Kentucky nursing homes have a duty to keep records on each resident in their care. These records are more than a formality. They are not meant to create a paperwork burden for the nursing home or simply fulfill the technical requirements of a state regulation. Instead, when nursing home records are kept correctly, they are supposed to provide important information about each resident that could otherwise be lost. Nursing home records provide an important safety net for residents and for their families who cannot always be present to know what is happening to their loved one.
What Must Be in Each Nursing Home Resident Record
According to 902 KAR 20:300(10), Kentucky nursing homes must maintain clinical records for each resident that are complete, accurately documented, readily accessible, and systemically organized. These clinical records must contain:
- Enough information to identify the specific resident.
- A record of the patient’s assessments. The facility must perform a comprehensive assessment to determine the resident’s ability to perform daily activities and the resident’s functional capacity. The assessment should include all of the resident’s medical conditions and medications, as well as other things. The first assessment must be done within 14 days of admission. Subsequent assessments must be done after any significant change in physical or mental health and at least every 12 months. Additionally, assessments should be reviewed every three months to determine if any further assessments need to be done.
- The resident’s plan of care and a description of the services provided to the resident. Within 7 days of completing an assessment, a comprehensive care plan should be developed to meet the resident’s needs.
- The results of any pre-admission screening done by the state.
- Progress notes. These notes will describe how the resident is doing with the services described in the care plan.
Together, this information is helpful in determining the specific care that each resident should receive.
When Records Must be Released
Clinical records are only helpful to you if you have access to them. The nursing home is required by law to keep the records confidential. However, in some situations the law requires the nursing home to release the records. This includes releasing the records to:
- Another health care institution. If your loved one is being admitted to a hospital or transferring to another long term care facility, the nursing home should send the clinical records to that institution when consent for the transfer is provided by your loved one or her legal representative.
- The resident. Nursing home residents have the legal right to access their clinical records.
- The resident’s legal representative. If you have the legal right to act on behalf of your loved one, the law may require that the nursing home share clinical records with you, upon your request.
The nursing home must protect these important clinical records for each resident. This includes not only maintaining confidentiality, but also protecting the records from loss or from being destroyed.
How Records May Be Used in a Nursing Home Abuse or Neglect Case
You can’t be present with your loved one in her nursing home every minute of every day. Things can happen when you are not there that your loved one may have a difficult time reporting to you. If you suspect that something is wrong—that your loved one is being hurt by abuse or neglect in the nursing home that should be protecting her—it is important to find out what is really happening.
Your loved one’s clinical records may provide important clues about the care that she has been receiving. Yet, the nursing home may be reluctant or unwilling to provide these records to you. While the clinical records may not tell the whole story, the records can provide important information about your loved one's assessments, care plan, and the nursing home’s compliance with the care plan. You need these records, and as long as you are legally entitled to receive them, we will help you get them.
To find out more about what you may learn from your loved one’s nursing home records and what other information you need if you suspect abuse or neglect, we encourage you to schedule a free and confidential consultation with our experienced nursing home injury lawyers today. Please call us or contact us via this website to learn more.