Documenting Signs of Elder Abuse or Neglect

The projected rapid increase in the senior population over the next 30 years raises the concern that the problem of elder mistreatment will grow at an epidemic rate in proportion to the increase in the demographic. Many factors contribute to the alarming number of elder abuse and neglect cases, including overcrowding in nursing homes, poorly trained and inexperienced staff, and, sadly, unaware family members. Once you know to watch for signs of abuse or neglect, the next step is to properly document any alarming or unusual incidents or behaviors.

Even if your loved one is receiving proper care from his or her nursing home or medical treatment facility, at times you may have questions about the care he or she is receiving. If you feel that your concerns have not been sufficiently addressed by the staff, request and obtain copies of your relative’s chart and records. This information is important should your concerns give rise to a complaint. Evaluating the chart will also give you an understanding of the level of care at the facility.

In addition to obtaining professional records, it is wise to maintain records of your own. Always document the date, place, and time of any questionable incident, as well as the people involved. Also, write down your own observations of your loved one’s health, including changes in mood or personality; and with his or her permission, take photographs of any physical indications of abuse or neglect, such as cuts, scrapes, bruises, or bedsores. If legal action is necessary, this evidence may work to substantiate your claim. Specifically, a thorough documentation of a suspected case of elder abuse or neglect should include:

  • The senior’s physical and mental health status and apparent functional capability
  • The senior’s emotional status
  • The senior’s perceptions of their own social situation; health status; and physical needs
  • The senior’s relationship with other family members, friends, social network, doctors, nurses, and other caregivers
  • Names of others in contact with the senior, such as other service providers who may be allowed access to the facility
  • Living arrangements of the elderly person, such as whether he or she has a roommate or frequents communal areas
  • The senior’s appearance, including hygiene, climate-appropriate clothing, and body language
  • Non-physical signs of abuse and/or neglect, including broken health aids such as glasses and dentures, or torn clothing
  • Physical signs of abuse, including information on the size, pattern, severity, and location of injuries

In the case we are currently taking to trial, Carl v. Rancho Specialty Hospital & Vista Health Care, Mr. Carl’s wife saw that he consistently had feces on his hands and that his catheter drainage bag contained blood, blood clots, and mucus discharge. It is important to document observations such as these as well as less egregious conditions.

Seek Experienced, Knowledgeable Representation

If you suspect that your loved one is the victim of elder abuse or neglect, we urge you to record your observations, and if you feel that your concerns may constitute a complaint, please contact The Law Offices of James R. Gillen for immediate assistance. We are dedicated to protecting the rights of California’s senior citizens.

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