Standards of Care Checklist (LTC)
A structured, attorney‑friendly checklist for evaluating compliance with long‑term care standards across assessment, monitoring, documentation, and interventions.
This checklist distills the essential standards of care required in long‑term care settings. It is designed to help attorneys quickly identify deviations, organize breach arguments, and evaluate whether a facility complied with federal regulations, state requirements, and accepted clinical practice.
Use this checklist during case intake, expert review preparation, and deposition planning.
ADMISSION & INITIAL ASSESSMENT
✔ Comprehensive Assessment Completed?
• Full head‑to‑toe assessment
• Review of hospital records
• Baseline vitals and functional status
• Identification of risks (falls, pressure injuries, dehydration, infection, elopement, etc.)
✔ Immediate Interventions Initiated?
• Fall precautions
• Skin protection
• Hydration/nutrition support
• Medication reconciliation
• Monitoring schedule established
CARE PLANNING
✔ Individualized Care Plan Developed?
• Based on assessment findings
• Includes measurable goals
• Includes specific interventions
• Developed by interdisciplinary team
✔ Care Plan Communicated to Staff?
• Nursing
• Therapy
• Dietary
• Social services
• Medical providers
✔ Care Plan Updated Promptly?
• After a change in condition
• After new risks emerge
• After the physician orders
• After a significant event
MONITORING & SURVEILLANCE
✔ Ongoing Monitoring Performed?
• Vital signs
• Pain
• Skin integrity
• Hydration/nutrition
• Behavioral changes
• Medication effects
✔ Monitoring Frequency Appropriate?
• Based on risk level
• Based on physician orders
• Based on facility policy
✔ Staff Recognized Changes in Condition?
• Early signs of infection
• Decline in mobility
• Cognitive changes
• Respiratory distress
• New or worsening wounds
DOCUMENTATION STANDARDS
✔ Documentation Accurate & Timely?
• Reflects actual care
• Matches clinical events
• No unexplained gaps
• No copy‑paste patterns
✔ Interdisciplinary Notes Consistent?
• Nursing
• Therapy
• Dietary
• Physician
• CNA flow sheets
✔ Incident Reports Completed Correctly?
• Detailed description
• Witness statements
• Timeline reconstruction
• Notifications documented
COMMON BREACH INDICATORS
✔ Missed or Delayed Response to Change in Condition
✔ Inadequate Fall Prevention
✔ Pressure Injury Development or Worsening
✔ Medication Errors or Poor Monitoring
✔ Poor Communication Between Staff or Providers
✔ Missing or Inconsistent Documentation
These indicators often signal systemic failures.