, FAMILIES AND STAFF

NORRISCUNNINGHAMCHAIRMAN, LITIGATION PRACTICE GROUPHALL, RENDERINDIANAPOLIS, IN

January 20 – 22, 2016

Tweetingaboutthisconference?

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Resident‐to‐ResidentAbuse

AfteranationalspotlightwasplacedonelderabuseperpetratedbyfamilymembersandLTCstaff,CornellUniversityresearchersdecidedtostudytheprevalenceofresidenttoresidentabuseinLTCsettings.

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CornellStudyFindingsAccordingtotheStudy,offensesofresident‐to‐resident

abuseranthegamut:• 20% of residents had experienced inappropriate, disruptive or hostile behavior at the hands of another resident.

• 16%ofresidentsexperiencedabusiveverbalincidents(cursingorscreaming)

• Over10%ofresidentshadtheirroomspilferedbyanotherresident

• Almost6%wereinvolvedinbiting,kickingorhitting• 1.3%ofresidentsexperiencedsexualincidents(indecentexposure,touchingorattemptingtogainsexualfavors)

• Variousinstancesofthrowingobjects,spittingandscratchingwererecorded

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CornellStudyFindings

Residentsmostlikelytoabuseare:•Younger•Physicallyhigherfunctioningthanotherresidents

•Cognitivelyimpaired•Diagnosedwithmooddisordersordementia

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ManwithAlzheimer'sallegedlybeats,killsotherresidentinALF

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WhenResident‐to‐ResidentAbuseOccurs

• Redirectorremovetheaggressiveresidentfromtheareausinganon‐threateningapproach,speakcalmlyandclearly.

• NotifytheAdministrator/EDandDirectorofNursingimmediately.

• Notifyresident’sPCPanddeterminewhetherpsychiatricservicesand/orhospitalizationarewarranted.

• Createanincidentreport,alertStateandalerttheresident’sresponsibleparty.

• Interdisciplinaryteammustreevaluatethecareplanandadjustappropriately.

• NotifyCorporateOffice/RiskManagement/Legal

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Resident‐to‐CaregiverAbuse

Inamemorycaresetting,itisnotunusualforresidentstostrikeoutatcaregivers,especiallyduringassistancewithADLs.

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ResidentAggressionandRisktoLTCProvidersResident‐to‐residentabusemayresultin:

‐ Statesurveys‐ CivilsuitsbroughtbyvictimsofabuseallegingtheLTCproviderfailedtoprovideforresidentsafety

Resident‐to‐caregiverabusemayresultin:‐ OSHAviolations‐ Workers’compensationclaims(highpercentageofworkinjuriesinALsaretheresultofresidentaggression)

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ExternalViolenceinLTCFacilities

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LTCViolence(randomactsorpreventable)CaseStudy

• Woman leaves abusive husband, history of violence, large gun collection.

• Tells her employer she believes mentally‐ill husband will hunt her down and kill her at work. 

• Husband enters Pinelake Health and Rehab, kills 7 residents and 1 nurse.

• Civil Lawsuit against Nursing Home on behalf of families of 4 victims (negligent, did not take proper safety measurers to protect residents from a foreseeable attack).

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AbuseofLTCResidents

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HouseGovernmentReformCommitteeStudy

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Nursinghomeemployeesarrestedforabuse

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GrannyCamsCaptureAbuse

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Whattodoafterabuseobservedoralleged?

• Skinchecks• StaffInterviews/writtenstatements• ReporttoStateAgency• Family(s)discussion• Marketing/PRmonitoring(socialmedia,pressinquires)• HoldingStatement• Police/DetectiveCoordination• Tenderclaim(noticeonly)?• Staffdiscussion(donotdiscuss/gossip).• Professionalthirdpartynotification?• In‐Service(abusetraining,etc.).• HRAction(suspension,termination).• DefenseCounselreferral• PreserveRecords/Evidence(video,photo,documents).

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• IsitappropriateforotherstobemakingdecisionsonaResident’sbehalf?Whatisthisdeterminationbasedupon?Doyouseeevidencethatsupportsthisdetermination?Theprimarydutyistoalwaysadvocateforresidentstomaketheirowndecisions.

• POAauthorityvs.ResidentRightsvs.State/DADS/Ombudsmanvs.Non‐POAFamilyMember(legaldecisionmakingauthority)

• FamilyDynamics

• Privacy(mail,visitors,familyconflict,visitation,roomsurveillance,photos,videos)

• FinancialExploitation(ontherise)

• Askedtoprovidewrittenstatements,visitorlogs,testifyetc.(don’tallowabsentsubpoena).

