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Nursing Home Investigation Tips Cheat Sheet (DRAFT) by [deleted]

Where to investigate in a Nursing Home

This is a draft cheat sheet. It is a work in progress and is not finished yet.


Demogr­aphics needed for Twist report. Usually located at the very front or very back of the medical record. Tells full name of resident (with correct spelling), date of birth, date of admission to the facility, social security number, diagnoses, previous address, family members and phone numbers (for possible collateral interv­iews), respon­sible party and/or guardian, attending physician, etc. Legal documents may include POA, Guardian, and code status of the resident.


H&P should be done annually by physician, P.A., or nurse practi­tioner. Gives a picture of the resident’s physical and mental health at the time of exam. Useful when trying to determine if a decline in status occurred. Discharge summaries are useful for past history and overview of resident status.


Care and services must be provided in accordance with physic­ian’s orders (defin­ition of neglect). Orders are always important in any invest­igation of neglect. Specific medication orders must be known before an error can be validated. If a pressure sore is not responding to treatment, look for changes in orders to promote healing. If the problem is weight loss, look for orders to address addition of supple­ments, vitamins, dietary changes, etc. When a resident experi­ences any signif­icant change in status, the orders should also reflect changes to address the problem


Provides important insight in to how often the physician sees the resident, how involved he/she is in the care, and notes progress, stabil­iza­tion, or declines.


Documents the day to day occurr­ences. Should be descri­ptive, factual, timed, dated, and each entry signed by the LPN or RN scribe. Nursing docume­ntation can be invaluable in neglect invest­iga­tions. Lack of proper docume­ntation combined with a negative outcome for the resident can support substa­nti­ation of neglect. Whereas, good descri­ptive docume­ntation can unsubs­tan­tiate neglect, even in the presence of decline at times. The cardinal rule taught in nursing school and observed by the Courts, “If it wasn’t charted, it didn’t happen.”

6. MDS (Minimum Data Set) 3.0 ASSESSMENT

The first part of a three part state mandated assessment tool to be utilized by all skilled nursing homes in Kentucky. The items in the MDS standa­rdize commun­ication about resident problems and conditions within facili­ties, between facili­ties, and between facilities and outside agencies. Assess­ments are mandated at specific times, i.e., upon admission, quarterly, annually, signif­icant change in status, and at each hospit­ali­zation and return to the facility. The assessment is used to ensure all facilities adequately and accurately review all body systems and identify problems that need to be addressed. Only MDS assess­ments pertinent to the time frame of the allegation should be reviewed and provide good indicators as to whether or not the facility was aware of developing medical problems.

7. CAAs and CATs

The second part of the state mandated assessment tool. The Care Area Assessment (CAAs) are a struct­ured, problem oriented framework for organizing the MDS inform­ation. The CAAs help identify and analyze social, medical, and psycho­logical problems, forming the basis for planning care. For example, the Cognitive CAA will tell all about the mental capacity of the resident, from memory to decision making abilities. The Nutrit­ional CAA would describe feeding problems, causal factors, referrals, studies, etc.

The CATs (care area triggers) gives an overall picture of the resident’s functi­oning level.


The third part of the state mandated assessment tool. The MDS assessment identifies the resident’s problems. The CAAs analyze the problems and consider the resident’s streng­ths­/we­akn­esses. All that inform­ation is used to develop a compre­hensive care plan with goals toward improving function, preventing avoidable declines in functi­oning, managing risk factors, and promoting care in accordance with physic­ian’s orders and current profes­sional standards of practice. For every allegation of neglect, the care plan should be reviewed to determine whether or not the problem was being addressed. The Nurse Aide Care Plan may also be called resident assessment tool or nurse aide flow sheet. Nurse aides usually document on these sheets the direct care provided daily.


Assess­ments are done by a registered dietitian, and day by day monitoring docume­ntation is usually done by the dietary manager. The dietitian assesses the resident’s admission body weight, ideal body weight range for height, and desired body weight. At least monthly weights are recorded, more often as needed. The dietitian documents the resident’s estimated caloric needs and daily fluid needs. Dietary notes are especially important in allega­tions of weight loss and/or dehydr­ation. First, determine if the weight loss was desired and planned for, i.e. through physic­ian’s orders for an exercise program and weight reduction diet. If not, then determine if the weight loss was identified and addressed by the dietitian. Were dietary supple­ments, increased calories, increased protein, multiv­ita­mins, appetite stimul­ants, etc. recomm­ended? Did the dietit­ian’s recomm­end­ations get to the physician for orders? Were labs (albumin and protein levels) monitored to ensure adequate protein stores? If not, question why.


Especially important in allega­tions of dehydr­ation. Records amount of fluid intake (orally, parent­erally (I.V.), or by gastric tube) and the amount of output, either by voiding or Foley catheter. Compare the amount of fluid intake to the dietit­ian’s recomm­ended daily fluid requir­ements to see if needs are being met. If not, that’s a problem. Determine how the facility addressed this.


Records the intake at each meal and snacks provided. Usually recorded in percen­tages. Review for allega­tions of weight loss and/or dehydr­ation. Review the dietit­ian’s recomm­ended caloric and fluid requir­ements, then determine if the resident’s needs are being met. If not, question whether or not the facility has done a calorie count to determine exactly what the resident is consuming.


ocument the specific problem, location, descri­ption of the site, response to treatment, and all changes in treatment orders. Some facilities use photog­raphic docume­ntation also. These records are especially important in allega­tions of pressure sores, wound infect­ions, failure to provide treatment, etc. Treatment records may also include bed, body, and chair alarms in use; incont­inence care.

13. Medication Admini­str­ation Records (MARs)

Docume­ntation of all medica­tions admini­stered. Allergies should be noted on the MAR sheet, usually in red ink to draw attention. MARs should document name of the medica­tion, type of admini­str­ation (orally, rectally, injection, etc.), month, date, time, initial and signature of person giving. PRN (as needed) medica­tions should also include a record of follow up response to the medica­tion. MASTER SIGNATURE LIST: this should include all of the nursing and nurse aides signatures in case there is a question about who made an entry in the medical record; they can cross-­ref­erence on this signature list.


Includes things such as turnin­g/p­osi­tio­ning, ambula­tion, range of motion exercises, bathing, bowel/­bladder output, etc.


These reports are critical documents useful as evidence to support findings.


Notes by profes­sionals involved in the care of the resident, i.e.; Physical Therapist (P.T.), Occupa­tional Therapist (O.T.), Speech Therapist (SPT), Pharmacy Reviews (RX), Psychi­atric, Wound Care, and Social Services (SSW).


Notes by profes­sionals involved in the care of the resident, i.e.; Physical Therapist (P.T.), Occupa­tional Therapist (O.T.), Speech Therapist (SPT), Pharmacy Reviews (RX), Psychi­atric, Wound Care, and Social Services (SSW).


Periodic assess­ments to include Braden Scale (skin assess­ment), pain, elopement, falls, restra­ints, mechanical lifts, and side rails. These are done at least quarterly and following an event.

Additional Documents

Additional documents that may need to be requested, but are not found within the medical chart are as follows:
1. INCIDENT REPORT­S/U­NUSUAL OCCURR­ENCE: First and foremost, this is a facility document which they are not legally required to provide copies. However, under KRS 209 they do have to allow you access to these documents for review upon request. These documents may reveal inform­ation that will not be recorded in the medical chart, such as falls, elopement, etc.
2. POLICY­/PR­OCE­DURES: Useful during invest­igation to evaluate if facility staff are delivering care and services in accordance with developed guidel­ines.