How Are Nursing Home Medical Records Used as Evidence in Abuse Cases?

Before you helped your loved one transition to their nursing home, you probably researched several facilities. You checked out their ratings and went on tours to meet the staff and inspect the rooms yourself. That’s exactly what you should do before you entrust the care of your loved one to a facility’s management.

Unfortunately, even after all your due diligence, an incident of abuse can still occur. This can be an isolated incident or an ongoing pattern of neglect due to understaffing or undertraining. Whatever the reason, you are entitled to seek a remedy, but that will depend a lot on the evidence you present in support of your claim. The strongest evidence might be found in the nursing home records. 

What Are the Essential Nursing Home Records

You expect the nursing home to keep records about your loved one, but you might not be aware of the full extent of those records. If there is an issue of neglect, all of those records should be analyzed and considered as evidence in your claim. Here’s what you should get copies of:

• Admission Face Sheet: This is the first form you filled out for your loved one. It contains basic demographic data, emergency contacts, insurance information, and legal representative details.
• Comprehensive Care Plan: The most important nursing home form is the comprehensive care plan. It outlines specific, measurable goals, identifies health risks, and details individualized staff interventions.
• Minimum Data Set (MDS): This is a federally mandated, periodic health assessment that evaluates functional capacity, cognition, and routine clinical needs of every nursing home resident.
• Physician Orders: The nursing home provides medical care for its residents. Each resident is also entitled to have their own independent doctor. Physician orders can authorize medications, dietary requirements, treatments, diagnostic tests, and therapy referrals.
• Medication Administration Records (MAR): These chronological logs prove exact times, dosages, and administration of prescribed drugs.
• Daily Nursing and Progress Notes: Staff who interact with your loved one daily should keep ongoing narrative logs tracking behavior, mood, physical complaints, and clinical observations.
• Vital Signs and Weight Logs: Regular tracking metrics used to catch sudden weight fluctuations, dehydration, or potential infections early.
• Incident and Accident Reports: This documentation details the context, witness accounts, and immediate medical responses following any type of fall or injury to your loved one.

These records are designed to provide a comprehensive overview of your loved one’s daily care. Gaps in recordkeeping or significant inaccuracies can be used as evidence of neglect.

Identifying Red Flags and Falsified Medical Entries

If you suspect your loved one is suffering from some type of abuse at their nursing home, the facility records will need to be reviewed. It can be overwhelming to sift through all these records to find a red flag, especially if you’re not sure what you’re looking for. An experienced nursing home abuse attorney can help decipher the records.

Look for writing crammed between lines or into tight margins to fit unauthorized late additions. If the ink or handwriting changes within a single progress note, that could also be caused by late additions. Look for physically scratched-out text, overuse of correction fluid, or completely blacked-out sections.

Some of these records will be kept electronically. In those cases, look for timestamp modifications that don’t match the clinical timeline of the visit. Also, look for identical, repetitive blocks of text across multiple patient encounter dates without updated assessments. 

The Legal Process for Obtaining Resident Records

Because most nursing homes work with Medicare for reimbursement, they fall under federal regulations. Under those federal laws, nursing home residents and their authorized legal representatives have the right to inspect any clinical and financial records within 24 hours of a request. You are also entitled to obtain copies within two business days to 30 days, depending on your state statutes. In order to obtain these records, you have to put a request in writing to the facility administrator. You’ll need to specify the resident’s full name, date of birth, and exact date ranges or record types needed. You must also include a signed, HIPAA-compliant authorization form if the facility’s compliance department requires it.

When your loved one’s care is at stake, My Nursing Home Abuse Guide has the resources to help you take action.