When a parent or loved one lives in a nursing facility, family members often depend on staff to recognize changes in their condition and respond to their needs. But families may not always see those changes as they happen.
You might visit and notice that your loved one has lost weight. Maybe there is a new bruise, a pressure sore, or a noticeable change in behavior. Perhaps they have fallen more than once or suddenly need help with tasks they used to handle on their own.
The facility may have an explanation, but you may still be left wondering what happened and whether your loved one’s needs were being properly addressed.
One place to start looking for answers is the resident’s care plan and medical records. These documents can provide a timeline of the resident’s condition, the risks staff identified, and the care that was supposed to be provided.
A Care Plan Is More Than a List of Instructions
A care plan is developed around a resident’s individual needs. It can address medical conditions, daily activities, safety concerns, and the assistance a person needs to maintain their health and well-being.
Depending on the resident, the plan may address needs such as:
- Mobility: Whether the resident needs help walking, transferring, or getting in and out of bed.
- Meals and hydration: Whether assistance is needed with eating or drinking.
- Medication: What medications are prescribed and how they should be administered.
- Fall prevention: Whether the resident has been identified as being at risk of falling and what precautions are needed.
- Personal care: Whether assistance is needed with bathing, dressing, or using the bathroom.
- Wound care: Whether the resident has an existing wound or requires measures to prevent one from developing.
The specific plan will depend on the person’s condition. New York State Department of Health materials describe a process that includes assessing a resident, developing a plan of care, following that plan, and evaluating the results.
That means the records may provide more than a snapshot of your loved one’s condition. They can help show what the facility knew about the resident and how those needs were supposed to be addressed.
What Happens When Someone’s Needs Change?
A person’s needs do not necessarily stay the same after moving into a nursing facility.
Someone who was able to walk independently may become weaker and require assistance. A resident who had not previously fallen may begin having balance problems. Someone who normally eats well may begin losing weight or need help with meals.
When a significant change occurs, an important question is whether the facility recognized it and responded appropriately.
For families, the timeline can be particularly helpful.
Consider a resident who falls several times within a few weeks. The first fall may have been unexpected. But what happened afterward? Was the resident assessed? Was a new risk identified? Were additional precautions put in place? Was the care plan changed?
Looking at what happened before and after an incident may provide a clearer picture than looking at the incident by itself.
Pay Attention to Patterns
Families sometimes focus on the most recent problem because it is the one they can see.
But earlier events may provide important context.
For example, you may notice several concerns over time:
- Repeated falls: Your loved one has fallen several times despite being identified as a fall risk.
- Unexplained weight loss: Their weight continues to decline without a clear explanation.
- Missed medication: You learn that medications were not given as prescribed on more than one occasion.
- Dehydration: Your family member repeatedly shows signs of inadequate fluid intake.
- Worsening wounds: A sore continues to worsen rather than improve with treatment.
- Unanswered calls for assistance: Your loved one repeatedly reports that staff did not respond when help was requested.
None of these situations automatically establishes neglect. There can be different explanations for an individual event.
However, repeated problems may give a family reason to take a closer look at the records, the resident’s changing condition, and the care being provided.
What Should Families Ask?
You do not need a medical background to ask reasonable questions about your loved one’s care.
Start with the basics. What changed? When did it change? Who noticed it? What did the staff do?
It may also help to ask:
- Was there a change in the resident’s condition before the incident?
- Had staff identified a particular risk?
- Did the resident’s care plan address that risk?
- Were specific precautions or assistance supposed to be provided?
- Was the plan updated when the resident’s needs changed?
- Who was responsible for providing the required care?
- What happened immediately after the injury or other concerning event?
- Was a doctor or other medical professional notified?
- Was the family contacted?
- What steps were taken to prevent the problem from happening again?
These questions can help establish a timeline and may also reveal whether the resident’s needs were being reassessed as their condition changed.
The Records May Answer Questions You Cannot
A family member may remember that their loved one looked different during a visit, but medical and facility records can provide additional details.
Depending on the situation, records may include assessments, progress notes, medication information, treatment records, incident reports, and care plan updates.
Comparing these documents over time may help show when a problem first appeared and how the facility responded.
For example, a family may believe that a resident’s mobility declined suddenly. The records could show that staff had already documented changes weeks earlier. Or they may show that a particular risk was identified but that the resident’s care plan was later changed.
The records do not automatically tell you whether someone was legally responsible. But they can provide information that helps answer important questions.
Families Have the Right to Raise Concerns
New York recognizes several rights for people living in nursing facilities, including rights involving dignity, quality care and treatment, complaint procedures, and protection from abuse and improper restraints. The New York State Department of Health also provides a process for reporting concerns about the care provided by a facility. Complaints can be submitted confidentially or anonymously. (health.ny.gov)
If you have concerns about your loved one’s treatment, you do not have to ignore them simply because you are unsure whether they rise to the level of neglect.
Asking questions is a reasonable place to start.
Keep Your Own Notes
Facility records are important, but families should also keep track of what they personally observe.
A simple log can make it easier to recognize changes and remember conversations with staff. Consider recording:
- Dates: When an injury, fall, or other concern occurred.
- Conversations: Who you spoke with and what they told you.
- Changes: New symptoms, changes in behavior, weight loss, or mobility problems.
- Medical care: Doctor visits, hospitalizations, treatments, or changes in medication.
- Documents: Copies of letters, emails, photographs, and other records provided to you.
Your notes do not need to be complicated. The goal is to create a clear record of what you observed and what you were told.
That information can become especially useful when several events occur over a longer period.
When Is It Worth Having the Situation Reviewed?
Not every mistake, injury, or change in condition means a facility has committed legal neglect.
Older adults and people with serious medical conditions can experience unexpected changes even when appropriate care is being provided.
The question becomes more complicated when a resident suffers a serious injury or decline and there are concerns that the facility knew about a risk but did not respond appropriately.
In that situation, reviewing the care plan, medical records, incident reports, and timeline may help determine what happened.
An attorney can also help a family understand what additional records or information may be important.
The goal is not simply to find someone to blame. It is to understand what happened and whether the care provided met the resident’s needs.
What the Care Plan Can Tell You
A care plan is only one part of a much larger record, but it can provide valuable context when a family has concerns about a loved one’s care. It can show the needs that had been identified, the precautions or assistance that were expected, and how those needs changed over time.
When something goes wrong, looking at those records alongside medical documentation, staff notes, witness accounts, and your own observations may help answer questions that are otherwise difficult to resolve.
If something about your loved one’s care does not seem right, you have the right to ask questions and seek answers. Contact Segan, Nemerov, Singer & Sonin P.C. to discuss your concerns and learn what the available records may reveal.