Nursing home neglect review: dehydration, malnutrition and decline
Neglect cases usually show slow decline: weight loss, dehydration, infections, contractures or pressure injuries that develop over weeks. A long-term care nurse compares the resident's assessments and care plan with the care documented, and checks whether changes of condition were reported to the physician and family.
What the nurse reviewer examines
- MDS assessments, care plans and whether the plan was followed
- Weights, intake and output, and dietitian involvement (F692)
- Change-of-condition recognition and reporting to the physician and family
- Activities of daily living documentation and its consistency
- Infection prevention and timely treatment
- Staffing levels on the shifts in question
- Survey and complaint history for the facility
Records to request
A starting checklist; the reviewer will flag what's missing once they have the chart.
- Complete chart including MDS assessments and care plans
- ADL flowsheets (CNA documentation)
- Weight and intake records
- Physician orders and progress notes
- Hospital transfer records
- Staffing records and payroll-based journal data
- State survey reports and plans of correction
Questions attorneys ask
Why do CNA records matter?
Certified nursing assistants document most daily care: meals, fluids, turning and toileting. Gaps or identical entries across shifts are common findings in neglect cases.
Where do staffing records come from?
Facilities report staffing to CMS through the Payroll-Based Journal, and payroll and schedule records can be requested in discovery.
Consultants
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