Spotlight on Prevention: Best Practices for Body Checks
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Spotlight on Prevention Partnering to Protect People with Special Needs
BEST PRACTICES FOR BODY CHECKS
This toolkit was created to provide information and resources to support the safety of people who require assistance to identify and report illness, injury, abuse, or neglect.
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Spotlight on Prevention: Best Practices for Body Checks
www.justicecenter.ny.gov
SPOTLIGHT OVERVIEW BACKGROUND
THE ISSUE People receiving services may not be able to report pain, injury, or illness, or may not recognize abuse or neglect. Body checks are an important tool to assess a person for these issues. The timing and manner of conducting body checks are key to their effectiveness in safeguarding people receiving services. Body checks can be used to determine if an injury has occurred, the extent of an injury, if there has been a change in a person’s condition from the time of admission, or to obtain a baseline of information. Body checks should be conducted routinely according to plans of care for people receiving services and after events such as falls, elopement, or restraints. Staff require training to understand the importance of completing body checks, documenting the findings, and seeking medical assistance when required. Preserving the privacy and dignity of people receiving services is also a critical component of the body check process. Sensitivity training is recommended for all staff who provide direct care as well as others involved in the body check process.
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Spotlight on Prevention: Best Practices for Body Checks
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INDEX TABLE OF CONTENTS
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Best Practices for Completing Body Checks Staff Actions Agency Considerations Sensitivity Skills Policy Guidance on Best Practices for Body Checks Case Studies Could This Happen In Your Program? Answer Key Sample Body Check Form
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Spotlight on Prevention: Best Practices for Body Checks
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BEST PRACTICES FOR COMPLETING BODY CHECKS
Spotlight on Prevention: Best Practices for Body Checks
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STAFF ACTIONS Body checks are an important tool to assess a person for injuries, illness or possible abuse and neglect. The timing and manner of conducting body checks are key to their effectiveness in safeguarding people receiving services.
COMPLETE BODY CHECKS AS REQUIRED Follow guidance in plans of care to conduct and document body checks on people receiving services. Note any marks or injuries found. Follow agency policies to complete checks after situational events such as a restraint, elopement, or a fall. When marks or injuries are noted, conduct and document body checks until all marks or injuries are healed. Seek medical attention from nursing, primary care physicians, or urgent care for any marks or injuries that require medical care.
DOCUMENT, DOCUMENT, DOCUMENT Write clearly to ensure that fellow staff, nurses and managers will be able to read the body check form. This will save time later. Don’t forget to sign and date the body check form. Include a printed name and staff title next to all signatures
BE DESCRIPTIVE
Include details when documenting marks or injuries found during body checks. Note whether it was completed for the person’s whole body or just one area, whether marks or injuries were old or new, their size, color, and location. For example: a quarter-sized faded bruise, light purple in color, was located on the person’s shin bone, just below his right knee.
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Spotlight on Prevention: Best Practices for Body Checks
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STAFF ACTIONS
ADD A PHOTO?
Check agency policies for requirements or restrictions on photographing marks or injuries found during body checks. This includes photographs to document an injury or the absence of one if it is being completed after an incident or the progression of an injury following its initial identification. Check with a supervisor or manager before taking a picture to confirm it is ok to do so. Avoid using a personal cell phone to take or text any photographs of people receiving services. Remember your HIPAA training!
PRACTICE SENSITIVITY
Consider the person’s feelings and what they need to feel comfortable and safe when preparing to conduct a body check. Explain what will happen before beginning the body check and while completing it. When possible, fit the body check into the person’s normal routine and have it completed by a preferred staff. Demonstrate understanding and patience if a person refuses to consent. Document the refusal and seek support from a manager or a supervisor.
FILL IN THE BLANKS
Complete all areas of the body check form and don’t leave any blanks. Include the type of mark or injury, the location, possible cause, whether the person required medical treatment, and whether the nursing department was notified.
