Uncover 12 Arizona Nursing Home Abuse Signs by reading the Patients Chart

To obtain good care for your loved one in a nursing home and to prevent Arizona nursing home abuse, you should know what to look for and how to ask the right questions. One way to understand the nursing home process is by learning about the resident’s nursing home chart.

Arizona nursing home residents have a right to review their medical records and charts. If your loved one is competent, he or she can ask the nursing home to permit you to have the same access.

The following records can be found in the nursing home chart:

1. Physician Orders
2. Physician Progress Notes
3. Nursing Notes
4. Laboratory Reports

You should periodically (every month or two) ask for copies of these records to make sure they accurately reflect your observations and the care provided to your loved one. In making your request, advise the staff that you are the eyes and ears of the family and you want to be in a position to provide the staff with accurate and detailed information.

If you don’t understand what is written in the record, you should request the nurses or the Director of Nursing to translate them for you.

1. Physician Orders

All physician orders and treatments must be documented in the nursing home record.

Physician orders are not evidence that the treatment, medication, or services were actually provided. They only show that these services were ordered.

2. Admission Orders

Admission orders are the first set of physician orders when a resident is admitted into the nursing home. These orders address items such as diet, weight, therapy, vital signs, and medications. They also address your loved one’s code status (such as whether a he or she has requested a “Do Not Resuscitate” order).

Once physician orders are placed, they remain in place until the physician changes them.

3. Physician Progress Notes

Physician’s notes should contain:

1. A description of the resident’s symptoms (the resident’s own observations and complaints).
2. The physician’s physical examination and lab results.
3. A diagnosis based on the resident’s symptoms, and the physician’s observations and lab results.
4. A treatment plan for the resident and how the plan will be monitored for success.

4. Nursing Notes

Nurses countersign physician orders. They write the orders on nursing forms, document that the orders have been followed, document that the physician has been notified of changes in the resident’s condition, record the resident’s bowel movements, the percentage of the resident’s food intake, and the condition of the resident’s skin.

The following documents are prepared and maintained by the nursing staff:

1. Nursing Progress Notes
2. The MDS (Minimum Data Set)
3. The RAPS (Resident Assessment Protocol)
4. The Care Plans
5. Vital Signs/Weight records
6. Pressure Ulcer Reports
7. The MAR (Medication Administration Record)
8. The TAR (Treatment Administration Record)
9. Laboratory Results
10. Nursing Progress Notes

These notes are often recorded by nursing on a day to day basis. They contain the nurses’ observations of the resident’s vital signs, appetite, skin condition, and changes in his or her condition. They state whether the physician was notified of the changes and the orders he or she gave in response to the change in condition.

5. Minimum Data Set (MDS)

This document is a comprehensive assessment that the nursing staff must complete on days 5, 14, 30, 60, and 90, after the resident’s admission. All nursing homes receiving federal medicare dollars must complete these forms.

By filling out this form (which contains hundreds of parts and sub-parts), the nurses gather information about the resident’s medical history, weight, mental status, physical status, skin condition, status of continence, and many other aspects of the resident’s condition.

The information gathered must then be reviewed by an interdisciplinary care team made up of nurses, the resident’s physician, the dietary staff, the activities staff, and the social services staff.

6. Resident Assessment Protocol

The Resident Assessment Protocol, or “RAP,” consists of questions about the resident’s condition contained in the MDS form. If the questions are answered affirmatively, they “trigger” the necessity of an analysis outlined in the RAP form. The RAP process forces the interdisciplinary care plan team to analyze the triggered conditions and arrive at an approach which they then spell out in the resident’s care.

For example, if the resident has a history of falls that are identified (“triggered”) in the MDS form, the RAP will outline possible medical, cognitive, and behavioral factors for the resident which may be the cause of his or her falls. These factors should be considered and discussed by the interdisciplinary care plan team to arrive at the best approach at minimizing the risk of the resident falling.

7. Care Plan

This is a written document which establishes a course of action and treatment to address the resident’s needs based upon the interdisciplinary care plan team’s analysis and recommendations.

Every course of action for care must be periodically re-evaluated to determine whether it is working for the resident. If the plan doesn’t provide the desired result, then the Care Plan must be redone to outline an alternative course of action for care.

8. Vital Signs / Weight Record

The resident’s weight is recorded monthly unless it is ordered to be taken more frequently.

A resident’s weight is important to determine whether there is weight loss or gain. Weight loss or weight gain may be caused by a medical condition which requires the attention of the resident’s physician.

Unplanned weight loss may be due to malnutrition. Unplanned weight gain may be a sign of fluid retention, or other medical conditions.

9. Pressure Ulcer Report

This report documents the condition of the resident’s skin and the progression of any pressure ulcers that the resident is suffering. It is updated and reviewed on a regular basis.

Remember, if proper care is given, residents should not develop pressure ulcers, and any existing pressure ulcers should heal if proper care is given.

10. The Medication Administration Record (MAR)

This record contains all medications that the physician has ordered for the resident, including the dosages and times they are given.

Each time the resident receives or is offered the medication, this should be noted on the MAR. If the medication is not taken by the resident, the nursing staff should describe the reasons why not in the record.

11. The Treatment Administration Record (TAR)

This record contains all recurring treatments ordered by the physician and the times the treatments are performed.

12. Laboratory Reports

These reports contain the results of blood and urine tests.

You should review these results and compare them to the normal ranges contained in the lab report. If there are any abnormal results, discuss them with your loved one’s physician.