Case guide

Keeping records of nursing home abuse

Keep a dated account and care papers you may lawfully use. Separate what you saw from guesses.

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Updated Oct 4, 202614 sources

This may apply to you if

  • Prepare the facility name, care dates and concern you want reviewed.
  • Check the resident’s wishes and actual authority to obtain records or act for them.
  • Ask about applicable duties, care, harm and the individual legal time limits.

The short answer

What should a dated account include?
Write down what you saw and when. Keep the resident’s account distinct from your own observations. Mark missing details instead of inventing a complete timeline. [2]
Which care records can I ask about?
Ask about assessments, care plans and relevant notes. Keep copies you already lawfully hold. Confirm who may request the missing parts of the resident’s file. [4]
Can I correct a medical record I think is wrong?
Ask to correct the entry and explain why. If the provider made the entry, it must fix inaccurate or incomplete facts. It may disagree; you can submit a statement. [12]
How should I handle sensitive accounts?
Ask how the recipient will use or share the facts. Share only what you have a right to share. No route promises secrecy in every case. [8]

The process

What happens next

  1. 01

    You answer a few questions

    About two minutes. Nothing is sent until you agree on the last step and press submit.

  2. 02

    A lawyer looks at it

    A lawyer at the firm reads your answers and checks them against the current case criteria.

  3. 03

    The firm decides and gets in touch

    If the firm takes your case, you get the terms in writing to read before you sign. You can always say no.

Keep a dated account and care papers you may lawfully use. Separate what you saw from guesses. Ask who may get and share private records.

What should a dated account include?

Write down what you saw and when. Keep the resident’s account distinct from your own observations. Mark missing details instead of inventing a complete timeline.

The home must check defined claims of harm under the federal rule. A clear account sets out the concern without treating a guess as fact. Keep written concerns and replies with the care papers you hold.

Which care records can I ask about?

Ask about assessments, care plans and relevant notes. Keep copies you already lawfully hold. Confirm who may request the missing parts of the resident’s file.

Federal resident rights include access to records and defined representative authority. HHS guidance also addresses access to covered medical and billing records. These rights have limits; being a friend or relative does not automatically authorize an unrestricted request.

Can I correct a medical record I think is wrong?

Ask to correct the entry and explain why. If the provider made the entry, it must fix inaccurate or incomplete facts. It may disagree; you can submit a statement.

HHS says the provider must respond to a request. If it created the information, it must amend inaccurate or incomplete facts. If it disagrees, you can submit a statement. Keep the original record and your request distinct.

How should I handle sensitive accounts?

Ask how the recipient will use or share the facts. Share only what you have a right to share. No route promises secrecy in every case.

ACL sets consent protections for an advocate sharing records, with exceptions. Court orders and limited cases involving inability to consent can matter. These rules differ from every provider’s policy; the resident’s rights still matter.

Does a missing document prove abuse?

No. State which paper is missing. The concern still needs a check. An unanswered request does not prove what care was given.

The home’s investigation duties and the resident’s record-access rights are separate protections. HHS describes covered access and possible exceptions. A record search can reveal questions, but does not by itself establish who caused an injury or whether a civil claim succeeds.

Find out where you stand.

The review is free and private. Asking for it doesn’t commit you to anything.

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Sources

  1. 42 CFR 483.1: Basis and scope42 CFR 483.1: Basis and scope · regulator
  2. 42 CFR 483.12: Freedom from abuse, neglect and exploitation42 CFR 483.12: Freedom from abuse, neglect and exploitation · regulator
  3. 42 CFR 483.25: Quality of care42 CFR 483.25: Quality of care · regulator
  4. 42 CFR 483.10: Resident rights42 CFR 483.10: Resident rights · regulator
  5. 42 CFR 483.35: Nursing services42 CFR 483.35: Nursing services · regulator
  6. 42 CFR 483.70: Administration and binding arbitration42 CFR 483.70: Administration and binding arbitration · regulator
  7. CMS: Repeal of Minimum Staffing Standards for Long-Term Care FacilitiesCMS: Repeal of Minimum Staffing Standards for Long-Term Care Facilities · regulator
  8. ACL: Long-Term Care Ombudsman FAQACL: Long-Term Care Ombudsman FAQ · regulator
  9. CMS: Five-Star Quality Rating SystemCMS: Five-Star Quality Rating System · regulator
  10. HHS OIG: Nursing Homes’ Inappropriate Use of Antipsychotic Drugs Poses a Risk to ResidentsHHS OIG: Nursing Homes’ Inappropriate Use of Antipsychotic Drugs Poses a Risk to Residents · regulator
  11. HHS OIG: Operation CAREHHS OIG: Operation CARE · regulator
  12. HHS: Your Medical RecordsHHS: Your Medical Records · regulator
  13. ABA Model Rule 1.5: FeesABA Model Rule 1.5: Fees
  14. SDNY: Lawsuit time limitsSDNY: Lawsuit time limits · court

Checked against 14 primary sources by People's Justice editors · Updated

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