| Background |
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| Patient/ Victim's Name: |
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| Contact E-mail |
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| Contact Phone (Optional) |
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| Date of Birth/ Age |
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| Marital Status |
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| Children/ Grandchildren |
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| What was the patient's pay
source? (Medicaid, Private, Insured, or combination of these) |
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| Did anyone maintain records of
the payments? |
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| Did anyone maintain records of
payments the facility received from other sources? (i.e. Medicare/
Medicaid Statements or Explanation of benefits from private
insurance) |
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| Who supplied medication?
(Facility pharmacy or private pharmacy) |
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| Facility |
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| Name of Facility: |
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| Location:
(Include county or parish) |
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| Time periods in the facility:
(admission/ discharge) |
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| Were there any transfers to the
hospital? (When, Where, Why, Who requested the
transfer, Date of return to the facility, etc...) |
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| What was the original reason for
the nursing home placement? |
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Did you obtain any brochures or
materials about the facility and the care that was to provided?
Check here if you
have these materials! |
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| Has anyone seen any
survey or citations at the facility? |
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| Were they posted at
the facility? |
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| When the decision was made to
place the patient at the facility, whom did you speak with? |
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| Who visited the nursing
facility? |
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| How often did they visit? |
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| Did they attend any
family counsel meetings? |
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| Were any family
counsel meetings scheduled? |
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| Complaints |
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| Impressions |
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| After admission into
the nursing facility, did anyone notice a change in your
family members' attitude? |
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| Did he/she become
quieter? |
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| Did he/she act
frightened? |
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| Did he/she ever say to
not complain? |
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| Did he/she fear
retaliation? |
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| Did anyone witness abuse or
neglect of other residents? |
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| In The Case of Death |
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| What was the cause of death? |
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| Do you have the death
certificate? |
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| What does the death certificate
indicate as the cause of death? |
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| Does the cause of death on the
certificate differ from statements from other health care providers?
(i.e. ER Physician, Nurses, Attending Physician) |
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| What were the events leading to
the death? |
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| What was done by the nursing
facility? |
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| Was there a delay in treatment? |
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| General Care |
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| What was the prognosis when
admitted to the nursing facility? |
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| Who was the treating physician
before admission? |
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| What medication (s) was the
patient taking prior to going to the facility? |
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| Were there any changes in
medications? |
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| Was anyone in the family
notified? |
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| Were any medications used that
altered his/her mentation? (Psychotrophic: Haldol, Xanax, Ativan,
etc...) |
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| Did the staff or physician
inform family members of the risks involved with the use of the
medications? |
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| Physical |
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| Were you notified of changes in
condition? |
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| What were the injuries? |
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| Did anyone take photographs of
the injuries? |
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| Did he/she develop bedsore? |
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| Did the staff provide physical
therapy or range of motion? |
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