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Spotlight on Prevention: Best Practices for Body Checks
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AGENCY CONSIDERATIONS
POLICY AND PROCEDURE
Review policies and procedures to ensure they provide clear guidance on how and when to complete body checks. Ensure policies address the importance of preserving the dignity and rights of people receiving services during this process. Provide staff practical guidance on how to respond if a person does not agree to undergo a body check. Address requirements for photographing marks or injuries and provide guidance for staff to use agency issued equipment for taking or transmitting photographs of people receiving services.
MEDICAL CARE
Train all staff to access nursing supports or other medical care such as a primary care physician or urgent care if needed when marks or injuries are discovered during the body check process. Provide training to staff on signs and symptoms of illness to assist staff in recognizing marks, bruises, or injuries that require medical attention.
FORMS
Use a body check form that has clear directions for completing and documenting the body check. Ensure the form instructs staff to answer questions and fill in blanks to capture as much information as possible. Structure the form to record whether marks or injuries are new or previously noted, the worsening or healing of previously identified marks or injuries, and whether a whole or partial body check was completed. Include a space on the form for staff to describe their findings.
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Spotlight on Prevention: Best Practices for Body Checks
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AGENCY CONSIDERATIONS
NURSING INVOLVEMENT
For programs that have nursing supports, consider how often and when nurses should review body check documentation and instruct staff on when to alert nursing for any marks or injuries discovered. Provide space on the form for the nurse to describe their findings.
THE BUDDY SYSTEM
Whenever possible have two staff conduct the body check so one staff can witness and verify findings.
DOCUMENTATION REVIEW
Review body check documentation on a regular basis to ensure it is thorough, accurate, and completed as required by plans of care for people receiving services and following situations such as restraints, falls, or elopement. Provide support to staff who may need additional training or follow up to thoroughly document body checks.
TRAINING
Provide comprehensive training to staff on the importance of completing body checks and the role they play in safeguarding people receiving services. Incorporate specific sensitivity skills into training to help safeguard privacy, dignity, and respect for people receiving services during this process. Train staff to recognize when marks or injuries found may be a sign of abuse or neglect and require reporting to the Justice Center.
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Spotlight on Prevention: Best Practices for Body Checks
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SENSITIVITY SKILLS SUGGESTED PRACTICES
Body checks used to determine the presence of marks or injuries on people receiving services are an invasive process that should be conducted in a respectful and supportive way. The list below is provided to support training and practicing of sensitivity skills for body checks and other direct care tasks. ENVIRONMENT
ASK PERMISSION Ask permission before beginning the body check. For example, “I’d like to take your shirt off so I can do your body check. Is that okay with you?” OFFER CHOICES Offer choices. For example, “Would you like to take your shirt off or do you want help?” or “I can help with that now or we can wait until Chris is free if you prefer.”
Conduct the body check in a private and comfortable room. Choose a location that is separate from other people receiving services and has a door that can be closed. KNOW THE PERSON Complete all training on plans of care for people receiving services so staff is familiar with their background, diagnosis, strengths, needs, experiences, preferences, and accessibility needs. KNOW YOURSELF Be aware of your own personal biases, triggers, comfort with the person and/or their diagnoses to maintain a therapeutic approach. EXPLAIN THE PROCESS Let the person know you value and respect them. Tell the person what you are doing or planning to do before beginning the body check. For example, “I heard you just fell. It’s important that we check your body to know if you hurt yourself.”
