Due to the highly regulated nature of the business, nursing homes (more so than ALFs) have no shortage of documentation within their files. Even a short stay of less than a month in a nursing home will fill a 3-inch binder with care-related records. However, a resident’s claims may not be well documented within the nursing home chart. Furthermore, while Adverse Incident Reports must be filed with the State, they are not generally produced or even subject to discovery in litigation, absent unusual circumstances. Most nursing homes and ALFs specifically spell out on their internal Accident or Incident Report forms that the document is “not part of the patient’s chart” therefore when the chart copy is requested, the critical information that the nursing home has on the Accident or Incident Report, and the state-required Adverse Incident Report, is not made available to the resident, the claimant or their attorney (unless those details were also included in the narrative nursing records).
Long-term care facilities have long been subject to intense scrutiny over poor documentation and obviously fraudulent documentation. Nursing home documentation of care provided when the resident is out of the facility (perhaps for a holiday weekend with family, at dialysis outside the facility, or in the hospital) is unfortunately, not unusual. Alarmingly, documentation asserting that medications and treatments were provided to a resident, in detail, on the day after a resident’s death is not unheard of. The many examples of such charting have created a crisis in credibility of some nursing home charts.
In the Assisted Living Facility setting, documentation requirements are much less voluminous and specific. As such, one Assisted Living Facility may provide documentation that is very detailed, perhaps even with the level of detail found in many nursing home charts, while another similar facility on the other side of town may contain only the sparsest of documentation regarding the residents’ daily activities.