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Who’s Watching Your Elderly Relative In The Nursing Home? When The Caregivers Have No Rules.

Who’s Watching Your Elderly Relative In The Nursing Home? When The Caregivers Have No Rules.

Last week I wrote a post titled Who’s Watching Your Elderly Relative In The Nursing Home? At the time, I had been taking depositions in a couple different Alabama nursing home abuse cases. While taking the deposition of one facility’s Director of Nursing, the witness basically admitted her facility only purchased a rulebook to get licensed. This Director of Nursing testified her facility obtained a canned rulebook years ago to get licensed. Since then, the rulebook sat on the shelf gathering dust. She could not testify to any of her own facility’s specific procedures.

Think about that — A facility full of caregivers with no common procedures. All caregivers are left to act as they deem appropriate. We also took the depositions of several different CNAs who provided care at the facility. Most of them had never worked with any other providers. So, they had no prior experience. This facility hired them and turned them loose on its elderly residents with no explicit policies.

When we reviewed the medical chart at the nursing home, we found almost nothing. By nothing, I mean almost nothing was charted despite doctor’s orders to monitor the elderly resident carefully due to his health condition. In my post last week I discussed the nursing home’s response to questions on its lack of charting. In response, the witnesses testified they only “chart by exception.”

Chart by exception? But, whose exception? And, exception to what? This is a practice in some facilities that really started in the last couple decades with staffing shortages. Not enough staff to fully chart. Not enough time to note the resident’s health. With too little staff, all workers are busy taking care of resident activities of daily living. Too busy to slow down and record real notes that will help the next shift see important health changes. Too busy to slow down and record real notes that can be reviewed by the doctor making healthcare decisions. In Alabama, we have no real staffing standards for the nursing homes caring for our elderly neighbors.

Take a shortcut and only chart health deviations. Here are a couple problems with this concept in my case. When the facility has no explicit rules or procedures, what things are deviations that should be charted? Every caregiver has a different idea about that! When the facility has no charted baseline, how does anyone know whether a significant deviation has even occurred? Every person is different and it is essential the baseline be fully charted so you can see deviations from it. When the facility has no consistent charting, little day-to-day changes can suddenly result in a serious health change. For example, the little signs of an infection may be missed. Suddenly, the patient is suffering a horrible infection.

After all, a flood starts with a single drop of rain. If you are not monitoring and charting, you can easily miss the signs and symptoms until it is too late.

It’s a hopeless scenario for residents. Instead of clear rules or consistent documented care, the elderly residents are relying on single caregivers (without much training) to recognize a serious health problem before it is too late. In a facility that follows the process of only charting by exception with no clear rules for it (or really lack of any rules), serious injuries and health issues will be missed. Residents will suffer. Residents who could be treated and healed, will die.

Many families are faced with no choice other than nursing home care. When our elderly relatives require nursing home care, we want to trust they are being treated with dignity. We want to trust that trained nurses are following real procedures designed to monitor their health. We want to trust that the facility will observe and intervene when health issues arise, before it’s too late. In a facility with no real rules, a bunch of caregivers acting without explicit guidelines, and a policy to only chart observations a sparsely trained CNA considers important, our elderly relatives and neighbors will eventually suffer. I think they deserve better. If you are looking at nursing homes for an elderly relative, ask questions about the home and its procedures.


From its office in Huntsville, the Blackwell Law Firm represents families across Alabama following a serious personal injury or death. Our lawyers ONLY handle personal injury cases so we can focus solely on maximizing our cases for our injured clients.