The Family Guide to New York Nursing Homes

Most problems that become serious later can be traced to the first few weeks: a care plan that was never finished, a risk no one noticed, or a family that did not yet know whom to call. Use this checklist to get off on the right footing.

Before or on admission day

• Bring copies of the health care proxy, power of attorney, MOLST or living will, and any guardianship papers. Give copies to the social worker and ask that they be placed in the chart.
• Bring the hospital discharge papers and a current medication list. Ask the admitting nurse to compare them with the new orders.
• Read the admission agreement before signing (see the next chapter). You do not have to sign an arbitration agreement, and you cannot be required to personally guarantee payment.
• Tell the nurse about anything the hospital may have missed: falls at home, swallowing trouble, skin problems, hearing or vision loss, dentures, behaviors, and what calms or upsets your loved one.
• Label clothing, glasses, hearing aids and dentures. Ask for the personal property inventory sheet and keep a copy.

The first week

• Ask for a copy of the baseline care plan, which must be done within 48 hours of admission.
• Meet the unit manager or charge nurse, the social worker and, if you can, the Director of Nursing. Write their names and numbers on the contacts sheet at the back of this guide.
• Ask how many nursing assistants work the unit on days, evenings and nights, and how many residents each one cares for.
• Look at the skin with staff during care, especially the tailbone, hips and heels. A pressure injury can start within days.
• Confirm that the facility has your phone number and knows you want to be called about any fall, injury, new medication or change in condition.

Weeks two through four

• The first full assessment (the MDS) is due within 14 days. The comprehensive care plan follows within 7 days after that. Ask for the date of the first care plan meeting and attend.
• Visit at different times, including evenings, weekends and mealtimes. Problems often show up when staffing is thinnest.
• Ask for the resident's weight each week for the first month. Early weight loss is common and easy to miss.
• Start a simple log of what you see and whom you speak with. The incident log at the back of this guide works well.

Arbitration agreements

Many admission packets include an agreement to send any future dispute, including a claim of neglect or abuse, to private arbitration instead of court. Under federal rules for Medicare and Medicaid facilities:

• Signing it cannot be required for admission or to keep receiving care.
• The agreement must say so, in plain language.
• You have the right to cancel (rescind) it within 30 calendar days of signing.

You may simply decline to sign. If you already signed and are within 30 days, cancel it in writing and keep a copy.

Payment guarantees

A facility may ask a family member who has legal access to the resident's money to use that money to pay the bill. It may not require a third party to personally guarantee payment as a condition of admission. If you sign as "responsible party," read exactly what you are agreeing to.

Other things to look for

• Charges that are not covered by Medicare or Medicaid, and how they are billed.
• The bed-hold policy if the resident goes to the hospital.
• Any waiver of liability for lost property or injuries. Facilities cannot ask residents to give up their rights.

The documents

• Health care proxy. Signed by the resident while able, naming a health care agent. The agent's authority begins when the resident is determined to lack capacity. The agent is entitled to the medical information needed to make decisions.
• MOLST. A bright pink New York form that records decisions about CPR, intubation, hospital transfer, artificial nutrition and other treatment as medical orders. It should be reviewed periodically and when the resident's condition changes.
• DNR (do not resuscitate). An order not to attempt CPR. In nursing homes it usually appears on the MOLST. A DNR does not mean "do not treat"; the resident is still entitled to all other care.
• Living will. A written statement of the resident's wishes, which guides the agent and the team.
• Surrogate. If there is no proxy and no guardian, the Family Health Care Decisions Act sets an order of priority (generally a guardian, then a spouse or domestic partner, an adult child, a parent, a sibling and a close friend).

What families should check

• Is a copy of the health care proxy in the chart, and does the facility have the agent's correct phone number?
• Does the MOLST reflect what the resident actually wanted, and was it discussed with the resident or agent?
• Was the MOLST reviewed after a hospital stay or major decline?

A power of attorney is different. It covers finances, not medical decisions. See does a power of attorney help.

Leadership

• Administrator: licensed by New York State; runs the whole facility, including budget, staffing levels and compliance. The person to escalate to when nursing leadership does not fix a problem.
• Director of nursing (DON): a registered nurse in charge of all nursing care and nursing staff.
• Assistant director of nursing (ADON): supports the DON, often responsible for staffing, education or specific units.
• Medical director: a physician responsible for the facility's medical care policies.

Nursing staff on the unit

• Unit manager or nurse manager: an RN who oversees one unit or floor. Usually the best first contact for a specific concern.
• Nursing supervisor: an RN in charge of the building on evenings, nights and weekends.
• Charge nurse, RN or LPN: gives medications and treatments, assesses residents and supervises the nursing assistants on the shift.
• Certified nursing assistant (CNA): provides most hands-on care: bathing, dressing, feeding, toileting, turning and transfers.
• Wound care nurse: in many facilities, a nurse with special training who assesses and treats pressure injuries.
• MDS coordinator: a nurse who completes the federally required assessments.
• Infection preventionist: responsible for the infection control program; required by federal rules.