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Spotlight on Prevention: Best Practices for Body Checks
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SENSITIVITY SKILLS SUGGESTED PRACTICES EMPATHY - PERSPECTIVES Take part in sensitivity training exercises that will help you better understand the experience of people who are different from you. For example: walk across a room blindfolded, or be fed by another person, or hear challenges that people who are different from you experience. EMPATHY - ACKNOWLEDGE MISTAKES Apologize when mistakes are made. For example, “I am sorry that I touched the controls on your wheelchair without asking first.” or “I am sorry that I did not explain why I took that picture and who will see it.” Show patience and interest in learning and understanding the person. Show that you are listening by remaining attentive, quiet, and accepting. EMPATHY - LISTENING & ATTENTIVENESS
EMPATHY - REFLECT & VALIDATE Reflect what you hear or see the person communicating. For example, “I see you pulling away. Do you need me to do something differently?” or “I heard you say you want Yolanda to help you instead…”. Validate the person. For example, “I can understand why you feel more comfort- able with more familiar staff. Do you want me to ask Yolanda if she can help you instead?”
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Spotlight on Prevention: Best Practices for Body Checks
www.justicecenter.ny.gov
POLICY GUIDANCE ON BEST PRACTICES FOR BODY CHECKS
Spotlight on Prevention: Best Practices for Body Checks
www.justicecenter.ny.gov
POLICY GUIDANCE ON BEST PRACTICES FOR BODY CHECKS This policy guidance was created by the New York State Justice Center for the Protection of People with Special Needs as a resource for provider agencies. It does not address every scenario that could occur and does not constitute legal advice. It is intended for use as a guide that may be modified as needed. Agencies should also make sure policies include or address the specific considerations noted below. TRAINING SUPPORTS & SAFEGUARDS
Require body check requirements to be included in plans of care. Require body checks after situational events such as restraints, elopement, falls, before and after home visits, upon discharge from a hospital, nursing home, rehabilitation facility, upon admission, etc. Provide guidance regarding the ability for a person receiving services to consent to or refuse a body check. Identify when marks or injuries found during body checks require medical attention or reporting to the Justice Center. Structured to record the documentation of checks until marks and injuries are healed or resolved. Reflect whether the body check is a whole body or partial body check. Require a manager or nursing review. Require printed staff names in addition to staff signatures. Include space for staff and nursing to write a free narrative of any marks or injuries found. Are maintained in an organized and easily accessible manner. 11
Establish staff training requirements for how and when to complete body checks. Establish skill-based sensitivity training requirements for staff. Require staff training on plans of care that include body check requirements. Identify mechanisms for training all staff, including float or relief staff, on plans of care to ensure they are completed as required. Include training requirements of recognizing and reporting abuse and neglect. Emphasize privacy and respect for people receiving services during the body check process. List requirements or limitations to photograph marks or injuries and use of agency equipment to take or transmit photos. Require two people whenever possible to complete body checks. Identify how often body check documentation will be reviewed to identify any concerns or systemic issues. Note who is responsible for reviewing body check documentation.
BODY CHECK FORMS
Spotlight on Prevention: Best Practices for Body Checks COULD THIS HAPPEN IN YOUR PROGRAM?
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www.justicecenter.ny.gov Spotlight on Prevention: Best Practices for Body Checks COULD THIS HAPPEN IN YOUR PROGRAM? CASE STUDY Case #1 Mary lives at the Main Street IRA and is mainly non-verbal. She recently had several falls at the IRA. Staff documented the falls, completed body checks afterward, and alerted nursing to the fact that Mary was falling a lot. Mary’s nurse made an appointment for her to see her doctor and wrote a note in Mary’s communication log for staff to be aware that Mary had an upcoming appointment and to remind staff of Mary’s increased risk for falls. That weekend, the Main Street IRA was staffed primarily with relief staff, some of whom had never worked there before. Mary tripped and fell as she was walking from the living room to the kitchen. She immediately stood up and continued to the kitchen where she used sign language to ask for some juice. The staff poured Mary some juice, patted her on the back and said, “Glad you’re okay Mary! Did you have a nice trip?” The staff did not document the fall, did not contact nursing about the fall and did not complete a body check to look for any injuries. When Mary saw the doctor, he noticed that Mary had a large bruise on her knee.
CASE CONCERNS
Use the space below to identify the case concerns. Answers can be found in the back.
