The following documents relating to a resident's care and treatment should be gathered for use in determining the appropriate civil claims and remedies when abuse or neglect occurs.
Important Documents: Initial Review of
Nursing Home Case
The following documents relating to a resident's care and treatment
should be gathered for use in determining the appropriate civil claims
and remedies when abuse or neglect occurs.
- Admission sheets, contracts, and related documents
- Transfer sheets, e.g., nursing home, ambulance, hospital
- Hospital discharge summary (if any)
- Physicians' orders
- Physicians' progress notes
- Records documenting communication with physicians
- Nursing admission assessment and monthly and other summaries
- Discharge plans
- All care plans
- Nursing notes
- Decubitus ulcer/pressure sore and/or skin reports
- Medications sheets, treatment sheets, graphic sheets, I&O
records, CNA flow sheets, ADL sheets, and any other CNA records
- Chronological drug reviews
- Nutritional assessments and notes along with weight records
- Lab and x-ray reports
- Restorative programs and notes
- Activity records
- Social service records
- Physical therapy records
- Occupational therapy records
- Speech therapy records
- Permits and releases
- Photographs
- Correspondence to and from the resident and family
- Initial Service Plan/Care Plan
- Minimum Data Set - initial and subsequent summaries
- Resident assessment protocol summaries
- Resident assessment protocol
- Itemized copy of the bill for treatment and services rendered to
date and submitted in the resident's name for the duration of the
resident's stay
- Any and all incident or occurrence reports that in any way relate to
the resident
Nursing Home Reform Act: Residents' Bill of
Rights
The Nursing Home Reform Act established the following seminal rights
for nursing home residents:
- The right to freedom from abuse, mistreatment, and neglect
- The right to freedom from physical restraints
- The right to privacy
- The right to accommodation of medical, physical, psychological, and
social needs
- The right to participate in resident and family groups
- The right to be treated with dignity
- The right to exercise self-determination
- The right to communicate freely
- The right to participate in the review of one's care plan, and to be
fully informed in advance about any changes in care, treatment, or
change of status in the facility
- The right to voice grievances without discrimination or
reprisal
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