“DIY” NURSING HOME NEGLIGENCE CASE EVALUATION

The following discussion offers ways in which to conduct a preliminary examination of the care records of a nursing home resident to determine if he or she has been the victim of negligence.  The suggested approaches should be useful not only to attorneys who are considering taking on potential lawsuits, but also to friends and family members who wish to see how their loved one was or is being treated.

Nursing home negligence is generally defined as a failure on the part of the nursing home to provide one of its residents with necessary medications and/or care services.  Examples include failing to take necessary precautions to address the resident’s risk of (1) developing skin breakdown; (2) developing pressure ulcers; (3) developing infections; (4) becoming malnourished or dehydrated; (5) having falls, accidents, or altercations; or (6) choking or aspirating.   

Even a person without legal or nursing training should be able to make an effective initial evaluation of a potential negligence action by reviewing certain portions of the resident’s nursing chart.  The facility must provide the nursing chart upon request to an authorized representative of the resident, although it may charge copying costs.    

Once you get the nursing chart, here is a suggested approach for how to decipher it.

1. Hospital Discharge Records.  In cases where the resident came to the nursing home from a hospital or other institutional provider, your review should begin with the hospital discharge summary and treatment orders.  These documents, which are normally sent to the facility from the hospital for inclusion in the resident’s nursing home chart, should establish the resident’s overall condition, medications, treatments, care needs, and risk factors as of the time he or she arrived at the nursing home.  If you don’t understand some of the diagnoses or medical terms you come across in these records, try looking them up at WebMD or some similar internet site.  
2. Physician’s Orders.  Next, you should look at the physician’s orders for the resident, which should be set forth both in an order sheet and in telephone order slips contained in the nursing chart.  By comparing the physician’s orders to the hospital discharge orders, you can identify any discrepancies between them.
3. Assessment Forms.  Next, take a look at all assessment forms completed by the nursing home for the resident upon admission.  These are documents that set out the resident’s medical condition and functional abilities.  They often assign scores to measure the resident’s risk of falls, developing pressures sores, and the like.  You should check to see that all concerns reflected in the hospital discharge papers were addressed by the nursing home in its assessment forms.
4. Minimum Data Set.  In investigating the resident’s condition upon admission to the nursing home, it is important to examine the resident’s Minimum Data Set (“MDS”) form, which is a comprehensive assessment document that nursing homes are required to prepare.  It is often the case that the MDS form will identify concerns, such as prior falls, skin breakdown, weight loss, incontinence, and behaviors, which the facility must address.  The MDS form will also identify activities with which the resident requires assistance, such as ambulation, transfers, bed mobility, and toileting, as well as the number of caregivers required to provide such assistance.
5. Care Plan.  Next, you should review the resident’s individualized care plan, which must be prepared upon admission to the nursing home and updated on a regular basis to reflect changes in the resident’s condition.  The care plan will not only identify problems that must be addressed, but will also list the interventions to be used by the facility to address them.  Often the possible interventions will be set forth in a pre-printed checklist with the measures to be put in place checked off.  Changes in the care plan are to be dated and typically are accompanied with a brief explanation of why they were made.  Normally, there should be a physician’s order to support such changes. 
6. Nursing Notes.  Once you have identified those care plan measures that the facility has deemed necessary and appropriate for the resident, as well as the needs such measures were meant to address, you should review the facility’s contemporaneous care records to determine whether and to what extent those measures were actually carried out. You should review the nursing notes to ascertain the care that the resident received, as well as changes in the resident’s condition that might suggest the need for changes in care plan interventions.  Situations to be looked for in the nursing notes include unsafe ambulation; falls; development of skin breakdown, infections, or contractures; weight loss; dehydration; combative or noncompliant behaviors; changes in continence status; and changes in mental or functional status.  
7. Medication and Treatment Administration Records.  You should then examine the resident’s Medication Administration Records (“MARs”) and Treatment Administration Records (“TARs”), which reflect when the resident received ordered medications and treatments.  Look for blank spaces in the MARs and TARs which indicate that an ordered medication or treatment was not given.  If a resident refuses a medication or treatment, the standard practice is for the caregiver to place his or her initials in the appropriate box on the MAR or TAR and circle them to indicate this fact.  A blank space on the MAR or TAR is thus a good indication that something was not done which should have been done.  A MAR or TAR with many holes in it is referred to by some in the nursing home trade as “Swiss cheese.”  As a quick but reliable test of the accuracy of MARs and TARs, you should check the care entries against the dates of the resident’s admission and discharge from the facility, as well as the dates of any hospitalizations (these should be reflected in the nursing notes) for evidence that care was being charted when the resident was out of the facility.  A MAR or TAR which contains entries for when the resident was absent from the facility is referred to by some nursing home practitioners as “baloney.”  

Looking at a nursing home chart can be a daunting prospect, even to a seasoned nursing home litigator.  However, by taking selected portions of the chart and reviewing them in an orderly and common-sense manner, even an individual with no legal or nursing training should be able to gain at least an initial understanding of whether the nursing home adequately and appropriately identified and met the care needs of his or her loved one.  

If your examination of the nursing records suggests that the nursing home did a good job of recognizing and meeting the needs of your loved one, the effort spent to obtain and review the records should be rewarded with peace of mind on your part.  If, on the other hand, your review causes you concern about the possibility of your loved one being or having been neglected or mistreated by the nursing home, you should, of course, consider contacting an experienced nursing home lawyer Maryland trusts to explore your options.       

Thanks to our friends and contributors from Brown, Gould, & Kiely LLC for their insight into nursing home negligence.