Other professionals

• Social worker: admission, discharge planning, family communication, grievances and emotional needs.
• Dietitian: assesses nutrition and weight loss and recommends supplements and diet changes.
• Physical, occupational and speech therapists: rehabilitation, mobility, safe transfers and swallowing (speech therapists evaluate choking and aspiration risk).
• Activities director: recreation and engagement programs.
• Attending physician, nurse practitioner or physician assistant: the resident's medical provider.

Not facility staff

The Long Term Care Ombudsman is an independent advocate for residents, reachable at 1-855-582-6769. Ombudsmen do not work for the facility.

Who to call about what

• Day-to-day care: the charge nurse, then the unit manager
• A pattern of problems or a serious event: the director of nursing
• Staffing, unresolved complaints or threats of discharge: the administrator
• Meetings, family communication or discharge: the social worker
• Medical decisions and medication changes: the attending physician or nurse practitioner

Typical duties

• Bathing, dressing, oral care and grooming
• Helping residents eat and drink, and recording how much was eaten
• Toileting, incontinence care and changing
• Turning and repositioning bedbound residents to prevent pressure injuries
• Transfers from bed to chair and help with walking, using lifts where required
• Taking vital signs and weights
• Answering call bells
• Reporting changes in condition to the nurse
• Documenting care on flow sheets

What CNAs generally may not do

CNAs generally do not give medications, perform wound treatments or make clinical assessments. Those are nursing duties. If a CNA reports a problem, a nurse is responsible for assessing it and acting.

Training and certification

Federal rules require nurse aides to complete a state-approved training program of at least 75 hours, including supervised clinical training, and to pass a competency evaluation. A facility may not use someone as a nurse aide for more than four months unless the aide has completed training and is competent. New York maintains a Nurse Aide Registry where certification can be checked.

Why this matters

When a facility is short-staffed, the CNAs feel it first: each aide has more residents, and turning, toileting and feeding help get skipped. New York requires a minimum amount of CNA care time per resident each day. See New York nursing home staffing requirements.

Tips for families

• Learn the names of the CNAs who care for your loved one on each shift.
• Ask how many residents each aide is assigned on days, evenings and nights.
• Tell the nurse, not only the aide, about any concern, so it is assessed and documented.

Registered nurse (RN)

• Performs and is accountable for nursing assessments
• Coordinates the MDS and care plans
• Assesses changes in condition and calls the physician
• Often serves as unit manager, supervisor or director of nursing

Federal rules require an RN on duty at least eight consecutive hours a day, seven days a week.

Licensed practical nurse (LPN)

• Gives medications and treatments, documented on the MAR and TAR
• Monitors residents and reports changes
• Often serves as charge nurse and supervises the CNAs on a unit

Charge nurse

Federal rules require a licensed nurse to serve as charge nurse on each shift. The charge nurse is the first person to ask about how a resident is doing that day, about medications, and about anything a CNA has reported.

Why it matters

When a resident has a change in condition, such as a fall, fever, new confusion, a new wound or not eating, a nurse must assess the resident and notify the physician and family. Ask who assessed the resident and what was done.

Responsibilities

• Supervising RNs, LPNs and CNAs, usually through unit managers and supervisors
• Nursing policies and procedures, such as fall prevention, skin care, incontinence care and medication administration
• Nurse staffing schedules and assignments
• Staff training and competency
• Reviewing incidents, falls, pressure injuries, infections and complaints about nursing care
• Working with the administrator and medical director on quality improvement

When to contact the DON

Start with the charge nurse or unit manager for day-to-day issues. Go to the DON when a problem repeats, when the unit does not fix it, or when something serious happens: a fall with injury, a new pressure injury, an unexplained bruise or fracture, a medication error, or signs of abuse. Put your concern in writing (an email is fine) and ask for a written response.

Related roles

• Assistant director of nursing (ADON) supports the DON.
• Unit managers run individual floors.
• Nursing supervisors are in charge of the building on evenings, nights and weekends, when the DON is usually not there.

Responsibilities

• Day-to-day management of every department: nursing, dietary, housekeeping, maintenance, social work, activities and admissions
• Budget and staffing levels, including use of agency staff
• Compliance with federal and New York regulations, including responding to Department of Health inspections
• Making sure allegations of abuse, neglect and injuries of unknown origin are reported to the state and investigated
• The grievance process and responses to family concerns

When to go to the administrator

• When the director of nursing has not resolved a serious or repeated problem
• Staffing concerns, such as too few aides on nights and weekends
• A threatened transfer or discharge
• Billing and admission agreement issues
• Suspected abuse or neglect, along with a report to the Department of Health

Put the concern in writing and keep a copy. If the administrator does not act, file a complaint with the Department of Health.

