While working on a home healthcare case, a nurse uses a digital tablet add notes to a patient's electronic medical chart.
(Credit: SDI Productions / Getty Images)

DENVER—Risk management begins with documentation, and good processes and procedures can go a long way in protecting providers from lawsuits, according to a healthcare risk management professional.

Deborah Denham, RN, MSN, vice president of quality and risk management at Gardant Management Solutions, spoke Sunday at NCAL Day, part of Delivering Solutions 23, this year’s American Health Care Association / NCAL’s annual conference.

The top reasons for litigation, Denham said, include falls, pressure injuries, infections, choking/dehydration/malnutrition, elopement, medication errors, and abuse and neglect. And documentation is what attorneys will look at to build a case against a provider, she said.

Denham also noted that trends emerging in litigation include naming nurses and other staff members as defendants, criminal or civil actions against staff members, allegations of inadequate staffing levels, record production issues, and settlement demands equal to — or exceeding — insurance policy limits.

To set themselves up for the best defense, providers should have documentation in place, available and accurate. Denham said it is important for providers to have a regular audit process in place to periodically review documentation and notes, confirm the completeness of required documentation, and provide opportunities to educate employees about requirements.

With the medical record as the legal record of care provided, a lack of documentation translates in lawsuits to care not provided, poor documentation translates to poor care, and incorrect or missing documentation can lead to accusations of record falsification, she said.

“If it’s documented, it’s a lot easier to defend the care,” Denham said.

Documentation also is important because it ties into reimbursements for quality measures, reflects resident care, demonstrates the standard of care provided, and supports evidence of quality care with the details to support it. It also can help organizations identify gaps and improve documentation procedures, she said.

But just as important are factors outside of medical record, including good policies and procedures that are reviewed regularly, and education of employees and residents, Denham said. That education of staff members could help providers avoid “cringeworthy” items in documentation, including incomplete records, negative comments about employees, opinions injected into records, and lack of followup on unusual events.

Regulatory requirements to maintain medical records and to safeguard the integrity of those records also exist, she said. Failure to do so, Denham said, may result in legal liability in the form of a malpractice suit or independent liability based on the nondisclosure of information that should have been maintained. And, she added, the improper release of medical records or the destruction of records can lead to civil and/or criminal liability.

Denham said that it is important for providers to have a procedure and form in place that meets the standards for everything that needs to be written down. Many providers run into trouble when they convert paper records to electronic records, she said, so it’s crucial to have a good process in place to find records and ensure that everything is labeled.


AHCA/NCAL honored assisted living and skilled nursing providers who achieved National Quality Awards during an Elevating Excellence Awards Ceremony on Tuesday. Assisted living providers received eight Silver and 57 Bronze National Quality Awards.

Recipients of the AHCA and NCAL awards program also were recognized. NCAL award winners:

  • Sarah Silva, Arete Living president, received the 2023 Jan Thayer Pioneer Award
  • Cecilia Owsley, chief operating officer and chief nursing officer for Guardian Angel Homes, Post Falls, ID, receive the NCAL Leader of the Year Award
  • Mary Duncan, Lakeview Assisted Living office manager, Battle Creek, MI, received the NCAL Noble Caregiver Award.
  • Koko Okano, Florida Health Care Association quality improvement and research analyst, received the 2023 Mary K. Ousley Champion of Quality Award.

The AHCA/NCAL conference ends today.