How Accurate Are Medical Records From Nursing Homes?

Medical Records From Nursing HomesAny environmentalist coming into my office would likely cringe at the heaps of medical records that I’ve accumulated from various nursing homes and hospitals on cases that I’m working on.

I’ve really got nothing against beautiful trees, but in order to properly review and prosecute cases, medical records remain an incredibly important piece of the puzzle in terms of evaluating cases.

After all, medical records are objectively comprised documents that reflects the care provided by staff and the patient’s condition throughout their entire stay at the facility.  Right?

A recent article in the Sacramento Bee, “Woman’s death raises questions about nursing home medical records,” identified an ongoing problem in the nursing home industry— doctored medical records.  The article documents the consistent inconsistencies between in a patient’s chart during a short-term admission at El Dorado Care Center (California), formerly part of Horizon Healthcare.

Specifically, the article referenced the negligent care and subsequent lawsuit relating to the care provided to Johnnie Esco.  Like most nursing home patients, Mrs. Esco was admitted to the nursing home in order to receive medical care for several medical problems including chronic constipation.

After initiating a nursing home negligence lawsuit, the family learned that in addition to not receiving proper care, the facilities inaccurate charting likely exacerbated her decline and subsequent death.

When compared with notes compiled by family members, medical records from other facilities and testimony from staff at the facility, it was quickly revealed that nothing in Mrs. Esco’s medical chart was really truthful.  Discovered problems included:

  • Documented assessment that were never really completed
  • Rote charting- where staff filled in boxes identically to the day prior
  • Late entries to the records that dramatically changed original entries
  • Missing physician orders
  • Drastic inconsistencies
  • Fraud

What soon developed was a situation where in a mere 13 days, Mrs. Esco went from an ongoing grandmother and great-grandmother into a terminally ill woman.  It turned out, that the chronic-constipation that Mrs. Esco and her family were readily controlling at home went completely unchecked and untreated during her short-term stay at El Dorado Care Center.

By the time she was transferred to a nearby hospital, Mrs. Esco had become completely bedridden and unresponsive.  A bowel obstruction had left her stomach distended and painful.  The extent of the fecal impaction was so extensive that doctor’s suggested that even with surgery her chances of living a quality life were minimal.  On March 7, 2008 Mrs. Esco died.

Doctored Medical Record

As a nursing home lawyer, I’m always amazed at how frequently I come across inaccurate and altered medical records. Particularly in cases where a facility knows that it ‘screwed up’ I find especially important to secure a set of medical records as soon as feasible in order to preserve the condition of the records.

Federal law imposes a duty on nursing homes to accurately maintain patient records.  Under Medicare requirements for long term care facilities, nursing facilities are required to maintain records on each resident in accordance with accepted professional standards and practice (42 CFR §483.75(l) or Tag F-514).

Pursuant to F-tag 514, nursing homes must do the following:

  • Maintain complete medical charts for patients
  • Accurately document treatment provided
  • Make sure the records are easily accessible
  • Organize patient charts

Learn more about the laws applicable to California nursing homes here.
Click on the links for information on nursing homes in San Diego , Los Angeles and San Francisco

Related Nursing Homes Abuse Blog Entries:

Nursing Home Administrator Pleads Guilty To Fraud After Lying About Genuineness Of Patient’s Signature

Nursing Home Settles Lawsuit After Fraudulent Records Discovered

Is It Time For Nursing Homes To Embrace Electronic Medical Records?

Admissions Suspended At An Emeritus Assisted Living Facility Following The Discovery Of: Medication Errors, Bed Sores & Falsified Medical Records

Documentation Wake-Up Call- How To Prevent Documentation Deficiencies (pdf) AUTHORS: MARY C. MALONE, ESQUIRE and MARY P. CHILES, RN, RAC-CT

Client Reviews

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Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa
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After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric