The evidence needed to prove nursing home abuse includes medical records, witness testimony, internal facility documents, inspection reports, and more. With over 75 years of experience providing compassionate advocacy for nursing home abuse victims, our attorneys will help you build your case and recover the compensation you deserve.
Essential Evidence for a Nursing Home Abuse Case
Proving a nursing home abuse claim requires proof that your loved one experienced an injury or health decline because the nursing home failed to provide the attention, support, and care they needed. The evidence outlined below is critical for proving the facility was negligent and that their actions impacted your loved one and your family.
Medical Records
Medical records are the foundation of a nursing home abuse case because they provide chronological documentation of your loved one’s health status dating back to their admission. They include information about the care your loved one received, injuries, adverse events, and health declines.
Lifelong medical records establish your loved one’s condition before entering the facility, and hospital emergency room records can help prove a pattern of neglect and abuse. You will usually need the following medical evidence:
- Hospital records
- Nursing home admission records
- Your loved one’s care plan and all updates
- Physician orders and notes
- Therapy and rehabilitation records
- Medication records, including adverse events
- Incident reports about falls
- Nurses’ notes
- Lab test results and diagnostic imaging tests
- Treatment plans and progress notes
A complete medical record can shed light on suspicious treatment delays, missing doctors’ notes, lengthy response times, and negligent care.
Health Inspection Reports and Complaint Records
The California Department of Public Health inspects nursing homes both annually and in response to complaints. The department publishes inspection reports and complaint notes on its website, and Medicare.gov publishes health inspections and complaint inspections that trigger citations.
Inspection reports can show a pattern of conduct consistent with the type of abuse or neglect your loved one experienced. They may also demonstrate that a facility was aware of the problems but failed to correct them.
Facility Employment Records
Nursing home operators are required to conduct thorough background checks, hire qualified staff, and provide comprehensive training. Establishing that staff are unqualified or poorly trained can help prove the facility was negligent in providing competent care.
Nursing home understaffing is one of the top driving factors of nursing home abuse. Residents in understaffed facilities are more likely to develop bed sores and suffer inadequate hygiene care. Their call lights may go unanswered for hours, and nurses may fail to notice or report health changes to residents’ doctors or families. Proving a facility is understaffed shows that it is systemically unable to provide quality care. The following evidence can help:
- Staffing schedules
- Staffing logs
- Training manuals
- Charting errors
- Training records
- Staff certifications
- History of medical malpractice lawsuits
Policies, Procedures, and Internal Documents
Nursing homes often present themselves to juries as perfect facilities. However, an internal investigation can quickly erode this defense. The following documents can illuminate how the nursing home operates behind closed doors:
- Ownership information
- Records from other facilities under the same ownership
- Accreditation reports
- The facility’s policies and procedures manual
- Incident reports
- Vendor information, including cleaning, maintenance, and laundry contractors
- Inventories of medical, cleaning, food, and medication supplies
- Internal memos
- Budget reports
- Resident sign-in sheets for activities
Witness Statements
Eyewitnesses can fill in gaps between what is in the medical record, the allegations, and the nursing home’s statements. Family members and other visitors can testify to the injuries they observe during visits and the changes they notice in their loved ones. Other residents and their visitors sometimes witness abuse or neglect, and their testimony can help prove your claim.
Nursing home staff also make strong witnesses. Even if they did not witness an incident, their testimony can be valuable for proving the following systemic problems within the facility:
- Understaffing
- Overworked staff
- Lack of training or support
- Lack of enforcement of policies and procedures
- Ignored or covered-up complaints
Some nursing home staff are reluctant to testify because they fear retaliation. However, some will testify if their outrage outweighs their trepidation. Former staff may also be available to testify.
Expert Witness Testimony
Expert witnesses are crucial in nursing home abuse cases because they can explain complex medical issues, industry standards, and financial irregularities to juries in understandable ways. They can also connect the dots between a facility’s conduct and the resulting harm. Expert witnesses must have credentials that qualify them as subject area experts. The following types of experts often testify in nursing home abuse cases:
- Internal medicine physicians
- Geriatricians
- Specialists in specific fields
- Registered nurses
- Nursing home administrators
- Forensic accountants
- Life care planners
- Economists
- Mental health professionals
- Accident reconstructionists
Photographic Evidence
Photographs and video recordings can be powerful in a jury trial because they offer visual representations of incidents, injuries, and living conditions that cannot be expressed in words alone. You can use pictures to document the progression of injuries, such as bed sores, and other unacceptable living conditions.
