This episode of Risk Insights Senior Living and Long-Term Care examines a topic that affects clinical care, operations, and litigation outcomes every day: documentation. Host Tara Clayton is joined by Kayla Meek, Vice President, Clinical Risk for Marsh’s Senior Living and Long-Term Care Industry Practice, and Jorie Zajihczek, an attorney with Quintairos, Prieto, Wood & Boyer, to explore how documentation functions differently across senior living settings and why those differences are often misunderstood by families, regulators, and juries. The discussion highlights a central tension in the industry: providers are expected to document enough to tell the resident’s story and support quality care, but not so much that documentation becomes impractical or burdensome.
The episode also offers a practical framework for improving documentation without losing sight of the real priority: resident care. Kayla and Jorie explain why “if it’s not documented, it didn’t happen” does not neatly apply in assisted living, where charting by exception has long been the norm. They discuss how strong documentation policies, meaningful staff training, leadership support, and objective language can help providers strike the right balance. Through real-world fall scenarios and litigation examples, the conversation shows that the most effective documentation is not exhaustive — it is timely, factual, consistent, and useful to both caregivers and those later asked to defend the care that was provided.