ResidentRightsvs.CommunityExposure

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• HigherAcuityisheretostay.• 50%ofseniorlivingresidentshavethreeormorechronicconditions

while42%haveAlzheimer'sorotherdementia• Increasing%ofpatientpopulationsarefrequentlyunabletomakeown

decisions.• WithrisingAcuitycomesanincreasedneedforacentralizeddecision

makertoactfortheresident.• 80%Assistedlivingprofessionalswhoareseeinggrowingdemandinmemorycare

• 87%Respondentswhoareseeingasubstantialincreaseinacuitylevelsintheresidentpopulation

• ThishigheracuitydictatesaneedforincreasedsophisticationbyAdministrators/EDtobeawareofwhatgiveslegalauthoritytofamilymembersandwhatthatlegalauthoritygrantstofamilymembers.

ComplicationofHigherAcuity(PointClickCare/McNights Survey)

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• Inter‐familydisputes• Conflictinglegalrepresentativepaperwork(educateonhierarchyofdecisionmakingauthority:guardianship,conservatorship,MPOA,DPOA,FPOA,responsibleparty,nextofkin…).

• Dutytoprotecttheresidentexistsregardlessofthedynamicsofasituation.

• Providersmustremainneutralandunbiasedduringfamilydisputes(estate,trust,guardianship,etc.).

ProtectingtheResident

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CMSEMERGENCYPREPAREDNESSCHECKLIST

• Revised February 28, 2014 to provide more detailed guidance or patient/resident tracking, supplies and inter‐organizational collaboration• Develop Written Emergency Plan• All Hazards Continuity of Operation Plan• Collaboration with Local EMA• Analyze Each Hazard• Collaboration with Suppliers/Providers• Decision Criteria for Plan Execution• Contingencies for Communication Infrastructure• Develop Shelter‐in‐Place Plan• Develop Evacuation Plan

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CMSEMERGENCYPREPAREDNESSCHECKLIST

• Emergency Preparedness Checklist (cont):• Transportation and Other Vendors• Training of Transportation Vendors/Volunteers• Facility Reentry Plan• Residents and Family Members• Resident Identification• Training of Facility Staff• Needed Provisions• Evacuation Location• Relocation• Plan Review• Communication with LTC Ombudsman Program• Exercises and Drills• Recovery of Personal Effects

• If it’s included on the checklist—do it!

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MEDICAIDFRAUDCONTROLUNIT

• Federally funded unit charged with investigating and prosecuting: Medicaid fraud; fraud in the administration of the Medicaid program; and abuse, neglect or financial exploitation occurring in Medicaid facilities or committed by Medicaid providers or their employees 

• Target must work for a Medicaid provider, such as a doctor, nursing home, hospital, adult care home, or home health agency 

• Unit consists of attorneys, investigators, auditors nurse investigators, some paralegals

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MEDICAIDFRAUDCONTROLUNIT

• *Responsibilities: • Investigators are assigned cases under the direction of the Supervising Deputy Attorney General. The Indiana Medicaid Fraud Control Unit Investigator investigates

• all patient abuse and neglect • theft of patient property • prescription drug diversion and • some provider fraud 

• The Investigator works independently or as a team, and is responsible for the entire investigation

*Taken from actual Job Announcement: Indiana Attorney General’s Office 

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MEDICAIDFRAUDCONTROLUNIT• DUTIES OF INVESTIGATOR:• Obtain various documentation from health care facilities, including medical records, 

incident reports, employee files; • Obtain other documents such as bank records, business records, and other records to 

be used as evidence in judicial proceedings; • Research the documentation for patterns of patient neglect and abuse, medication 

errors, or falsified records; • Locate, conduct surveillance and interview witnesses, suspects, and possible expert 

witnesses; • Prepare written and recorded statements and evaluate testimony for credibility; • Conduct undercover operations; • Prepare comprehensive investigation reports for presentation to a Deputy Attorney 

General or state or federal prosecutor for criminal referrals; • Assist the Deputy Attorney General or state or federal prosecutor in preparing the 

case for court; • Locate and serve subpoenas on witnesses and suspects; • Testify in criminal and administrative proceedings; • Complete any necessary component of the Indiana Law Enforcement Academy;

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MEDICAIDFRAUDCONTROLUNIT

• Federal law requires each state tohave a MFCU or to provide a waiverto the Secretary of HHS

• 49 states and the District of Columbia have MFCUs• 44 MFCUs are in the Office of the Attorney General• 6 are in other state agencies such as the State Police

• 42 C.F.R. 1007.1 – 1007.21• Statewide prosecutorial authority:

• Direct MFCU prosecutors• Local prosecutors• Federal prosecutions

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MEDICAIDFRAUDCONTROLUNIT

• 42 C.F.R. 1007.1 – 1007.21• MFCU must be independent of the state Medicaid agency

• No Medicaid agency official has authority to review Unit activities

• No state Medicaid agency funds go to MFCU and no MFCU funds may go to the state Medicaid agency

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MEDICAIDFRAUDCONTROLUNIT

• WHAT TO DO WHEN THE MFCU COMES CALLING:• DETERMINE THEIR IDENTITY AND AUTHORITY

• ASK TO SEE BADGE OR BUSINESS CARD• ASK FOR “HIPAA LETTER”

• DETERMINE THE REASON FOR THEIR VISIT

•CALL YOUR LAWYER!