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www.justicecenter.ny.gov Spotlight on Prevention: Best Practices for Body Checks COULD THIS HAPPEN IN YOUR PROGRAM? CASE STUDY Case #2 Alyssa eloped from her residential treatment program. She was located and returned to the treatment program two days later. Staff informed Alyssa that she would need to see the nurse to have a body check. Alyssa said,”I don’t need one, I’m fine.” Staff told Alyssa that the body check was required by policy and told her “You need to let the nurse check you. The sooner you comply, the sooner this will be over with.” Alyssa continued to refuse to see the nurse for the body check and became more and more agitated as staff insisted that she do so. Finally, staff offered Alyssa a PRN medication because she was so agitated.
CASE CONCERNS
Use the space below to identify the case concerns. Answers can be found in the back.
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www.justicecenter.ny.gov Spotlight on Prevention: Best Practices for Body Checks COULD THIS HAPPEN IN YOUR PROGRAM? CASE STUDY Case #3 Henry was required to have body checks completed three times a day at each change of shift due to his history of self-injury. During a team meeting before Henry’s annual review, staff reported that Henry was responding well to the new strategies in his Behavior Support Plan and was not self-injuring as much. The behavior intervention specialist (BIS) said, “Great, that’s awesome to hear!” and proceeded to pull the occurrence reports and body check forms from the past year to review the data so Henry’s plan could be updated. But when the BIS looked at the body check forms, he found that many were missing and the forms that were completed were either missing information or were messy and staff’s handwriting was hard to read. This resulted in the inability of Henry’s plan to be updated.
CASE CONCERNS
Use the space below to identify the case concerns. Answers can be found in the back.
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www.justicecenter.ny.gov Spotlight on Prevention: Best Practices for Body Checks COULD THIS HAPPEN IN YOUR PROGRAM? CASE STUDY
Case #4
Lucas had just returned to work from a week-long vacation. He immediately noticed that Sean, one of the people receiving services, had a large bruise on his arm. He looked in Sean’s binder of personal information and the house communication log but did not see any occurrence reports or body check documentation about the bruise. Lucas took a picture of the bruise with his personal cell phone and texted the photo to his friend and co-worker Brian who had worked with Sean while Lucas was on vacation. Lucas texted “What happened to Sean??“
CASE CONCERNS
Use the space below to identify the case concerns. Answers can be found in the back.
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www.justicecenter.ny.gov Spotlight on Prevention: Best Practices for Body Checks COULD THIS HAPPEN IN YOUR PROGRAM? CASE STUDY
Case #5
Kareem requires arm’s length, line of sight supervision at all times and receives body checks on each shift. While staff were assisting him in theshower, they noticed a large bruise on his left side. Nursing was contacted and Kareem was taken to the hospital and diagnosed with a fractured rib. No one knew how or when Kareem was injured. A review of the body check forms for the days prior to staff discovering the bruise revealed that body checks were not completed on each shift as required, some completed forms did not document the bruise at all, some completed forms noted the bruise as “old”, and some completed forms noted the bruise as “other.” Staff also reported that body checks were completed while the person was fully clothed.
CASE CONCERNS
Use the space below to identify the case concerns. Answers can be found in the back.
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ANSWER KEY
Spotlight on Prevention: Best Practices for Body Checks
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ANSWER KEY COULD THIS HAPPEN IN YOUR PROGRAM?
Case #1
Case Concerns
• Relief staff did not review the communication log and did not know about Mary’s history of falls. • Staff did not complete a body check after Mary’s fall, document the fall, or alert nursing. • Staff did not ask Mary if she was hurt. Although Mary is primarily non-verbal, she may have been able to indicate if she felt any pain or point to a body part that hurt. • Staff did not treat Mary with respect when they teased her about the fall. • There were no other body checks documented for Mary in the days following her fall so staff were not aware of the bruise on her knee.
