The Daughter Who Does Not Want the Safety Concerns Documented

Document objective, measurable facts and the patient's or caregiver's statements as statements, not as conclusions. Include Ms. R's cognitive presentation and ability to recall the stove incident and burn; the daughter's request not to document; medication nonadherence (donepezil missed three times); the stove incident; the 3-cm healing burn and Ms. R's inability to explain it; your safety assessment; and the physician notification. Do not write 'patient safe and well cared for' if the evidence does not support it; do not omit the medication and stove information; and do not alter the record later to satisfy the daughter. If the daughter's request is relevant to the plan or creates a safety concern, document that the request was made and how you responded. Use quotes where possible for key statements. Complete the note within the agency's 24-hour requirement. Notify the physician as required and document the time, method, and response. If you suspect abuse or neglect of a vulnerable adult, make the required report and document that separately.

Ms. R retains confidentiality and the right to make her own decisions unless a court has appointed a guardian or a valid durable power of attorney for health care authorizes the daughter to act. A HIPAA authorization lets the daughter receive information; it does not make her the decision-maker or give her the right to direct you to falsify or omit clinical findings. You should speak with Ms. R directly, at her level, and assess her capacity to understand the safety issues. If she can participate, obtain her preferences about the daughter's involvement. If she lacks decision-making capacity for a specific issue, follow Nevada law and facility policy for identifying a surrogate; do not simply treat the daughter's request as consent. Explain to the daughter that you can involve her but cannot document untrue statements. Share only the minimum necessary information with the daughter and others. If the daughter pressures you or interferes with care, document and escalate to your supervisor.

It may. A healing burn of unknown cause, a stove left on, medication nonadherence, and memory impairment in an 82-year-old who cannot recall the injury create reasonable suspicion of self-neglect or neglect of a vulnerable adult. Nevada mandatory reporting laws require certain health professionals, including OTs in relevant settings, to report suspected abuse, neglect, or exploitation of older or vulnerable adults to the appropriate agency, typically Adult Protective Services or law enforcement. Do not investigate the daughter or try to prove who caused the burn; that is not your role. Ensure immediate safety, call the physician, and make the report promptly under Nevada law and agency policy. HIPAA permits disclosures to public health or protective services as required by law. Document the facts reported, the agency and person contacted, the time, and any instructions received. Do not tell the daughter that you made a report if doing so could endanger Ms. R; follow the reporting agency's guidance.