What social services does

• Helps with admission paperwork and adjustment to the facility
• Schedules and often leads care plan meetings
• Serves as a point of contact between the family and the care team
• Addresses mood, behavior and psychosocial needs, and arranges mental health services
• Handles complaints about lost items, roommate conflicts and dignity concerns
• Often serves as, or works with, the facility's grievance official
• Plans safe discharges home or to another setting

What social services does not do

The social worker does not direct nursing care. Concerns about falls, wounds, medications or hands-on care should go to nursing (the unit manager or director of nursing), with a copy to the social worker.

Tips

• Ask the social worker to send you the date of every care plan meeting in writing.
• Send a short written summary after each meeting.
• If the facility starts talking about discharge, ask the social worker for the written notice and the appeal rights. See discharge rights.

Attending physician

• Writes the orders for medications, diet and treatment
• Reviews the resident's overall plan of care
• Must be notified of significant changes in condition
• Residents have the right to choose their attending physician, subject to the facility's credentialing requirements.

How often visits happen

• Every 30 days for the first 90 days after admission
• At least every 60 days after that
• After the initial visit, required visits may alternate between the physician and a nurse practitioner or physician assistant

Many residents are actually seen more often by a nurse practitioner. Ask who the resident's provider is and how to reach them.

Medical director

The medical director is a physician responsible for implementing resident care policies and coordinating medical care in the facility. The medical director is not usually each resident's personal doctor, but is a person to involve when medical care problems are systemic.

Tips

• Ask for the attending's name and the best way to schedule a call.
• Ask to be called before any new psychotropic medication is started.
• Ask that the physician attend, or give input to, the care plan meeting.

The rules

• New York minimums: 3.5 hours of care per resident per day, including 2.2 hours of CNA care and 1.1 hours of licensed nurse care.
• Federal requirements: sufficient staff with the right skills to meet each resident's needs, an RN at least eight consecutive hours a day, seven days a week, a full-time director of nursing, and a licensed charge nurse on each shift.

The minimum is a floor, not a target. A unit with many residents who need two-person transfers, feeding help or frequent turning may need far more.

How to check staffing

• Read the posted staffing. Nursing homes must post daily nurse staffing numbers at the start of each shift, in a place residents and visitors can see. Facilities must keep these postings for at least 18 months.
• Check the staffing rating for any facility in our directory. It is based on payroll data the facility reports to Medicare.
• Visit at different times, including evenings and weekends, when staffing is usually thinnest.
• Ask how many residents each CNA is assigned on days, evenings and nights.

Signs of understaffing

• Call bells ringing for a long time
• Residents left in bed, in wet briefs or in the same position for hours
• Meal trays left untouched for residents who need feeding help
• Heavy use of agency staff who do not know the residents
• Repeated falls and new pressure injuries on the unit

What a care plan contains

A care plan is organized by problem. For each one you should see:

• The problem or risk, for example "at risk for falls due to weakness and dementia" or "at risk for pressure injury."
• A measurable goal, such as "will have no falls with injury this quarter" or "skin will remain intact."
• Interventions: the specific things staff must do. Good interventions are concrete: "turn and reposition at least every two hours," "bed in lowest position with floor mats," "offer fluids every shift," "two-person assist for transfers."
• Who is responsible (nursing, the nursing assistants, dietary, therapy, social work) and when the plan will be reviewed.

When it is written and updated

• Within 48 hours of admission, a baseline care plan covering immediate needs such as medications, diet and safety.
• Within 7 days after the first comprehensive assessment (the MDS, which is due within 14 days of admission), the full care plan.
• After every later assessment, usually about every three months, and whenever the resident's condition changes significantly, such as after a fall, a hospital stay, a new wound or a big weight loss.

Your right to take part

Residents have the right to take part in planning their care, to choose who else attends, to see the care plan, and to have meetings scheduled when they and their family can attend. If the resident cannot participate, the health care agent, guardian or other representative steps in. See how to prepare for a care plan meeting.

How to tell whether the plan is being followed

A care plan only matters if staff carry it out. Compare what the plan says with what you see. If the plan calls for a pressure-relieving mattress, heel protectors, a bed alarm or two-person transfers, look for them. If the plan says "encourage fluids" but the water pitcher is always full and out of reach, raise it.

The records show whether interventions were documented: the nursing assistant flow sheets, the medication and treatment records, and the nursing notes. Gaps between the plan and those records are often the first sign of neglect.

Red flags

• The same generic plan for every problem ("monitor," "encourage," "as needed") with no specific steps.
• The plan was not updated after a fall, a new wound, a hospital stay or major weight loss.
• No one has invited you to a care plan meeting in months.
• Staff on the floor do not know what the plan says.

Who attends

The team (often called the "interdisciplinary team" or "IDT") must include the attending physician, a registered nurse responsible for the resident, a nursing assistant responsible for the resident, and a member of the food and nutrition staff, plus others as needed such as social work, therapy and activities. In practice the physician and the nursing assistant are often missing. You can ask that they attend or that their input be provided.

