In 2016, there were 15,600 nursing homes in the U.S. Approximately 1.3 million Americans are residents of long-term care facilities.
State and federal laws require nursing homes to document incidents, accidents, and substantial injuries. Reports of these events are often kept separate from the medical file or in different departments and must be specifically requested.
Business Department
These records include department reports, budget and financial reports, incident reports, and theft and loss logs.
Nursing Department
These records include nursing staff schedules, assignment records, 24-hour reports from nursing stations, sitter logs, medication refrigerator temperature logs, mandatory annual training logs, and policy and procedure manuals.
Dietary Department Records
These include menus with nutritional requirements for specific patients, feeding and choking precautions, food allergies, and dietary workers’ schedules and assignments.
Maintenance Records
These records include preventive maintenance logs, water temperature logs, requests for repairs, fire, disaster, and safety drill reports.
Environmental Services
These records include the schedules of cleaning and routine maintenance, assignment schedules for maintenance workers, laundry records, delivery schedules, and equipment operation manuals and directions.
Social Services
These records include documentation of financial, social, and emotional, and family situations requiring social services. These records are also needed to document services were rendered and for submission to payers for reimbursement.
Rehabilitation, Speech, and Physical Therapy Department
These are basic services that are mandated by state and federal regulations. They include any therapies received as well as any warnings of vulnerabilities to accidents or hazards such as falls or choking.
Laboratory and Diagnostic Testing
Basic familiarity with laboratory tests and the range of normal results is needed to evaluate nursing home medical records. These tests include urinalysis testing, chemistry, complete blood count counts and differentials, blood urea nitrogen (BUN) levels, and drug level monitoring tests. Due to the diminished liver and kidney functioning, people over the age of 65 are susceptible to drug toxicities because of lowered clearance rages. An undetected urinary tract infection (UTI) or other sequestered infection can cause a spectrum of mental status and behavioral changes that can lead to injury.
Medication Administration Records (MARs)
Reviewing the MARs is an essential component of nursing home record review. Particular medications are potentially harmful in geriatric clients. Guidelines may designate some medications as contraindicated or relatively contraindicated or may advise the prescriber to use caution. Best practice requires proper documentation of the need for the medication, consideration of the relative risks and benefits, and informed consent. More than 90% of people over the age of 65 use at least one prescription medication and more than 66% use three or more medications (National Center for Health Statistics, 2018). Refer to the American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
The medically inexperienced attorney will want to hire a trusted medical consultant with experience working in a nursing home to assist in the review of nursing home medical records.