Typically, when a family member comes to my office, it is because their loved one has suffered a serious injury or even death under surprising or suspicious circumstances. We are called upon to review clinical charts and records and consult with experts to determine whether anyone did anything wrong and, if so, how egregious was the misconduct. In prior posts, I blogged about the heightened pleading standards associated with an elder abuse claim. This blog expands upon the topic of proving a knowing disregard of someone's health or safety, or providing corporate liability for authorizing or ratifying misconduct, by finding false charting in a medical record.
Fraudulent medical records can be used to show any manner of problems with a facility that elects to "skirt the rules" and offer after-the fact "paperwork compliance" rather than the care the patient needs. Below are some of the ways in which a frauded record may prove your case:
1. Uncovering the fraud might actually reveal the true condition of your loved one, such as when abnormal vital signs have been changed to look normal.
2. A changed medical record might be used to show that a nurse knew a certain fact (like a fall risk factor), but later changed the record to show no risk.
3. Frauded records might also serve to prove that a medical condition requiring attention went unnoticed for an extended period of time, such as when a time or date is altered to make it seem a change in medical condition happened too quickly to intervene, rather than over time.
4. Rote charting, sometimes referred to as "dry-labbing" can be used to show care was documented, but not actually provided, such as the same person documenting 3 shifts per day for 30 days in a row that a patient was turned and repositioned every 2 hours to prevent formation or worsening of bedsores.
In addition to the above, one of the best uses of fraudulent charting is to show that after the fact, staff members of the nursing home tried to conceal misconduct leading up to a bad outcome. Many inferences can be drawn when a chart is made to look like all due care was given, when in fact care needs were ignored. After-the-fact alteration tends to prove that the nursing home knew what they were supposed to do, felt guilty about not doing it, and charted that they did it, hoping no one will figure out what they've done.
If after-the-fact alteration can be proven, fraudulent records can cause a case to unravel by totally discrediting the chart, the care documented, the witnesses who are attesting that each entry is true and each intervention was taken. Even the facilities' expert witnesses, who rely on the chart as the truth regarding what really happened, can be discredited through an evaluation of medical records by a capable plaintiffs attorney.
It takes skill to find frauded records, particularly regarding subtle and complex clinical issues. Our office makes it a priority to comb the records and outside materials to root out the real truth about what happened to a loved one. We never take the chart on face value unless and until it is proven to be credible. More often than not, we find alterations that challenge the truthfulness of the entire record.