How often

Most facilities hold a meeting after each scheduled assessment, which is roughly every three months, plus after a significant change in condition. You can ask for a meeting at any time if you have concerns. You can also ask to attend by phone or video.

How to prepare

• Ask for a copy of the current care plan before the meeting. Read it and mark anything that does not match what you see.
• Write down dates and specifics: weight changes, falls, bruises, missed meals, soiled bedding, call bells not answered.
• Bring the resident if he or she wants to attend, and anyone else the resident wants there.

Questions to ask

• What is the current weight, and how does it compare to one, three and six months ago?
• Is there any skin breakdown or redness anywhere? What was the latest skin assessment and Braden score?
• How many falls have there been since the last meeting, and what changed in the plan after each one?
• What medications were started or changed, and why? Is the resident on any antipsychotic or sedating medication?
• How much of each meal is the resident eating, and how much fluid is the resident drinking?
• Who is the resident's regular nursing assistant on each shift?
• What exactly will be done differently before the next meeting, and who is responsible?

After the meeting

Send a short email or letter to the social worker summarizing what was agreed. That creates a record. If the agreed changes do not happen, raise it with the director of nursing, and if needed file a grievance or a complaint with the Department of Health.

What it measures

The MDS is organized into sections, including cognition (often a short memory test called the BIMS), mood, behavior, ability to perform daily activities such as eating, toileting and walking, bladder and bowel continence, weight and nutrition, skin condition including pressure injuries, falls since the last assessment, and certain medications such as antipsychotics.

When it is done

• Within 14 days of admission
• A quarterly review at least every three months
• A full reassessment at least once a year
• Within 14 days after a significant change in condition, for better or worse

A registered nurse must conduct or coordinate each assessment. Many facilities employ an "MDS coordinator" for this.

Why it matters to families

• It drives the care plan. Problems identified on the MDS should appear in the care plan with specific interventions.
• It shows decline over time. Comparing MDS assessments shows changes in weight, mobility, continence and skin.
• It feeds public ratings. Medicare's quality measures for each facility, shown in our directory, are calculated largely from MDS data.
• It should match the chart. An MDS that reports no falls or no pressure injury when the nursing notes say otherwise is a serious documentation problem.

You can ask for copies of the MDS assessments as part of the resident's records. Our records request kit includes them.

The main parts

• Physician orders. Every medication, diet, treatment, test and precaution must be ordered. Telephone orders are written by a nurse and later signed by the practitioner.
• Progress notes. Notes by physicians, nurse practitioners, nurses, social workers, dietitians and therapists describing the resident's condition and events.
• MAR and TAR. The record of each medication dose and each treatment (such as a wound dressing) and whether it was given.
• Nursing assistant flow sheets. Shift-by-shift documentation of bathing, eating, toileting, incontinence care and repositioning.
• MDS assessments and care plans.
• Skin and wound records. Weekly skin checks, Braden Scale risk scores, and wound measurements, descriptions and photographs.
• Weights, intake and output. Weekly or monthly weights, the percentage of each meal eaten, and fluid intake.
• Fall risk assessments and post-fall notes. Note that the facility's internal incident report itself may be kept outside the chart.
• Labs, x-rays and consultations, and hospital transfer forms sent with the resident to the emergency room.
• Admission documents, including the admission agreement and any arbitration agreement, and advance directives such as a health care proxy or MOLST.

What families often miss

• Electronic records have an audit trail showing who entered or changed each entry and when. Late entries and edits made after an injury can matter.
• Blanks are information. A blank box on a flow sheet or MAR usually means the task was not documented, and often that it was not done.
• "Charting by exception" means some facilities only write a note when something is abnormal. Ask how the facility documents.

How to get the chart

Residents and their legal representatives have the right to see the record within 24 hours and get copies within two working days. After a death, the executor, administrator or a close family member can request the records. Our free kit generates the request letter.

How to read them

• Each row is one order: the drug or treatment, the dose, the route and how often.
• Each box is one scheduled administration. Initials mean the nurse documented giving it.
• Codes or circled entries explain exceptions, such as "refused," "held," "resident out of facility" or "drug not available." The reason should be explained in a note.
• "PRN" means "as needed." For PRN pain or anxiety medications, the nurse should document why it was given and whether it worked.

What to look for

• Blanks. An empty box means the dose or treatment was not documented.
• Repeated "not available" codes, which can mean the pharmacy delivery failed.
• Wound treatments on the TAR that do not match the wound notes, such as a dressing ordered daily but documented only a few times a week.
• Frequent PRN sedatives or antipsychotics, especially in the evening. See antipsychotics and chemical restraints.
• New medications started without notice to the family, particularly psychotropic drugs.

Federal rules require each facility to keep its medication error rate below 5 percent and to ensure residents are free of significant medication errors.

What they record

• "ADLs" are activities of daily living: bathing, dressing, eating, toileting, transferring and moving in bed.
• For each, the aide documents how much help was needed (independent, supervision, one-person or two-person assist).
• Meal intake is usually recorded as a percentage of each meal eaten.
• Repositioning and incontinence checks may be recorded each time or once per shift, depending on the facility.

