Nursing Home Patient Records Often Neglected and Occasionally Deliberately Falsified

Nursing homes are responsible for every aspect of care for their residents. To this end, nursing homes must keep accurate and timely documentation of the services that they provide their patients–from feeding and medication administration to physical therapy sessions. Accurate record keeping is essential to providing adequate nursing home care.

Unfortunately, , many nursing homes fail to keep proper records. Others still will falsify patient records to protect themselves from liability for personal injury lawsuits for the neglect and/or abuse of patients.

While these practices are not uncommon, even inadvertent or neglectful inaccurate recordkeeping is dangerous and unacceptable. Inaccurate recordkeeping can and often does lead to severe injuries to patients. Sadly, in some cases these practices can even lead to the death of the resident.

Nursing homes are required to keep certain records by federal law. Under the federal Nursing Home Reform Act (Act), 42 USC § 1395I-3, a nursing facility is required to conduct an initial assessment of a resident‘s capabilities, medical issues, and needs within 14 days (7 days for Medicare) of admission. These assessments should be conducted annually and immediately after there is a significant change in the mental or physical condition of the resident.

Based on the assessment, nursing facilities are required to formulate a comprehensive care plan within 7 days after the assessment is finalized. Falsification of assessment documents or care plans carries a civil monetary penalty that ranges from $1,000 to $5,000 per occurrence. Nursing facilities are also required to document pharmaceutical, nursing, rehabilitation, dietary, and social services performed.

However, reports around the country demonstrate on-going fraud and falsification of records in nursing homes. Research and case studies have revealed that there are several ways in which a nursing home can forge records and harm patients. The three most common patterns include falsification of records to cover up unfavorable outcomes, “fill-in-the-blank” chart keeping, and false medicine recording.

In many cases, nursing homes try to minimize their liability by changing a patient‘s records or failing to report incidents after an injury or death. Earlier this year, a nurse at a New York nursing home was found guilty of falsifying a patient‘s medical chart after the resident suffered a serious fall that was not documented. In another case, after witnessing a member of the staff severely beating a patient, an EMT was advised not to report the incident by a nursing supervisor. Though these may seem extreme lesser instances of failed reporting occur with regularity.

Some of these result from a variety of institutionalized practices. For instance, fill-in-the-blank charting occurs when nursing home staff members fill large numbers of charts at the same time without really knowing whether the treatment, medication, or diet was provided or whether the information they enter is accurate. This may happen in understaffed nursing homes or when an employee is not being properly trained and supervised. One nursing home in Santa Monica recently settled a case where a patient‘s chart claimed that the resident was given physical therapy several times a week. However, up to 28 of the sessions were documented by staff members who were not working on those specific days.

Similar to the above, falsified medication recording are not uncommon where staff members document that medication is being given in a certain dosage when in reality the dosage is incorrect, the medicine is not being administered at all or the wrong medication is being given. Other patterns that are not as common but still occur include backdating or forging arbitration agreements and falsification of consent forms to sedate residents. This practice may become more common with the recent United States Supreme Court opinion holding these agreements fully enforceable even under rather suspect circumstances surrounding the execution of the agreements.

Even though falsification of records and documentation is widespread in the nursing home industry, facilities are not often prosecuted or cited for this violation. Discovering and proving the falsification of records is so difficult and time-consuming that state agencies rarely have the time and resources to complete a thorough investigation.

Even though it may not avoid falsifications entirely, many personal injury attorneys suggest that staff is less likely to alter the records of a patient whose family is involved in their care. If you suspect that a nursing home is falsifying a loved one‘s records, it is important to contact a personal injury attorney immediately. Delay may make proving the violations somewhat more challenging.