Articles Tagged with medical charting

Last week I wrote a post titled Who’s Watching Your Elderly Relative In The Nursing Home? At the time, I had been taking depositions in a couple different Alabama nursing home abuse cases. While taking the deposition of one facility’s Director of Nursing, the witness basically admitted her facility only purchased a rulebook to get licensed. This Director of Nursing testified her facility obtained a canned rulebook years ago to get licensed. Since then, the rulebook sat on the shelf gathering dust. She could not testify to any of her own facility’s specific procedures.

Think about that — A facility full of caregivers with no common procedures. All caregivers are left to act as they deem appropriate. We also took the depositions of several different CNAs who provided care at the facility. Most of them had never worked with any other providers. So, they had no prior experience. This facility hired them and turned them loose on its elderly residents with no explicit policies.

When we reviewed the medical chart at the nursing home, we found almost nothing. By nothing, I mean almost nothing was charted despite doctor’s orders to monitor the elderly resident carefully due to his health condition. In my post last week I discussed the nursing home’s response to questions on its lack of charting. In response, the witnesses testified they only “chart by exception.”