Why they matter

Pressure injuries, dehydration and weight loss usually develop when basic care is missed. Flow sheets show whether a resident at risk for bedsores was actually turned, whether a resident who needs feeding help was actually fed, and whether incontinence care was done. Compare them with the care plan: if the plan says "turn every two hours" and the flow sheet shows one entry per shift, that is a gap.

Warning signs in the records

• Blank shifts, especially nights and weekends
• Identical entries every shift, which can mean "copy-forward" charting
• Entries documented when the resident was in the hospital
• Meal intake consistently below 50 percent with no dietitian follow-up

Staffing assignment sheets show which aide was responsible for the resident on each shift. Those are generally not available through a records request, but can be obtained in litigation.

The six factors

• Sensory perception: can the resident feel and report discomfort?
• Moisture: how often is the skin wet from sweat or incontinence?
• Activity: is the resident bedbound, chairbound or walking?
• Mobility: can the resident change position without help?
• Nutrition: how well is the resident eating?
• Friction and shear: does the resident slide down in bed or the chair?

What should happen when the score is low

A risk score is only useful if it leads to action. For an at-risk resident, the care plan should include specific prevention steps, such as a pressure-redistributing mattress, a turning and repositioning schedule, heel protection or "floating" heels on a pillow, prompt incontinence care, barrier creams, and a dietitian review.

What to ask

• What is the current Braden score, and what was it on admission?
• When was it last reassessed? (It should be redone regularly and after any change in condition.)
• What prevention steps were added when the score dropped?

A falling Braden score with no change in the care plan, followed by a new wound, is a common pattern in pressure injury neglect cases.

Why staff ask you to leave

• The resident's privacy. Residents have a right to privacy in personal care. Many residents prefer family not see them undressed.
• A roommate's privacy, if care is being given in a shared room.
• Facility habit. Sometimes "please step out" is simply routine, and sometimes it is used to avoid scrutiny.

When you can ask to stay

If the resident can make decisions and wants you present, the resident can say so. If the resident lacks capacity and you are the health care agent or guardian, you can ask to be present or to see the skin, keeping the resident's dignity in mind. Close the curtain and ask that the roommate's privacy be respected. If staff refuse, ask why in writing and raise it with the director of nursing.

Practical ways to check on the skin

• Ask the nurse for a skin check while you are there. A nurse can look at the high-risk areas (tailbone and buttocks, hips, heels, ankles, elbows, shoulder blades, back of the head and ears) and tell you what is seen.
• Ask direct questions. "Is there any open area, redness or dressing anywhere on her body?" is harder to deflect than "How is she doing?"
• Ask for the latest weekly skin assessment, Braden score and any wound measurements. Residents and their representatives have the right to see the records within 24 hours.
• Attend care plan meetings and ask about skin every time.

Warning signs you can see without undressing anyone

• A dressing on the heel, hip or lower back, or a new air mattress or heel boots that appeared without explanation
• A strong odor, or drainage on sheets or clothing
• Pain or wincing when the resident is moved or sits
• The resident left in the same position for hours, or in a wet brief
• Fever, new confusion or loss of appetite, which can signal an infected wound

Do not remove dressings yourself. If the resident agrees, photographs of a wound taken by family with a date can be useful later; avoid capturing other residents. The facility must notify the resident's representative of a significant change in condition, which includes a new or worsening pressure injury. See bedsore stages explained.

The stages

• Stage 1: intact skin with a persistent red area (on darker skin, a color or texture change) that does not turn white when pressed.
• Stage 2: partial-thickness skin loss: a shallow open wound or an intact or broken blister.
• Stage 3: full-thickness skin loss with fat visible. There may be tunneling under the edges.
• Stage 4: full-thickness skin and tissue loss with exposed or palpable muscle, tendon, ligament, cartilage or bone. High risk of bone infection (osteomyelitis) and sepsis.
• Unstageable: the base is covered by slough (yellow, tan or gray) or eschar (black or brown), so the true depth cannot be seen. Once cleaned, these are usually stage 3 or 4.
• Deep tissue pressure injury: a persistent deep red, maroon or purple area, or a blood-filled blister, from damage to underlying tissue. These often open into deep wounds.

Where they form

Over bony areas that bear weight: the tailbone (sacrum and coccyx), buttocks, hips, heels, ankles, elbows, shoulder blades, and the back of the head and ears.

What the rules require

Federal rules require nursing homes to ensure that a resident does not develop a pressure injury unless the resident's condition made it clinically unavoidable, and that a resident with one receives the treatment needed to promote healing and prevent infection. The facility must document that it assessed risk and carried out prevention before claiming a wound was unavoidable.

Watch the progression

Wound records should show weekly measurements and descriptions. A wound that keeps getting larger or deeper, a stage 2 that becomes a stage 4, or a wound first documented at stage 3 or 4 (meaning earlier stages were missed) are serious warning signs.

