What is the legal process to view my fathers chart and records at his nursing home? - AgingCare.com

What is the legal process to view my fathers chart and records at his nursing home?

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We live in Florida. My father was abused by a CNA 2 weeks ago. He could not give her name and said he didn't know who she was. The administrator told me they are still investigating. 2 WEEKS LATER ??? They told me they still haven't figured out who it was that abused him. That is a bunch of garbage. Dad did tell me that it is the CNA who showered him that day. I told them this and they said they would do more investigating. In the meantime they will be having some sensitivity seminar with all staff members. WHAT?? My friend is a CNA and said to ask to see his chart because they are mandated by the state to chart everything they do with each resident. I asked today and was told I couldn't see it right now and I could only see specific parts of it. I have to complete a form stating which parts of his records I want to view and submit it. On top of that there is a charge to view it?? That is when I lost my cool.. but only for a minute.. "You mean I have to pay to find out who abused my father?". This is the craziest stuff I've ever encountered. On top of that they called yesterday and said dad was being moved to a private room they use for Isolation because he has MRSA in his blood and urine. The only precaution they are using is gloves. No gowning up.. He does have a trash can for Toxic garbage and a yellow one for his linens. He doesn't even have gloves anywhere in his room for us to use. I had to get them from a housekeeping cart. When I spoke to the administrator and the Director of Nursing the other day I mentioned that dads roomate had told me how one of the residents had died in the dining room at lunch 2 weeks ago because the CNA's failed to render aide after dads roomate had alerted them to her distress. Finally her face went into her plate and he got up and went to the back of the room where they were talking and told them " now see, Ms Jewel is dead. I told you to help her". She did die. I saw her Obituary in the paper 3 days later. My brother says I should contact her family but I don't know them and I could get in major legal trouble if something else really happened. But I will say these 2 ladies were really shocked that I knew about it. I told my husband " watch and see how long it takes them to move dad to another room so I don't talk to this man again" 2 days later dad gets moved. I asked to see his chart and verification of his MRSA and they got very upset!! Dads roomate is Autisitc. He has a memory like a tape recorder. He knows what he saw and what was done. I went to visit after this happened to the lady and I heard a nurse tell him not to mention Ms Jewell again after she heard him saying that he saw the funeral home van come pick her up. While I was visiting dad in his Isolation room today I stopped in and saw his roomate. I told him after I visited with dad for a while I would be back to see him to get his list of goodies that he always gives me to bring back for him on my next visit. This man has no family. As I was getting his list and saying goodbye a lady walked up and taped a big notice to his door. "All visitors please stop at the nurses station before visiting this patient". I asked why and she said she didn't know, it was probably for health reasons. Talk about some strange stuff going on!!!! I thought about moving dad to another home but if he has MRSA nobody will take him. I also wondered about having him admitted to the hospital to see if he really has MRSA and to just get him out of there.. Seems like they would be taking more precautions than just gloves if he really had it. I don't know what to do!!!

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wrong, unless laws differ from state to state. in CA patient rights give patients or their representative the right to view their medical records at anytime....do not let them do this to yoou....call the ombuds immediately to meet you at the facility and/or the licensing board for your state; report the denial of medical records and the abuse to both immediately and let them investigate; the NH should not be investigating themselves.....
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If you have medical proxy, you have the right to see any and all of the medical records. The Freedom of Information Act gives the patient or his medical proxy the legal right to this.
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They are hiding something. The chart has probably already been changed. If you can find a new nursing home do so ASAP.
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There should be a required care plan meeting scheduled every 60 or 90 days if they are on Medicaid. The time between is different by each state. My mom is in TX and it is every 90 days, with a required letter going out to the family member as the primary contact as to the date and time. Usually is a 30 minute session.

BUT you can request a care plan meeting at any time and do NOT have to wait for the next one to roll around. The request should be done in writing to the DON -
the Director of Nursing. I'd fax it as you can have a transmission report done on most fax systems - so they can't say we didn't get it. I would have at least another person go with me to take notes and I'd also record the session. Most states have it such that only 1 person needs to be aware of recording.......You should be able to look at their chart or binder during the meeting and there will be a write up done of your concerns that you will sign off on. If it were me, I'd already have a list of items done and printed out with a place for you and the NH rep to sign off acknowledgement of receipt. And I would write next to my signuature on the NH form something like " also as per attached page, dated whatever, from Jane Smith MPOA for Ann Adams, resident" .

Realize that all this is going to pose issues for all and it could get ugly. But if he is on Medicaid, they cannot just sent you a "30 Day" move out notice. Medicaid requires a suitable comparable facility for the transfer. With MRSA, they won't find another NH easily. I'd be on the watch for them saying that he needs to be hospitalized and then saying they cannot readmit him to the NH when he is set to be discharged from hospital. Good luck
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If you have legal say over your dad, you have the RIGHT to see his chart. I NEVER withheld the charts from family who's names were in the chart as being responsible for their care. Period. (I am a nurse.) This sounds incredibly fishy to me. I would get an attorney. Now, the chart very well may have been altered by then.... I had a Director of Nursing that demanded I change something I charted one time! She pulled the page and asked me to rewrite it. It would also cause 2 other nurses to have to go back and rewrite what they had written, and not to mention it was INCREDIBLY ILLEGAL, but it didn't stop her from telling me to do it. I refused. I said if what I wrote was WRONG I could add a note at the bottom of the page to clarify, but I would not remove the charting. It was an official document. It doesn't sound like this place would be above doing the same.

This sounds really fishy. I would get a lawyer to get the documentation and MOVE him at the same time. I would also petition the courts about the roommate as well. So sad. :(
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Here's what you need to do:

1) Contact the State Ombudsman's office. It is required to have this information posted in the lobby in a prominent place.

2) When I was having my problems with the first nursing home my mother was in I casually mentioned "The Channel 2 Troubleshooter" and all of a sudden it was as if the Red Sea had parted.

So I would definitely go and contact the Ombudsman, and if necessary a local news crew. Nothing will get you the answers you want quicker than visibility...and in this instance negative visibility.

3) Definitely transfer your father. Not all nursing homes are as bad as this one. The second I found for Mom was much better.

I contribute for AgingCare and you can read more about my story here:

https://www.agingcare.com/articles/finding-nursing-home-caregiver-experience-156113.htm
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