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WORKPLACEVIOLENCE

Active Shooter Incidents• Active Shooter:  an individual actively engaged in killing or attempting to kill people in a confined and populated area; in most cases, active shooters use firearm(s) and there is no pattern or method to their selection of victims

• FBI “Study of Active Shooter Incidents in U.S. Between 2000 and 2013”

• 160 incidents in 40 states• Total casualties = 1,043• 2000‐2006:  avg of 6.4 incidents annually• 2007‐2013: avg of 16.4 incidents annually

• Lowest number of incidents occurred at a health care facility

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WORKPLACEVIOLENCE

Active Shooter Incidents• Active Shooter:  an individual actively engaged in killing or attempting to kill people in a confined and populated area; in most cases, active shooters use firearm(s) and there is no pattern or method to their selection of victims

• FBI “Study of Active Shooter Incidents in U.S. Between 2000 and 2013”

• 160 incidents in 40 states• Total casualties = 1,043• 2000‐2006:  avg of 6.4 incidents annually• 2007‐2013: avg of 16.4 incidents annually

• Lowest number of incidents occurred at a health care facility:• 4/160 = 2.5 percent.

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WORKPLACEVIOLENCE

Active Shooter Incidents• All‐hazards approach to emergency planning means you must have a plan/policy/SOP that addresses active shooter events

• Guidance:  Incorporating Active Shooter Incident Planning Into Health Care Facility Emergency Operations Plans. http://www.phe.gov/Preparedness/planning/Documents/active‐shooter‐planning‐eop2014.pdf

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WORKPLACEVIOLENCEActiveShooterCard

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WORKPLACEVIOLENCEActiveShooterCard

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WORKPLACEVIOLENCE

Rate for non‐fatal workplace violence‐related occupational injuries 

Private Industry• 1999 = 2 assaults per 10,000 workers• 2012 = 4 assaults per 10,000 workers

Health Care Industry• 1999 = 8.3 assaults per 10,000 workers• 2012 = 15.1 assaults per 10,000 workers

Bureau of Labor Statistics

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WORKPLACEVIOLENCEIncidence rates for nonfatal assaults and violent acts by industry, 2000Incidence rate per 10,000 full‐time workers

Private Sector Overall

Health Services Overall

Social Services

Nursing & Personal Care 

Facilities

Source: U.S. Department of Labor, Bureau of Labor Statistics. (2001). Survey of 

Occupational Injuries and Illnesses, 2000. 

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ReducingWorkplaceViolenceThecommonerrorsthatlong‐termcarefacilitiesmake,basedonOSHAcomplianceaudits,include:• Failingtocreateastand‐alonewrittenviolencepreventionprogram.

• Failingtoensurethattheprogramaddressesspecificactionsemployeesshouldtakeintheeventofanincidentandtheproperreportingprocedures.

• Failingtoensurethatstaffmemberstrainedtodealwithaggressivebehaviorarereadilyandimmediatelyavailabletorenderassistance.

• Failingtoensurethatallresidentsreceivingapsychiatricconsultationarescreenedforapotentialhistoryofviolence.

• Failingtouseasystemthatflagsaresident’schartanytimethereisahistoryoractofviolence.

• Failingtotrainstafftounderstandtheresidentchartingsystem.• Failingtoputinplaceadministrativecontrolssothatemployeesarenotalonewithpotentiallyviolentresidentsinthefacility.

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WhatcanProvidersDo?SecurityVulnerability/RiskAssessmentforLong

TermCareFacilities• Riskassessmentratingbaseduponon‐sitevisit:• RiskDefensibility(Low– Strong)• MeasuringRisktoDefensibility• Note:Thisreportisbeingpreparedforinsurancepurposesand/orinanticipationoflitigation(couldbecoveredbyPLPremium).

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RiskAssessment

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AreasofAssessment• Staffing(whoisresponsible,dotheyknow?)• Trainingofsecuritystaffandothers• Electroniclockingsystems/accesscontrolsystems• Videosurveillance• Securityrounds/patrols• Reporting• Parkingutilizationandenforcement• Organizationandadministration• Violencecontainment• Security‐sensitiveareas(backdoors,kitchen,laundry).• Emergencyplanningandprocedures• Exteriorlighting• Locks,keys,delayedegress,keypads,fobs• LocalPolicerelationship

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WORKPLACEVIOLENCE

Actions to Mitigate Risks• Workplace Violence Restraining Orders

• Employers can obtain this order to prohibit unlawful violence or credible threats of violence against their employees.

• These orders can be in effect up to 3 years and may be renewed only once for an additional 3 year period

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•QUESTIONS??