Events that should trigger a call

• A fall or other accident with injury
• A new or worsening pressure injury
• Significant weight loss, dehydration or stopping eating
• New confusion, fever, infection or breathing problems
• Starting or significantly changing a medication or treatment
• A transfer to the hospital or a plan to discharge

Make sure the facility can reach you

• Confirm in writing who the designated representative is and the best phone numbers.
• Ask that notifications be documented in the chart, including the time and who was called.

If you were not told

Late or missing notification is a common finding in Department of Health inspections. Ask for the nursing note documenting the notification. If you learned of an injury or wound on your own, write down when and how, and raise it with the director of nursing.

What the facility should do

• Assess for pain, injury and range of motion before moving the resident
• Monitor neurological signs after a head strike or unwitnessed fall, especially for residents on blood thinners
• Notify the physician and the resident's representative
• Investigate the cause: footwear, lighting, a wet floor, a call bell out of reach, medication changes, an unanswered call for help, or a missing alarm or mat
• Update the fall risk assessment and the care plan

Questions to ask

• Was the fall witnessed? Where and when did it happen, and who found the resident?
• Was the resident supposed to have assistance, an alarm, a low bed or floor mats? Were they in place?
• How many falls has the resident had, and what changed after each one?
• Was the resident on any new medication?

Fractures and head injuries

Hip fractures and brain bleeds are among the most serious nursing home injuries. A fracture with no explanation, or bruising in unusual places, is an "injury of unknown origin" that the facility must report to the state and investigate. Facilities must report alleged abuse or serious bodily injury within two hours, and other alleged violations within 24 hours.

Warning signs

• Loose clothing or dentures, sunken cheeks
• Meal trays left untouched or set out of reach
• Dry mouth, cracked lips, dark urine, new confusion or repeated urinary infections (signs of dehydration)
• A resident who needs help eating but is not being helped

What should happen

• Regular weights (weekly after admission or a significant change, then usually monthly)
• Recording the percentage of each meal eaten
• A dietitian assessment, supplements, and help or cueing at meals
• A speech therapy swallowing evaluation for coughing or choking at meals
• Notice to the physician and family

Questions to ask

• What is the current weight, and what was it one, three and six months ago?
• Who helps the resident eat at each meal?
• When did the dietitian last see the resident, and what changed?

Physical restraints

Whether something is a restraint depends on its effect on the resident, not its name. Common examples:

• Vests, belts and wrist ties
• Lap trays or tables the resident cannot remove
• Chairs that tilt back or are placed so the resident cannot get up
• Sheets tucked so tightly the resident cannot move
• Bed rails that keep a resident from getting out of bed voluntarily

Chemical restraints

A medication becomes a chemical restraint when it is used to make a resident easier to manage rather than to treat a diagnosed condition. Antipsychotics and sedatives given to calm "behaviors" are the most common concern. See antipsychotics in nursing homes.

When restraints are allowed

Only when needed to treat a specific medical symptom, after less restrictive alternatives have been tried, for the shortest time possible, with the resident's or representative's informed consent and regular reassessment. Staff convenience and short staffing are never valid reasons.

Why restraints are dangerous

Restraints do not reliably prevent falls. They can cause strangulation and entrapment, pressure injuries, muscle loss, incontinence, agitation and depression.

What families can do

• Ask what medical symptom the restraint is treating and what alternatives were tried.
• Ask to see the order, the assessment and the consent.
• Raise it at the care plan meeting, and file a grievance or Department of Health complaint if the restraint continues without justification.

The dangers

Residents can become trapped between the rail and the mattress, between split rails, or between the rail and the headboard, which can cause suffocation, strangulation and death. Residents also climb over rails and fall from a greater height.

What the facility must do

• Try alternatives first, such as a low bed, floor mats, a concave or bolstered mattress, or more frequent checks
• Assess the resident's entrapment risk
• Explain risks and benefits and obtain informed consent
• Make sure the rails, mattress and bed frame are compatible and properly installed, and inspect them regularly

What to look for

• Gaps between the mattress and the rail large enough for an arm, head or chest
• A mattress that is too small for the frame, or an air mattress that compresses at the edge
• A resident who tries to climb over the rails

If you see an entrapment risk, report it to the nurse in writing immediately.

Signs of overmedication

• Sudden or excessive sleepiness, or the resident "not like herself"
• New falls, unsteadiness or shuffling
• Drooling, stiffness or tremors
• Poor appetite, weight loss or trouble swallowing
• Withdrawal and loss of interest

What the rules require

• A psychotropic drug may be given only if necessary to treat a specific condition diagnosed and documented in the record.
• The facility must attempt gradual dose reductions and use behavioral approaches, unless clinically contraindicated.
• "As needed" (PRN) psychotropic orders are limited to 14 days unless the prescriber documents the rationale; PRN antipsychotics require a new evaluation to renew.
• Residents may not receive unnecessary drugs, including drugs in excessive doses, for excessive duration or without adequate monitoring.