Some nursing homes have surveillance cameras in hallways and common areas, which can document staff entering residents’ rooms and critical incidents in common areas, such as abuse or falls. You can place a camera in your loved one’s room with the permission of your loved one, their roommate, and the facility.
Tips for Collecting Photographic Evidence
When taking photographs to be used as evidence, make sure they are time-stamped with the location clearly identified. Photographs and video recordings of the following conditions can help:
- Bruises, skin conditions, and injuries
- Dirty rooms
- Wet or soiled clothing or bedding
- An unkempt appearance
- Malfunctioning medical equipment
- Disorganized medication cart
- Labels showing expired foods or drugs
- Unappetizing food
Be aware that you cannot photograph or record nursing home staff without their consent because it would violate California’s Invasion of Privacy Act.
Financial Records
Financial records are crucial in financial exploitation cases. You will need property records or credit card and bank statements showing unusual withdrawals or transfers. You may need copies of your loved one’s will, power of attorney, and insurance beneficiary information if any of these have changed.
You also need evidence proving your and your loved one’s monetary losses, including medical bills. If you took time off work to protect your loved one or care for their injuries, you will need pay stubs, time sheets, or a letter from an employer documenting the missed time and wages. If you moved your loved one to a new facility, you may need the following documentation to prove your costs:
- The admission agreement
- Payment records
- Moving company receipts
- Receipts for ambulance or other transport services
- Documentation of higher costs at the new facility, if applicable
Family Observation Logs
An observation log is a written journal of your loved one’s care and treatment, based on what you see and hear. Keeping a written record provides the jury with a first-hand account of what happened from your perspective. It can provide a valuable picture of gradual changes in your loved one’s condition, capture information missing from the medical records, and corroborate other evidence. It should include your observations of the following:
- Physical appearance
- Mood and behavior
- Changes in weight or health
- Bruises or other injuries
- Staff availability
- How staff treat your loved one
- Assistance staff provide
- Cleanliness of the room and facility
- Safety hazards
- Odors and overall comfort level
- Interactions with staff
- Incidents you observe and their outcomes
- Your loved one’s statements
When recording observations, include your name, relation to the resident, the time, date, location, and signature. Keep it factual, and avoid emotional statements or opinions.
Preserve Evidence Quickly Before It Disappears
Nursing home conditions can change rapidly, and crucial evidence may only be available for a limited time. For example, a cleaning crew might remove evidence of unsanitary conditions, and the facility could modify staff schedules to conceal understaffing. Witnesses may forget important details over time, and medical records could be altered. Taking photographs, securing medical records, and interviewing witnesses shortly after abuse or neglect incidents preserves valuable evidence before it disappears and protects your claim.
“I encourage you to visit your loved one at a nursing home at many different hours of the day. If you come at the same time every day, the staff at the nursing home is going to know that they need to clean up your loved one because you're on your way. And the best care your loved one is going to get all day is that 30 minutes before you get there. I encourage people to go at different times of the day and show up at night because you want to see what's going on 24 hours a day at the nursing home, and that resident has a right to visitors 24 hours a day.”
Preserve Evidence Quickly Before It Disappears
If you feel something is wrong, trust your instincts. Collect any evidence available, but don’t wait to take action. Call the California Department of Aging Long-Term Care Ombudsman’s 24-hour CRISIS Line at (800) 231-4024, and share your evidence. The ombudsman can visit your loved one, investigate potential abuse, and provide education and advocacy.
If you see potential violations, call the California Department of Health at (800) 554-0354 to file a complaint. The department will investigate the complaint and provide a written report of its findings.
Contact our experienced nursing home abuse lawyers at Lanzone Morgan, LLP as soon as you suspect abuse or neglect. We can gather additional evidence to sue a nursing home for abuse, let the nursing home know we are watching, and help you report the abuse.
Let Lanzone Morgan, LLP, Set You on the Path to Justice
Building a case against a nursing home is hard work, but you don’t have to do it alone. Nursing home abuse is all we do, so we know how to prove nursing home negligence with a level of efficiency you won’t find anywhere else.
We’ll conduct a full investigation into the nursing home’s conduct, interview witnesses, consult with expert witnesses, gather internal documents, and fight for the compensation you deserve.
Contact us online or call (888) 887-9777 today for a free case review.