Case #2
Case Concerns
• Staff did not demonstrate sensitivity to Alyssa’s apprehension about the body check which led to an increase in Alyssa’sagitation and her needing a PRN medication. • Staff did not attempt to contact the nurse to come see Alyssa or reassure her that her privacy and dignity would be respected during the body check process. • Staff were not trained on what to do when a person receiving services refuses a body check.
Case #3
Case Concerns
• Staff did not complete and document body checks as required by the plan of care. • The body check forms that were completed were either incomplete or the staff’s handwriting was hard to read. • The body check forms were not routinely reviewed by a manager or a nurse so missing, incomplete, or illegible documentation could not be addressed in a timely manner. • The body check forms were not routinely reviewed to identify trends, concerns, or systemic issues.
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Spotlight on Prevention: Best Practices for Body Checks
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ANSWER KEY COULD THIS HAPPEN IN YOUR PROGRAM?
Case #4
Case Concerns
• Lucas used his personal cell phone to take a picture of a person receiving services. • Lucas texted a photo of the person receiving services to his friend. • Sean’s bruise was not documented on any body check form. • Once he discovered the bruise, Lucas did not document it on a body check form, complete an occurrence report or notify a supervisor of the bruise.
Case #5
Case Concerns
• Body checks for Kareem were not completed on each shift as required. • Body checks were completed while Kareem remained clothed and did not reveal his bruise. • Body check documentation was not consistent. Some staff marked the bruise as “other” and some marked the bruise as “old.” • The body check forms were not routinely reviewed to identify missing documentation, trends, concerns, or systemic issues.
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Spotlight on Prevention: Best Practices for Body Checks
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SAMPLE BODY CHECK FORM
Spotlight on Prevention: Best Practices for Body Checks Spotlight on Prevention: Best Practices for Body Checks
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www.justicecenter.ny.gov SAMPLE BODY CHECK FORM Instructions: Mark on the diagram the location of the injury with the corresponding letters from the key below. Whenever possible, 2 staff are to complete the body check.
Name _______________________________ Date ______________________ Time _________________
Check here if no marks or injuries noted.
KEY
A - Abrasion/Scratch
C - Cut/Laceration
BL - Blister
BL - Blister BU - Burn/Scald P - Possible Head Injury Other:
ST - Skin Tear B - Bite (human/animal) SW - Swelling
O - Open Area/Wound SO - Sore/Tender N - Nothing Noted
BR - Bruise/Discoloration D - Damaged Teeth RA - Rash
Circle one:
Whole Body Check
|
Partial Body Check
If partial body check, what areas were not checked? ____________________________________________
Description of Findings:
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Spotlight on Prevention: Best Practices for Body Checks Spotlight on Prevention: Best Practices for Body Checks
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www.justicecenter.ny.gov Possible cause of mark or injury?
Were marks or injuries noted on previous body check? Y or N Date of previous body check: _________________________
Comments? __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________
Injury above the neck? Y or N If yes, was Head Injury Protocol started? Y or N
RN notification of marks or injuries? Y or N Person notified (print clearly): _________________________ Date/Time notified: __________________________________ Notified by (print clearly):_____________________________ Manager/Supervisor notification of marks or injuries? Y or N Person notified (print clearly): __________________________ Date/Time notified: ___________________________________ Notified by (print clearly): ______________________________ Family notified of marks or injuries? Y or N Person notified (print clearly): ___________________________ Date/Time notified: ____________________________________ Notified by (print clearly): _______________________________
Photos taken? Y or N Note: Only agency issued equipment to be used for taking photos.
Findings noted in Communication Log? Y or N
RN Review/Findings: ______________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ RN (print): ________________________ Sign: _______________________ Date: _____________ Manager Review/Findings: _________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Manager (print): ________________________ Sign: ___________________ Date: _____________
Staff (print): ____________________________ Sign: ___________________ Date: _____________ Witness (print): _________________________ Sign: ___________________ Date: _____________
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Spotlight on Prevention: Best Practices for Body Checks
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www.justicecenter.ny.gov | 1 (800) 624-4143
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