Four RCFE Operational Breakdowns That Turn into Claims

Author, Jack Marrs, Account Executive, Rancho Mesa Insurance Services, Inc.

In Residential Care Facilities for the Elderly (RCFE), most claims do not start with just one huge mistake. They usually begin with small breakdowns that get repeated and eventually one incident turns into a complaint, a licensing issue, or a lawsuit. In my experience working with RCFEs, there are several areas that tend to lead to claims.

1) Falls and Transfers

Falls are common with older adults. According to the Center for Disease Control (CDC), once a person falls, they can become afraid of falling again, which leads them to be less active, resulting in them growing weaker and increasing the likelihood of another fall.

So, when a resident falls, ask :

• Was the environment safe (e.g., lighting, clutter, wet floors)?

• Was the resident supervised the way the care plan outlines?

• Did staff respond the right way?

• Does the documentation match what actually happened?

Even if staff did everything right, the facility can still get pulled into a claim if the story looks messy or inconsistent on paper.

RCFEs can reduce the risk of a claim by following regular risk management activities:

• Complete a daily hazard walk where you document that you checked the floors, rugs, cords, poor lighting, slippery bathrooms, call buttons, etc. through the SafetyOne™ mobile app.

• Make care-plan transfer rules non-negotiable (i.e., 1-person vs. 2-person assist).

• Use the same post-fall routine every time:

  - check the resident

  - monitor

  - notify family and stick to facts

  - document clearly

• Track patterns (i.e., same hallway, same time of day, same shift) and treat repeated falls like a system problem.

2) Medication Assistance Drift

Medication issues get serious fast. Even a small mistake can turn into an emergency room visit, a fall, or a family complaint. It also grabs attention because medication practices are a big focus area in RCFE licensing, according to the California Department of Social Services’ Medications Guide for Residential Care Facilities for the Elderly.

The biggest reason medication mismanagement turns into claims is the phenomenon called process drift, or more, specifically medication assistance drift, where over time, staff get busy, they rush, take shortcuts and steps get missed that are designed to safe guard medication administration.

RCFEs can reduce the risk of medication assistance drift by:

• Keep one clear, consistent Medication Administration Record system (i.e., clean, readable, auditable).

• Create a no-interruptions rule during medication assistance.

• Tighten controls for higher-risk medications.

• Complete quick refresher trainings, not just at onboarding.

3) Wandering / Elopement

Even if a resident is not hurt, families usually see their loved-ones wandering as a major failure in facility safety.

Facilities also have to balance safety with resident rights, which can come up during disputes, according to the California Code Regs. Tit. 22. § 87705 – Care of Persons with Dementia.

Facilities can reduce therisk their residents face from wondering by:

• Identifying at-risk residents early and document why they are a risk for wandering.

• Ensure alarms and door controls work and staff know how to respond.

• Treat shift change like a danger zone and implement a headcount routine.

• Keep expectations simple and documented.

4) Staffing Breakdowns

Staffing pressure can lead to rushed care, injuries, documentation issues, and human resources (HR) complaints. Many employment claims come down to inconsistencies within the workplace.

• RCFEs can help reduce the risk of these types of employment claims by ensuring they: Document training clearly.

• Build a basic modified duty and/or return-to-work plan.

• Keep HR documentation short and factual.

• Make it easy for staff to report issues early.

RCFEs do not need to be perfect in order to reduce claims. However, they just need to be consistent by running the same routines every time. This prevents incidents and strengthens the facility’s position when something does happen.

To discuss your facility’s operational risks, contact me at jmarrs@ranchomesa.com or (619) 486-6569.