On September 18th and 19th, the Sacramento Bee published an alarming series on the common complaint that nursing home records often have little to do with reality. The two-day series examined cases involving falsified nursing home records, including fabricated records that played a role in the death of a resident. In addition to pointing the finger at nursing homes for creating fake records, the articles illustrate how little the California Department of Public Health is doing to address this problem.
The series included the following tips from CANHR on monitoring nursing home records.
CHARTING – YOUR CHECKLIST
• Nursing home residents and their representatives have a right to review the individual’s medical records.
• Review the resident’s written assessment, known as the minimum data set, or MDS. Also ask to see the resident’s care plan upon admission, and each time it is updated. Ask the nursing home to make changes and corrections as needed.
• Review medication records periodically to make sure the resident is not being given any drugs, especially psychoactive drugs, without knowledge and consent.
• Check routine nursing records, such as bathing ledgers, if neglect is suspected.
• If a resident is injured or abuse is suspected, review the nursing notes during the period in question and ask for copies of any official reports.
• If therapy services are being discontinued, denied or are otherwise in question, examine the therapy notes and physician orders to evaluate if the resident’s therapy needs and services are appropriately documented.
• Social service notes can be a good source for learning the resident’s overall status and care needs.
• If the doctor has ordered lab work, review test results and whether the staff and doctor have taken appropriate action.• If you have concerns about the content or accuracy of any records, request copies immediately.