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25th Feb

Effective communication is a challenge that affects all areas of health care. Often times the lack of communication alone will precipitate a resident harm event. How do you ensure that all the care providers have the necessary information to work with your residents? The complex medical diagnoses and surgical procedures that we commonly care for these days require more specialized care than in the past. How do you ensure that due to ineffective communication, the well-intended staff person does not inadvertently provide a service that could cause harm?

Consider some of these special situations.

We should all have a falls policy and specific guidelines of what to report, who to report to, how to care for a resident after a fall. Some residents are recurrent fallers, and those present specific challenges in planning for care delivery. Consider the resident that is now taking an anticoagulant, coupled with a fall; they are now at an increased risk for injury. What can initially present as an innocuous injury could develop into something more serious and in some cases become deadly if we are not diligent in following up.

In patients who are on an anticoagulant regimen, there are reported cases where a minor head “bump” results in a subdural bleed several days after the fall. The increased risk from bleeding can affect any other major organ and increase the severity of injury from an initially no injury fall. In a recent case in Texas, a 69 year old resident fell and was reported to have no injuries from the fall except for purple bruising on her right buttock. More than 24 hours after her fall, she was admitted to a hospital with internal bleeding from blunt-force trauma in her fall. She had a retroperitoneal bleed.

Residents who take anticoagulants need to be monitored more closely and frequently after a fall. Can you be certain that all the care providers are aware that resident is on anticoagulant therapy thus putting them at increased risk for injury? Every care provider should have this information which could alert them to minor changes and allow them to be able to pass along a change in status to correct medical personnel and prevent an injury from extending.

Residents are NPO from time to time for various different reasons. Without proper communication, the helpful staff member (or in some cases a Volunteer) may deliver a cup of water to a resident who should be NPO. It’s not only important for staff to know the NPO status, but why the resident is NPO. Do they need to be on the lookout for signs and symptoms of aspiration? Was the status related to an upcoming test or procedure that may need to be postponed or canceled? How is NPO communicated to all the care providers in your facility to prevent this from happening? \


So many other circumstances should be communicated:

– Hard of hearing

– No BP or lab sticks in a certain limb

– Droplet isolation

– Resident is blind

– Code status


How does your facility share this information with all the care providers?

We do have a special challenge in healthcare to provide effective communication while protecting confidential information. There has to be an acceptable balance. Residents have the right to privacy in treatment and personal care. They have the right to keep records confidential and private. However, anyone providing care must be aware of special circumstances that place a resident at risk for increased injury.

One of our greatest challenges is effective and complete communication. As the direct care provider, I should know special circumstances, but communicating out to the team is not often easy. Think of all the persons who come into contact with residents on any given day. Are your residents really safe from unintentional harm because the staff was not aware of a limitation?

I challenge you to review your facility’s policies and ensure that all direct care providers have necessary medical information to be able to pass along any minor change in status that might otherwise be overlooked.


Lisa Chadwick, Director of Risk Management | Functional Pathways

Resource: Legal Eagle Eye Newsletter |  July 2015 | Vol 23 | No. 7


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