A change in a nursing-home resident’s condition can call for prompt medical attention and communication with the care team. This page does not determine whether an event is neglect, ordinary negligence, or medical malpractice.

Start with the resident’s immediate needs

For an emergency, use emergency services. Otherwise, ask the facility how it is assessing the resident, what care plan is in place, what changes have been documented, and who is the appropriate clinical contact. The federal nursing-facility requirements in 42 C.F.R. Part 483 address resident rights and quality-of-care requirements, but they do not answer every factual or legal question in an individual situation.

Keep an organized record

  • Dates, times, observations, names or roles of people contacted, and the facility’s response
  • Care-plan materials, discharge or transfer records, medication information, and communications provided to the resident or authorized representative
  • Photos taken lawfully and safely, bills, and any incident or emergency documentation
  • Questions for the treating team about current needs, follow-up, and available records

Separate a concern from a legal conclusion

The condition, clinical judgment, facility records, applicable regulations, causation, and damages may all matter. Avoid altering original records or assuming that a poor outcome alone proves a claim. Questions about a North Carolina medical-malpractice matter require a careful review of the individual record and applicable law.

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