If you suspect a loved one has suffered from nursing home neglect, you may not know where to start or what could help explain what happened. Records can help show the care your loved one needed, what staff provided and how their condition changed over time. They also can help connect a serious injury or illness to a failure in care.
Here are the records and other documentation that can help establish what happened.
Medical and care records
These can show your loved one’s medical needs and whether staff followed the required treatment. Look for:
- Care plans and treatment notes
- Medication records
- Wound-care records
- Hospital and transfer records
These materials can help you compare the care your loved one required with the treatment they actually received. For example, a care plan might call for regular repositioning, while later medical notes could show that your loved one developed a serious pressure injury.
Incident and facility records
Incident reports can help establish when an injury or other concerning event occurred and how staff responded. Depending on the situation, you also may want records involving falls, hospital transfers, safety checks or staffing.
Illinois law gives a nursing home resident, guardian or parent of a minor resident the right to inspect and copy clinical and other records concerning the resident’s care and maintenance. This means you can request records that may help you understand what care your loved one received and identify gaps in that care.
Communication records
Written communications can show what concerns you reported to the facility and how staff responded. Keep emails, letters and messages, along with notes that record:
- Who you spoke with
- When you raised the concern
- What you reported
- What response you received
These details can also help prove whether the facility knew about a problem before your loved one suffered further harm.
Personal notes and photographs
Your own notes and photographs can document changes in your loved one’s condition that facility records may not fully capture. Keep dated notes about symptoms, injuries, changes in behavior or mobility and conversations with staff. When appropriate, photographs can also document visible injuries, such as bruising, swelling or pressure injuries.
Together, these materials can help show when a problem appeared and how your loved one’s condition changed between visits or medical evaluations.
Review the records with an attorney
If you suspect neglect caused serious harm, reviewing the available records with an attorney can help you identify missing information, understand what the entries show and determine what additional evidence you may need. Gathering these materials early can also help preserve important details while they remain available.