After a nursing home calls to report a fall, a family may hear only a few sentences: your mother was found beside the bed, someone checked her, and she seemed all right. Those details leave a lot unanswered. What help was she supposed to have? Who examined her? Did anything change later that evening?
The records should help answer those questions. Ask for the resident’s chart covering a reasonable period before and after the fall, rather than accepting a one-page incident summary as the whole account. A fall alone does not establish neglect. The useful evidence shows what the facility knew, what care the resident needed, and what actually happened.
Make the request through the resident or an authorized representative
Being a concerned family member does not automatically give someone authority to receive the entire chart. If the resident can authorize disclosure, obtain that authorization. Otherwise, provide the documents establishing the representative’s authority and confirm its scope.
For covered nursing facilities, 42 C.F.R. 483.10(g)(2) gives residents access to their personal and medical records within 24 hours of an oral or written request, excluding weekends and holidays. It separately allows copies with two working days’ advance notice, subject to permitted reasonable, cost-based charges. Electronic records may be requested electronically. Louisiana’s medical-records statute also addresses access and copying.
Put the request in writing even when an oral request would suffice. Identify the resident, dates, requested format, and where the records should be sent. Keep the request and the facility’s response. If documents are missing, ask whether they are maintained separately, withheld, or simply not included in the production.
Find out what assistance was required before the fall
The starting point is the resident’s condition before the event. A person who walks independently has different needs from someone who requires two staff members and a lift to transfer safely. Ask for:
- Admission assessments, fall-risk assessments, and the Minimum Data Set assessments used to document the resident’s needs.
- The care plan in effect on the fall date, earlier relevant versions, and physician orders.
- Nursing notes and nursing-assistant flow sheets showing transfers, toileting, walking, and other daily assistance.
- Physical and occupational therapy evaluations, recommendations, and progress notes.
- Medication administration records and recent medication changes.
- Records of earlier falls, balance problems, or changes in cognition and mobility.
Compare the documents with one another. If therapy recommended assistance for transfers, did the care plan reflect it? Did the instructions reach the people helping the resident at night? A risk score can identify a concern, but it does not explain how staff addressed that concern.
The federal accident-prevention rule addresses hazards, supervision, and assistance devices. Its application depends on the resident’s circumstances. Even good care cannot prevent every fall.
Follow the care after the resident was found
Request the first assessment, later nursing observations, vital signs, neurological observations if performed, pain records, physician communications, new orders, and family notifications. Note the difference between when care occurred and when someone entered a note.
A notation that no injury was observed is one point in the timeline. Compare it with later complaints, changes in movement or behavior, additional examinations, imaging, and transfer decisions. Our article on why complete medical records matter explains why isolated entries can give an incomplete picture.
If the resident went to a hospital, request the ambulance and hospital records separately. Include the emergency department notes, imaging reports, actual image files when needed for review, specialist consultations, and discharge instructions. The nursing home’s chart may contain only a summary of that care.
Some important evidence is outside the chart
Surveillance video, call-light data, alarm records, staff assignments, and equipment-maintenance records may help explain the event. They may be stored in different systems and kept for different lengths of time. A prompt preservation request should identify the resident, location, approximate time, and relevant equipment or systems.
Preservation and disclosure are different requests. Asking the facility to retain incident reports or internal investigation materials does not establish an immediate right to receive every document. Privilege and confidentiality disputes may require legal review.
Keep your own original photographs, messages, and notes of conversations. Record who supplied each detail. If nobody witnessed the fall, describe the resident’s position when found without treating a later explanation as an eyewitness account.
You do not need a complete chart before asking about a possible claim. The Louisiana nursing-home lawsuit guide explains why the conduct and provider’s status affect procedure and deadlines. Our Baton Rouge nursing-home abuse practice can review the information you have and identify what remains missing. Contact us or call (225) 500-5000.
Editorial & Legal Accuracy Notice (Louisiana)
This article provides general Louisiana legal information, not advice about an individual case. Event dates, policy language, responsible parties, and the evidence may change the analysis.