Safety
Elderly people frequently have visual, hearing, and mobility issues. Thus, the safety of the physician’s office environment is critical from a risk management perspective. The staff should perform a weekly or more frequent safety review of the premises. The results of premises checks must be documented and retained. If defects are observed, the physicians and/or landlord(s) must promptly make arrangements for repairs. All necessary repairs must be carried out in a timely manner for patient safety.
The immediate sidewalk must also be in good repair. Snow and ice removal must be performed on a regular basis. If it is necessary for the patient to step up from the parking area to a curb, the step must be of reasonable size and in good condition. Sidewalks and steps are also frequent sources of falls, which result in general liability claims and lawsuits.
It is recommended that a wheelchair be available in the office, in the event a patient requires one during the visit. Chairs in examination rooms should have arms to assist patients to a standing position. Grab bars should be available at scales. The waiting area should be able to safely accommodate patients who use walkers, canes, and wheelchairs and contain no hidden obstacles or dangers. For patients who have the ability to climb stairs to reach the office, the steps must also be evaluated for safety, including whether there are secure railings. All permanent and temporary floor/steps coverings or carpets must also be secured. One of the most frequent causes of falls to patients is the temporary carpet used only during inclement weather, and particularly during the winter. These floor coverings often buckle or slide and must be fully taped down and checked daily to prevent trips and falls by patients and other visitors. Wet floors pose another risk. Spills must be cleaned up promptly. Bathrooms must be kept clean and dry. Bars and other assistive devices must be present to make the bathroom safe and fully handicapped accessible. Completion of all regular room safety checks should be documented daily in a log.
Examining rooms also contain risks for the elderly patient. They should be sufficiently large to easily accommodate a patient in a wheelchair. It may be difficult for many patients to step up or down unattended from the examining table and nursing staff should assist them. The staff must be educated about the proper use of such tables, and consistently lower the tables before the patient is assisted to move and step down. If a patient is confused, the staff should not leave the patient unattended. Serious injuries (e.g. fractured hip) can occur when an elderly patient is left alone, even momentarily, on an examination or x-ray table. Patients often attempt to sit up or move off of the table without assistance. Elderly patients often need to be first assisted from a reclining position to a sitting position, and allowed to remain there for a brief time before standing, to avoid their fainting or falling. Signs advising the patient to wait for assistance should be posted in large print in highly visible areas in these rooms. Necessary patient mobility equipment (e.g. canes and walkers) or personnel should be made immediately accessible to the patient, after a test or examination has been completed to enable them to move about safely. If indicated, patients may need assistance from the nursing staff to safely undress for and dress after an examination. Patients who are both elderly and obese require appropriate equipment which can accommodate their weight.
The Patient’s Home Environment
It is important for the physician to learn as much as possible about the patient’s home situation. An assessment should be made of the patient’s home environment, including whether he/she lives alone or with others, the patient’s eating habits, and who responds if he/she needs urgent or emergency help (Lifeline, family members, 911). The physician may need to refer the patient to an agency who can assess whether the home environment requires additional assistive devices, such as an elevated toilet seat or grab bar in the bathroom(s). If the patient does not shop for and prepare his/her own meals, it is crucial to determine how and when the patient receives food and/or cooked meals. If the patient has a problem with mobility on stairs, the physician may decide to prescribe adaptive devices which are available and can be installed. Finally, it is important to assess whether the patient can perform household chores, requires housekeeping assistance, or whether the delivery of prescriptions or medication dispensing by a nurse or competent relative, friend, or third party is required. Geriatric patients are often reluctant to tell the physician when they are unable to pay for food, rent, and medications. Thus, the patient may not be compliant in taking all prescribed medications, and as a result, may become ill. Therefore, it is important to ask the patient about these issues and also provide these patients with information about less costly or free medication programs.
Elder Abuse
There is often a darker side which may be uncovered when providing medical care to the elderly. Elder abuse is far more common than most physicians realize. As with child abuse, signs include: a patient with numerous unexplained bruises; the patient’s fear of speaking in the presence of a controlling third party; a third party who answers all questions for the patient and/or never permits the patient to be alone with the physician; the presence of unexplained broken limbs; and a patient with extremely poor hygiene and nutrition. Adult Protective Services should be contacted if the physician reasonably believes the patient is in danger of his/her life and health. If nursing care at home is required to protect the patient’s safety, there are agencies available to provide such services. However, if the patient and the family refuse to have these services in the home, the physician’s recommendations must be well documented in the record and Adult Protective Services notified if indicated. This is crucial in the event the patient is later injured or dies from neglect or abuse.
Elder Bias
Treating geriatric patients can be rewarding as long as the physician realizes the frailty of this patient population. Assessment of these patients and formulation of care plans can be complex. The treatment plan must be thoughtful and comprehensive. A physician must also examine his/her own feelings about treating or not treating elderly patients, particularly those who are terminally ill or face end of life decisions. For example, it may require great effort for the patient to simply get to the office for a scheduled appointment, and therefore the patient may have a higher expectation that the physician will pay close attention to his/her needs. Such patients may require more time at routine office visits, or more intensive efforts in providing instruction and information. Moreover, it is not uncommon for a seriously ill patient to receive less aggressive treatment than indicated, merely because the patient is elderly, even though the patient might well benefit from the treatment and not suffer serious consequences. If the physician is committed to building a relationship with the patient, and is prepared to accept the challenges of this population, patient safety will be enhanced and the risk of liability will be minimized.
Our next issue of Risk Review will cover older drivers and end of life decisions.