Nursing Homes

Resident assessments document needs, strengths, functional status, cognition, medical conditions, medications, and other factors relevant to care. Person-centered care plans identify goals, services, interventions, and timeframes based on assessed needs. Comparing assessments, care plans, progress notes, and later changes can help evaluate whether identified needs were reflected in the resident’s ongoing care.

Staffing schedules, assignment records, Payroll-Based Journal data, resident assessments, and facility-assessment records can help show what staff were available and what staffing needs the facility had identified. The analysis should also consider resident acuity, staff competencies, unit and shift needs, and the federal and state requirements in effect at the time rather than relying on a single staffing number. CMS requires payroll-based staffing reporting and facility assessments that address staffing needs and competencies.

Nursing notes, vital signs, medication records, incident reports, practitioner communications, transfer records, assessments, care-plan revisions, and notifications can be reviewed chronologically to determine when a change was documented and what actions followed. Federal nursing home requirements also address reassessment and care-plan review after significant changes in condition. Questions about diagnosis, prognosis, or medical causation may require separate medical expertise.