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Senior Care Vital Signs
ProAssurance Risk ManagementJanuary 20244 min read

Documentation Inconsistencies Hinder Defense Against Alleged Adult Abuse


The estate of a deceased individual alleged negligence and vulnerable adult abuse/neglect/exploitation under the state’s Adult Protective Services Act.

Case Details

The repercussions of inadequate documentation may not only affect patient care but also challenge the defense of healthcare organizations when faced with legal action. This Vital Signs newsletter involves a case in which the estate of a deceased individual alleged negligence and vulnerable adult abuse/neglect/exploitation under the state’s Adult Protective Services Act, which exposed a lack of comprehensive documentation that compromised an effective defense.

An 85 YO female was admitted as a resident to an assisted living facility as a DNR while receiving hospice services. She exhibited signs of confusion, forgetfulness, and depression, requiring caregiver assistance for daily activities. She utilized a walker and wheelchair due to mobility issues, and experienced occasional pain in her left heel. At the time hospice services were initiated, the resident had various medical diagnoses, including Alzheimer’s disease, hypertension, major depressive disorder, and others. Her functional limitations encompassed bowel and bladder incontinence, limited endurance, ambulation difficulties, and dyspnea with mild exertion. The resident encountered a series of health challenges and lapses in care during her two-and-a-half year stay in assisted living.

Allegations included deficiencies such as maximizing profits through underfunding and understaffing; failure to implement adequate nutrition, skin care, and fall prevention interventions; and a disregard for physicians’ orders. The order of events, from admission to hospitalization, highlights the prolonged nature of the alleged lapses.

On various occasions, concerning incidents occurred including falls resulting in injuries. The subsequent documentation revealed gaps in detailing the incidents, hindering a comprehensive understanding of the circumstances. Preventive measures taken included advising the resident not to get up without assistance.

Medical encounters indicated a decline in mental health and complaints of swelling, leading to specialized treatments. Throughout her stay, medication adjustments, wound care, and specialized services were documented. Notably, however, the lack of detailed information on wound locations and inconsistent documentation of medication changes raised concerns.

Communication with healthcare providers acknowledged the resident’s bed/wheelchair-bound status. The care plan noted bruises and wounds, however no details of progression or comprehensive documentation of preventive measures. Ordered changes to the plan of care such as wound care, the discontinuation of medication, and changes in diabetic management reflected inconsistencies in care.

The resident’s decline continued over her two-and-a-half year stay, marked by referrals to specialized care and examinations. Documentation by healthcare providers noted the resident’s inability to perform certain activities. A subsequent hospitalization marked the end of her stay at the facility.


Throughout the resident’s journey, documentation inconsistencies, communication gaps, and the absence of a unified care approach were evident. The lack of detailed records hindered understanding and implementation of tailored preventive measures, potentially impacting the resident’s overall well-being.

Evidence also revealed a failure to promptly rectify similar issues identified when the state conducted on-site compliance inspections and issued citations. This failure not only risked jeopardizing the safety and care of residents, but also eroded the facility’s credibility and hindered its legal defense.

Due to the documentation inconsistencies, communication gaps, and the absence of a unified care approach, as well as the failure to rectify previously cited deficiencies, the case was settled.

Risk Reduction Strategies

Enhance Initial Assessment Evaluation

Implement a thorough and standardized initial assessment process to accurately determine the appropriate level of care for residents, ensuring that their specific needs are addressed from the outset and minimizing the risk of inadequate care in the facility throughout the residents’ stay.

Enhance Documentation Protocols

Implement and enforce standardized documentation protocols that ensure the thorough recording of patient assessments, interventions, and responses. This includes comprehensive records of falls, injuries, and preventive measures taken, enabling a clear understanding of the resident’s progress or decline.

Regular Training and Education

Conduct routine training sessions for healthcare workers on documentation best practices, emphasizing the importance of accuracy, completeness, and timeliness. This empowers healthcare professionals, from physicians to medical assistants, to consistently adhere to high standards and reduce the likelihood of oversights or omissions.

Establish Comprehensive Night-Time Protocols

Develop and implement thorough policies and procedures tailored to night-time care. Encompassing resident monitoring, emergency response protocols, and guidelines for addressing nocturnal issues, these protocols are crucial. Proper training helps ensure staff confidence and competence in nocturnal care practices. Consider conducting frequent training sessions for night-shift staff, addressing unique challenges associated with providing care during nocturnal hours. This includes training on effective communication, emergency procedures, and proactive measures to prevent issues like falls or medical emergencies.

Enhance Interdisciplinary Communication

Establish and reinforce protocols for interdisciplinary communication within senior care facilities. Facilitate regular meetings and information-sharing sessions among healthcare providers, caregivers, and support staff. Clear channels of communication can enhance the collective understanding of a resident’s condition, leading to more informed decisions and a unified defense in potential legal cases.

The gravity of the alleged lapses, as framed by the estate’s accusations of negligence and vulnerable adult abuse/neglect/exploitation, underscores the critical need for healthcare facilities to prioritize comprehensive and accurate record-keeping. By implementing robust documentation practices, embracing risk reduction strategies, and enhancing interdisciplinary communication, healthcare workers can enhance patient care, foster transparency, and fortify their institutions against potential legal challenges.


If you have questions on this topic, please email or call 844-223-9648.


ProAssurance Risk Management

The ProAssurance Risk Management department is here to help you promote patient safety, minimize risk, and improve defensibility of claims by providing comprehensive assessment and training resources that are relevant and easy to share. If you have a question you would like to discuss with a risk consultant, email or call 844-223-9648.