When your loved one’s condition raises concerns about nursing home care, it can be difficult to know what happened when you were not there. Records can help you compare what staff documented with what your loved one actually experienced.
If you are the resident, you can request your personal and medical records from the facility. HIPAA, the federal health privacy law, may also allow a health care representative, such as someone with an effective health care power of attorney, to request records on the resident’s behalf.
The following documents can help you understand whether the nursing home met your loved one’s needs:
1. Medication records
These records show which medications staff gave, the dosage and when they administered them. Missing entries, delayed doses or other inconsistencies may raise questions about whether staff followed medication orders.
2. Nursing notes, MDS assessments and daily care logs
Nursing notes document changes in your loved one’s condition. The Minimum Data Set (MDS), a federally required resident assessment, tracks health conditions and functional abilities. Daily care logs can also show how much help your loved one received with activities of daily living, such as eating, dressing, using the toilet or moving around.
3. Care plans and doctor’s orders
A care plan outlines the services and assistance your loved one should receive. Comparing that plan with doctor’s orders and nursing notes may help reveal whether staff followed those instructions.
4. Incident and accident reports
Kentucky nursing homes must document certain accidents, medication errors and other incidents. These reports may provide important details about what happened, who responded and what steps staff took afterward.
5. Inspection and staffing information
Kentucky publishes inspection findings for certified nursing homes. Medicare’s Care Compare website also provides information about inspections, staffing, quality measures and certain penalties.
Compare the records to see the bigger picture
One document may not explain everything. Still, comparing medical records, care plans, incident reports and public inspection information may reveal gaps or conflicting information. Keeping copies of available records can help you better understand what happened and identify questions that may need further attention. If the documentation suggests that inadequate care harmed your loved one, learning about your legal options can help you understand whether compensation may be available.