• Documentation is the Key to Winning or Losing a Lawsuit
  • October 27, 2011 | Author: David S. Barmak
  • Law Firm: Law Offices Of David S. Barmak, LLC - Princeton Office
  • Our firm defended a case in which an extremely ill, middle aged woman came to my client’s nursing home.  She had severe circulatory problems.  She went back and forth many times to a nearby hospital. Every time she returned from the hospital, she had a stage 3 decubitus ulcer. The hospital recorded in the chart that it discharged her with a stage 2 decubitus ulcer. We are all seeing this discrepancy because of reimbursement considerations. Unfortunately, these intentional misidentifications result in ultimate liability for our nursing homes. Our client performs one miracle after another in healing all of the decubitus ulcers. Sadly, the resident did not return from her last hospital visit because she died.  The family sued our client, the nursing home and did not sue the hospital. The family acknowledged that she developed ulcers in the hospital; however, they claimed that these ulcers never healed in the nursing home.  They were wrong but the nursing home chart did not definitively show that the ulcers had healed. The nursing home chart was not complete because of sloppy documentation.  After three and a half years of litigation, the insurance carrier decided, against my recommendation, that the case was not defensible.  The insurance carrier settled for many thousands of dollars.

    The point of this story is that your staff can provide miraculous care but like the tree falling in the woods, miraculous care without complete and accurate documentation goes unheard during a lawsuit.