The Record That Changed
Mr. L is a 78-year-old man with moderate dementia who lives with his daughter. He attends PT for gait training after a hip fracture. During a session, the PT notices a 6 cm bruise on his upper arm and a smaller bruise near his ear. The daughter says he 'falls a lot' and answers all questions for him. When the PT asks Mr. L privately, he says 'she gets mad when I spill.' The PT writes in the note 'patient declined to discuss' and later, after the daughter complains, adds 'no signs of abuse.' The clinic's office manager tells the PT not to report because 'it will ruin the family and we don't have proof.' The daughter then requests a copy of the record. Mr. L is also on contact precautions for MRSA; the PT notices the treatment table was not cleaned between patients and an aide used the same gait belt.
1. What are the PT's reporting obligations and documentation obligations after the bruising disclosure?
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The PT has reasonable suspicion of elder abuse or neglect and must report it under DC mandatory reporting law. The bruising pattern, the patient's statement, and the daughter answering for him are enough to trigger a report; proof is not required. The PT should report to Adult Protective Services or the police as the statute directs and document the objective findings, the patient's exact words, who was present, and the report. The note 'patient declined to discuss' is incomplete and potentially misleading. The later addition 'no signs of abuse' should not be made; it contradicts the findings. A late entry should be labeled as late, dated, and timed, and the original note should not be altered or destroyed.
2. How should the PT respond to the daughter's records request and the office manager's instruction?
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The daughter may have a right to records if she is the patient's personal representative, but the PT should not let that override the abuse report. The PT can disclose to APS as required or permitted by law. The office manager's instruction not to report is unlawful and should not be followed. The PT should escalate to a supervisor or compliance officer, make the report, and seek legal guidance on the records request. The PT should not alter the record to appease the family.
3. What infection-control and safety issues are present, and what should the PT do?
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MRSA contact precautions require hand hygiene, gloves and gown as indicated, cleaning the treatment table between patients, and not sharing gait belts without disinfection. The aide's reuse of the gait belt and the uncleaned table are breaches. The PT should stop the session, clean and disinfect, use a dedicated belt, and report the breach through the clinic's infection-control process. The PT should also ensure staff are trained and document the corrective action.