394 CHAPTER 25 | Understanding the Risks for Litigation


date is included in the history and physical section of the EHR. The older adult’s leg heals in 2 months. If the history and physical data from the previous admission are copied and pasted into the new EHR entry, the leg fracture may seem to be current. In instances in which previous records were simply copied into a new EHR, the timeline created will not pass the logic test and can raise many competency questions for RDNs. Box 25.1 presents examples of documentation problems and possible solutions.


RDNs should be aware of how to handle data-


sharing requests, such as a request for a copy of a grandmother’s medical record by a granddaughter who is in nursing school. A person who is related or close to a resident may ask for information from the medical record, and staff at times may provide it even if that person is not the power of attorney or entitled to the information. Sharing of medical information should not be done without written permission from the client or their power of attorney.


Following Current Standards of Care


RDNs must stay up to date on nutritional treatments, such as enteral feedings, wound care, diabetes care, hydration, and current MNT protocols for older adults. Generally, the gold standard of care in the skilled nursing environment is the Omnibus Budget Reconciliation Act of 1987 (also referred to as Chap- ter 483 of Code of Federal Regulations Title 42). The final regulation and the interpretative guidelines for surveyors published by the Health Care Financing Administration (the predecessor to CMS) provide structure and govern facilities participating in Medi- care and Medicaid programs.13


Current MNT proto-


cols, federal and state regulations, practice acts, and the facility’s organizational policies and procedures are also considered standards of care. It is important that all facility policies and procedures be kept up to date. Although they are not a standard of care, acute care and hospital-affiliated skilled nursing facilities may regard The Joint Commission guidelines as another standard. RDNs are expected to implement appropriate


treatment, assessment, and monitoring systems based on any such standards of care. In addition, the


Box 25.1 Solutions to Common Documentation Problems


Revise data collection forms. Whether handwritten or electronic, forms should aid in data collection and reflect current policies.


Review policies to eliminate unnecessary orders, such as intakes and outputs for every admittance for the first week. Unless the reason for obtaining such data is clear, the policy is perhaps unnecessary.


Document interaction and education of residents and family members.


Systematically and consistently conduct medical record audits to determine potential problems. Peer reviews and consultants can help with this.


Understand that it is necessary to keep a complete and accurate medical record.


contractual agreement may set the standard of care for a contracted employee or independent contrac- tor. For example, the contract of an RDN with ABC facility may state that the consultant RDN or licensed dietitian will evaluate all individuals with substan- tial weight loss and residents receiving dialysis each month. A resident was hemodialyzed three times per week for an entire calendar year and lost 45 lb (20.4 kg) during that period. No documentation was done by the RDN for 4 of 12 months during the year. The clinical record in this instance confirms a devia- tion from the standard of care. If the RDN’s deviation from the standard of care is regarded as a causative factor for a negative outcome, then the RDN is possi- bly at risk of litigation, stress, professional and finan- cial losses, and, in extreme cases, criminal allegations. Box 25.2 lists several current industry standards


of care that may help to clarify the role of RDNs in minimizing the risk of MNT litigation in the nutrition care and assessment of older adults. Adherence to these standards will place the RDN in


a relatively strong position. However, if one or more of the standards is not followed, it is possible to argue that the professional’s care was negligent or that failure to follow a particular standard contributed to the harm of a person. Demonstrating that these standards were fol- lowed is often difficult 2 to 3 years after care was given, when memories have faded. Complete, accurate, and timely documentation is therefore critical.


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