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False charting at nursing homes

By Barry Doyle

One thing that we do when we are handling a nursing home abuse and neglect case is thoroughly review the chart for false chart entries. Every nursing home staff member I have ever deposed has always testified that false chart entries are totally unacceptable. There are a lot of reasons for this. The most important one is that the chart is a tool for communication among the staff and it facilitates good patient care, and if the chart cannot be relied on, the staff is flying blind.

From a litigation perspective one of the reasons that we check the chart thoroughly for for false chart entries in a nursing home abuse and neglect suit is that it undermines the credibility of the claims of the staff that they provided good patient care. Usually, the process of finding false chart entries is a pretty labor-intensive process, going through the various parts of the chart with a fine-tooth comb.

Other times, the false charting jumps out at you. We recently took in a case where the daily nursing notes contained these notations:

SECOND SHIFT

5:20 p.m. Resident expired, no pules, no respirations.

5:55 p.m. Funeral home here to pick up resident

THIRD SHIFT

6 pm - 6 am Resident up and down all night, O2 on at 6-10, no signs or symptoms of distress noted

There was also a check chart for the third shift which indicated that the resident was alert, the resident was passing clear, yellow urine, the resident had active bowel sounds, that skin tone within normal limits, that the heart had a regular rhythm, and the resident had normal breathing.

Some of these notes on the third shift may be a little hard to explain. Of course, it will be easy for the nursing home to say that none of this caused any harm to the resident -- he was already dead. However, it will be much harder for the the defense to argue that the staff should be believed when their records of what occurred are at odds with what my clients are claiming happened.

Originally posted at InjuryBoard by Barry Doyle

Full post as published by Cook County Personal Injury Lawyer on February 15, 2010 (boomark / email).