Evaluating Standard of Care in Long-Term Care Through Daily Documentation
In long-term care litigation, proving a breach in the standard of care doesn’t always require a dramatic incident. More often, it’s found in the everyday details—the small decisions and omissions that accumulate over days or weeks and are revealed in daily documentation.
From nursing notes to medication records, these entries create a timeline of care—or lack thereof—that can make or break a case.
At Lexcura Summit Medical-Legal Consulting, our legal nurse consultants (LNCs) help attorneys assess whether long-term care providers have met their clinical and legal responsibilities by analyzing the daily documentation that reveals the true story. Here's how we evaluate the standard of care through routine records in nursing home and assisted living cases.
🏥 What Is “Standard of Care” in Long-Term Care?
The standard of care refers to what a reasonably prudent healthcare provider would do in similar circumstances. In long-term care, this includes:
Following care plans tailored to individual needs
Monitoring for signs of medical deterioration
Documenting interventions accurately and in real-time
Preventing avoidable injuries (falls, infections, pressure ulcers)
Communicating changes in condition to providers and families
📌 Daily documentation is the primary evidence of whether these expectations were met.
📋 Key Types of Daily Documentation We Analyze
✅ 1. Nursing Progress Notes
These narrative notes describe the resident’s condition, behavior, and response to care.
What we look for:
Consistency between shifts
Clinical observations linked to vitals or labs
Evidence of physician communication
Patterns of vague, repeated entries (“resting comfortably,” “no complaints”)
Signs of “charting by exception” or backdating
Why it matters: Inadequate or repetitive notes can signal inattentive care or staff shortages—and weaken the facility’s defense.
✅ 2. Activities of Daily Living (ADL) Logs
These records track the level of assistance a resident requires with activities such as eating, dressing, grooming, toileting, transferring, and mobility.
Red flags include:
Identical ADL entries for weeks with no variation
“Independent” ratings despite cognitive decline or falls
Lack of updates after changes in condition or hospitalization
📌 Incorrect ADL documentation often indicates fraudulent billing or failure to reassess a resident's needs.
✅ 3. Medication Administration Records (MARs)
The MAR shows what medications were ordered, given, missed, or refused.
We examine:
Missed or late doses (especially for critical meds like insulin or antibiotics)
Gaps in documentation
Lack of follow-up on refusals or side effects
Medications marked as administered after discharge or death
Why it matters: MAR errors may reflect poor staff training, underreporting, or neglect.
✅ 4. Vital Sign Logs and Monitoring
Vital signs are essential for spotting infections, dehydration, and declining health.
Documentation gaps include:
No vitals for days before a sudden event
Identical readings for multiple shifts
Missing blood pressure, temperature, or weight trends
📌 These omissions may indicate failure to monitor or noncompliance with care protocols—especially in residents with known risks.
✅ 5. Care Plans and Interventions
A care plan should reflect the resident’s evolving needs—and be updated after changes in condition.
Red flags:
Outdated care plans are still in use
Care plans that don’t match ADL logs or incident reports
No documentation of preventative measures (e.g., fall mats, repositioning, hydration)
Why it matters: If daily care doesn’t align with the plan, it's a clear breach of the standard of care.
👩⚕️ How Lexcura Summit Supports Long-Term Care Litigation
Our legal nurse consultants:
Conduct a thorough review of daily documentation across shifts and disciplines
Build clinical timelines of care and decline
Identify inconsistencies, omissions, or documentation errors
Compare the care provided against state and federal regulations
Provide litigation-ready summaries, visual chronologies, and expert annotations
✅ We translate technical records into clear, fact-based narratives that strengthen your legal position.
📁 Real-World Case Insight
Case: Undocumented Deterioration Leads to Sepsis and Death
A 90-year-old resident experienced increasing confusion and poor appetite over several days. CNA logs claimed “100% meal intake” and “alert & oriented,” despite family concerns and eventual ER transfer for sepsis. Lexcura Summit’s LNCs identified charting inconsistencies and outdated care plans, which contributed to a $650,000 settlement.
🛡️ Why Attorneys Choose Lexcura Summit
Over 200 licensed medical professionals with LTC and wound care experience
HIPAA-compliant systems and 7-day standard turnaround
Trusted by plaintiff and defense attorneys nationwide
Experts in falls, infections, pressure ulcers, dehydration, and elder neglect
Final Thoughts
Daily documentation in long-term care facilities isn’t just paperwork—it’s the foundation of every legal case. At Lexcura Summit, we help you evaluate whether the standard of care was met—or missed—by examining the records that tell the untold story of each resident’s care.
📞 Contact Lexcura Summit Medical-Legal Consulting today to strengthen your long-term care case with expert clinical analysis.
www.lexcura-summit.com or Tel: 352-703-0703
