One of the hardest decisions for many Missouri and Illinois families to reach when a loved one becomes unable to care for themselves is whether or not to place them in a nursing home. It is an unfortunate truth that nursing home abuse and neglect does happen, and it can not only physically injure the elderly resident but also leave the family scrambling to cover further medical and other related expenses. Some families may feel overwhelmed when it comes to proving that nursing home abuse or neglect has even taken place. That is where our St. Louis personal injury law firm can step in to assist.
Federal law requires all nursing homes which receive Medicare and Medicaid reimbursements to follow certain standards in care and recordkeeping. Families may not realize this, but they have the right to request — and receive — a copy of a patient’s records within 24 hours after requesting it from the nursing home facility.
Records which can help prove nursing home and neglect include the following:
• Hospital records just prior to admission in a nursing home;
• Admission evaluations upon entering the nursing home;
• A comprehensive plan of care for the resident, which must be established no later than 14 days after admission to the facility;
• Interdisciplinary and nursing notes from the resident’s chart, which detail the daily care and changes in condition to a patient;
• Physician entries that must occur upon admission and at least every 30 days for the first 90 days, then on a regular basis;
• Records of therapy which detail the assistance and education a resident receives for physical therapy (related to balance, mobility and ambulation) and occupational therapy (for activities of daily living like washing, dressing, eating and toileting);
• Medication and treatment administration records. Also referred to as MARs and TARs, these represent monthly charts that are maintained by the licensed nurses on staff at the nursing facility and detail not only the medications and care that a physician orders for the resident, but also how those medications and care were actually carried out;
• ADL flow sheets showing how certified nursing assistants (or CNAs) assisted a resident in the basics of custodial care with items like cleaning, eating, walking and moving in bed (to avoid development of bed sores/pressure ulcers);
• Minimum data sets (MDS). These are part of the federal mandates under Medicare and Medicaid payment guidelines, and require facilities to detail certain aspects of a resident’s underlying medical conditions, capacity to function, what care needs they have and other items;
• Investigation reports. These are prepared in the event that a serious injury occurs to a resident, and are typically required to be presented to the state’s department of health or other supervisory office;
• Laboratory and imaging studies showing detailed images of any fractures or other injuries a patient may have suffered;
• Photographs showing pressure ulcers or other injuries, which some nursing home facilities still maintain; and
• Electronic charts and computer audit trails which are becoming more common with the advent of mobile computers used in healthcare.
While the list of records that could become critical in proving that nursing home abuse or neglect has taken place might seem extensive, this is a process that our St. Louis personal injury law firm is experienced in conducting. We can help the families of Missouri and Illinois victims injured due to nursing home abuse or neglect obtain the answers they seek, and pursue financial restitution from the facility believed responsible for causing the injuries to their loved one.
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Source: “Nursing Homes: Use the resident’s records as a road map” by Martin S. Kardon. October 2013, Volume 49, No. 10.