Questions to ask

• What diagnosis is this medication treating, and who prescribed it?
• What non-drug approaches were tried first?
• When is the next attempt to reduce the dose?
• Why was I not told before it was started?

Check the MAR for how often PRN sedatives are actually given. Each facility's antipsychotic use rate is a Medicare quality measure.

What the facility can and cannot do

• Can: apply reasonable limits needed for clinical care, infection control or other residents' safety and privacy, and limit a specific visitor who is abusive or a danger.
• Cannot: impose arbitrary visiting hours on family, or restrict a family member because the family has complained.

Why visits matter

Regular, unannounced visits at different times of day are one of the best protections a resident has. Families notice weight loss, poor hygiene, unanswered call bells and changes in mood that the chart may not show.

If a facility restricts your visits, ask for the reason in writing, contact the Ombudsman and consider a complaint to the Department of Health.

The notice

A discharge notice must be in writing, state the reason and effective date, say where the resident will go, explain how to appeal, and give contact information for the Long Term Care Ombudsman. A copy must go to the Ombudsman. Shorter notice is allowed only in limited situations, such as an emergency or when the resident has been in the facility less than 30 days.

What to do

• Ask for the notice in writing if you only got a verbal warning.
• Appeal right away, following the instructions in the notice. In New York, appeals are heard by the Department of Health.
• Call the Ombudsman at 1-855-582-6769.
• Be cautious about "hospital dumping": a facility refusing to readmit a resident after a hospital stay. Residents generally have the right to return to the facility after hospitalization.

Discharge as retaliation

A discharge threat that follows family complaints is a red flag. Residents and families may voice grievances without reprisal.

How to file

• Ask for the name of the grievance official (often the social worker or administrator).
• Put the complaint in writing: what happened, when, who was involved and what you want done.
• Keep a copy and note the date you delivered it.
• Ask for a written decision.

What the facility must do

• Investigate promptly and take action to prevent further problems while it investigates
• Report allegations of abuse, neglect, exploitation or injuries of unknown origin to the state
• Give a written decision that summarizes the complaint, the findings and the corrective action
• Not retaliate against the resident or the family

When to go outside the facility

For abuse, serious injury, or a problem the facility does not fix, file a complaint with the New York State Department of Health (1-888-201-4563) and contact the Ombudsman (1-855-582-6769). Ask for any grievances about the resident and the facility's written responses as part of the records request.

When you see a problem, it is natural to feel angry or unsure whom to tell. A calm, organized approach gets faster results and protects your loved one if the problem turns out to be serious.

Step 1. Make sure your loved one is safe

If there is an emergency, a serious injury, or you believe a crime has occurred, call 911. Otherwise, ask the nurse on duty to assess the resident now and to call the doctor. Ask what the doctor ordered.

Step 2. Write it down

• Note the date, time, what you saw or were told, and the names and titles of the staff involved.
• If you have authority to act for the resident, photographs of an injury, a wound or conditions in the room can be very helpful. Respect roommates' privacy.
• After an important conversation, send a short email or letter: "To confirm our conversation today…" Keep copies of everything.

Step 3. Go up the ladder

Start with the person closest to the problem and move up if it is not fixed.

1. The nursing assistant or nurse on duty for day-to-day care.
2. The charge nurse or unit manager when the problem continues or involves a nursing assessment.
3. The Director of Nursing for repeated problems, injuries, staffing or skin breakdown.
4. The Administrator when nursing leadership does not fix it.
5. A written grievance to the facility's grievance official. The facility must investigate and give you a written decision.

Step 4. Go outside the facility when you need to

You do not have to finish the steps above first. For abuse, a serious injury, or a problem that keeps happening:

• New York State Department of Health nursing home complaint hotline: 1-888-201-4563.
• Long Term Care Ombudsman, an independent advocate for residents: 1-855-582-6769.
• Police (911) for assault, sexual abuse or theft. The New York Attorney General's Medicaid Fraud Control Unit also investigates abuse and neglect in nursing homes.

Step 5. Get the records

The chart shows what the facility documented and what it did not. See "Getting the medical records" in this part.

Step 6. Know when to get legal advice

If the resident suffered a serious injury, a severe pressure injury, a fracture, major weight loss, an infection that led to sepsis, abuse, or an unexpected death, speak with a lawyer early. Deadlines can be short, and evidence such as video and staffing records may be overwritten.

Use this chart when something does not look right. Each row points to the chapter that explains the rules and what to ask.

