Nursing homes are affected by many challenges, many of which directly affect the quality of care and allegations of nursing home negligence. The challenges were highlighted by speakers at Preventing and Defending Long Term Care Litigation at The Conrad in Miami. Pat Iyer moderated a panel of defense and plaintiff attorneys and another legal nurse consultant.
What are the most common charting issues?
- Failure to document physician notification of significant change
- Failure to record blood sugar prior to administering medication
- Significant gaps in nurses’ notes
- Failure to record blood pressure or pulse prior to administering medication
- Medications not started or timely discontinued
- Failure to document follow up with physician after leaving messages
- Documenting on the medical record after the resident is out of the facility
- Cut and paste documentation
- Missing records
- Altered records
- Block charting
- Discrepancies between different sections in the medical record
- Significant gaps in medication records, treatment records, and or activities of daily living records
- Late entries
- Unsigned notes or orders
Patricia Iyer is president of Patricia Iyer Associates Inc. and the editor of Nursing Home Litigation, Investigation and Case Preparation. She edited Nursing Documentation, Fourth Edition. This material is based on the slides of John Wade, Esq., Brunini, Grantham, Grower and Hewes and Bradley Kelly, Esq., of Quintairos, Prieto, Wood and Boyer.