Problem	Warning signs	What to do first	Read
Bedsores (pressure injuries)	Redness that does not fade, blisters, open areas on the tailbone, hips or heels; odor; resident left in one position	Ask the nurse to look now; ask for the wound measurements, the Braden score and the turning schedule	Ch. 20
Falls	New bruises, pain, a new limp, a resident found on the floor, an alarm or mat that is missing	Ask whether the doctor and family were notified, what caused it, and what the care plan now requires	Ch. 22
Weight loss or dehydration	Loose clothes, uneaten trays, water out of reach, dry mouth, dark urine, new confusion	Ask for the weight record and intake records; ask for a dietitian review	Ch. 23
Sudden confusion or sleepiness	A change from the resident's usual self over hours or days	Treat it as a change in condition; ask about infection, new drugs and a doctor's evaluation	Ch. 21
New sedating or antipsychotic drug	Drowsiness, falls, withdrawal, drooling, stiffness	Ask what the drug is for, who consented, and the plan to reduce it	Ch. 26
Restraints or bed rails	Belts, trays, chairs the resident cannot leave, rails raised on both sides	Ask for the assessment, the medical reason and the consent form	Ch. 24
Unexplained injury or possible abuse	Bruises, fractures, fear of a staff member, torn clothing, withdrawal	Report it to the Administrator in writing and to the Department of Health; call 911 for a crime	Ch. 29
Family not told	You learn of a fall, hospital trip or new drug after the fact	Remind the facility in writing that you are the contact to be notified	Ch. 21
Call bells not answered	Long waits, a resident left wet or soiled, missed meals	Note times and dates; ask about staffing on that shift; take it to the Director of Nursing	Ch. 11
Discharge or transfer notice	A notice that the resident must leave, or a refusal to readmit after a hospital stay	Do not move the resident; read the notice, appeal, and call the Ombudsman	Ch. 28
Visits restricted	Limits on hours or on who may visit	Ask for the reason in writing; contact the Ombudsman	Ch. 27

Who can ask

• The resident.
• The health care agent, guardian or other legal representative, when the resident cannot act.
• After a death, the executor or administrator of the estate. A family member without those papers may still be able to obtain records in some situations.

What to ask for

Ask for the complete record, not a summary: nursing notes, care plans, MDS assessments, medication and treatment records, nursing assistant flow sheets, wound records and photographs, weight records, incident reports and physician orders. Ask for electronic records in electronic form.

A free kit to help

Our free Records Request Kit includes a request letter, instructions and the forms families most often need. It is at rightsforvictims.com/nursing-home-records.

Most concerns can and should be raised with the facility first. But some situations call for legal advice right away, because the facility's records, video and staffing information may not be kept for long, and legal deadlines may be running.

Situations that warrant a call

• A stage 3 or stage 4 pressure injury, or an "unstageable" wound
• A fall that caused a fracture, a head injury or a hospital stay
• Significant weight loss or dehydration that required hospital care
• An infection that led to sepsis
• Abuse, sexual abuse, or an injury no one can explain
• A wandering incident or an unsupervised exit from the building
• A death that was unexpected or followed any of the above

Deadlines

New York sets strict time limits for injury and wrongful death claims. Claims involving a county- or city-run nursing home can require a formal notice within as little as 90 days. Do not wait to find out whether a deadline applies.

What to bring

Your log or notes, any photographs, letters and emails with the facility, the admission agreement, discharge papers, and any records you have already received.

ADL

Activities of daily living: bathing, dressing, eating, toileting, moving and walking.

Baseline care plan

The first, short care plan, due within 48 hours of admission.

Braden Scale

A score used to measure a resident's risk of developing pressure injuries. Lower scores mean higher risk.

Care plan

The written plan listing each of the resident's problems, goals and the steps staff must take.

CMS

Centers for Medicare & Medicaid Services, the federal agency that sets nursing home rules.

CNA

Certified nursing assistant. Provides most hands-on care.

DNR

Do not resuscitate order.

DOH

New York State Department of Health, which licenses and inspects nursing homes.

DON

Director of Nursing. Leads the nursing department.

Flow sheet

Records where nursing assistants document care such as turning, toileting, bathing and meals.

Grievance

A complaint the facility must investigate and answer in writing.

Health care proxy

A document naming an agent to make health care decisions if the resident cannot.

IDT

Interdisciplinary team: nursing, social work, dietary, therapy, activities and the physician.

LPN

Licensed practical nurse.

MAR

Medication administration record, showing each dose given or missed.

MDS

Minimum Data Set, the standard federal assessment done at admission, quarterly and after major changes.

MOLST

Medical Orders for Life-Sustaining Treatment, New York's form for end-of-life treatment wishes.

Ombudsman

An independent advocate for residents who does not work for the facility.

PRN

"As needed," used for medications given only when a need arises.

Pressure injury

Damage to skin and tissue from pressure, also called a bedsore or pressure ulcer. Staged 1 through 4.

PT / OT / SLP

Physical therapy, occupational therapy, speech-language pathology.

RN

Registered nurse.

Statement of Deficiencies (Form 2567)

The inspection report listing a facility's violations, available on our directory pages.

TAR

Treatment administration record, showing wound care and other treatments.

24-hour report

A shift-to-shift report of residents with changes, falls or new problems.