How to Document Nursing Home Neglect: A Step-by-Step Guide for Families

When you start to suspect a loved one is being neglected in a nursing home, you’re often dealing with two things at once: worry for their safety and confusion about what to do next. One of the most powerful things you can do—both for their immediate care and any future legal action—is to document what you’re seeing.
This guide walks you through, step by step, how families can document nursing home neglect in a way that is organized, respectful, and useful if you later decide to speak with a lawyer or report the facility.
STEP 1: Put Safety and Medical Care First
Before you think about evidence, focus on your loved one’s health and safety.
- If there’s an emergency (trouble breathing, serious fall, uncontrolled bleeding, sudden confusion), call 911.
- Insist on seeing a doctor if your loved one’s condition has clearly changed—new pain, fever, confusion, open wounds, bed sores, or signs of infection.
- If you believe your loved one is in immediate danger from a specific staff member, politely but firmly insist that person be kept away and ask to speak to a supervisor.
Once urgent needs are handled, you can start documenting. Don’t feel guilty about prioritizing safety first—that’s exactly what you should do.
STEP 2: Start a Dedicated “Neglect Journal”
Pick one place for everything: a notebook, a notes app, or a document that you can easily access and update.
In this journal, record:
- Date and time of each visit or phone call
- Who was present (staff, other residents, family members)
- What you saw, heard, and smelled
- What your loved one told you in their own words
- Any questions you asked staff and the answers you received
Be specific and factual. For example:
- Not helpful: “Mom looked bad.”
- Helpful: “2/10, 3:30 pm – Mom’s hair and clothes were dirty, strong urine smell. Found her in bed with lunch tray untouched. She said, ‘Nobody helped me eat; I was too weak.’ Nurse A said they were short-staffed at lunch.”
Don’t worry about sounding “formal.” Just aim for clear, detailed notes. Over time, this journal can show patterns: missed meals, soiled clothing, repeated falls, or worsening bed sores.
STEP 3: Take Photos and Videos (The Right Way)
Visual evidence can be very powerful, especially for:
- Bed sores and other wounds
- Bruises, cuts, or marks
- Dirty bedding or clothing
- Unsafe conditions (wet floors, broken rails, lack of call bells, cluttered hallways)
- Significant weight loss or alarming changes in appearance
Tips for doing this appropriately:
- Always be respectful: focus on the problem area, not your loved one’s whole body.
- Note the date and time for each photo or video (and say it out loud in the video if helpful).
- Take multiple angles in good lighting.
- Don’t argue with staff about taking photos; if they object, calmly note that in your journal (“Nurse B said I couldn’t take pictures of Mom’s bed sore”).
If you can, back up your photos to a secure place (cloud storage, password-protected folder) so they’re not lost if you change phones.
STEP 4: Collect and Save Written Records
Paperwork may feel overwhelming, but it’s often crucial in a nursing home neglect case. Start a folder (physical and/or digital) for:
- Admission papers and the contract
- Care plans and care plan updates
- Medication lists and changes
- Discharge summaries from hospitals or rehab
- Notices of falls, injuries, or “incidents”
- Letters or written notices from the facility
Whenever the facility gives you a new document, add it to your folder and jot a quick note in your journal about what it is and why it was given. If you’re given an “incident report” or told about an internal investigation, ask (politely) whether you can have a copy, and note their response either way.
STEP 5: Save All Communications with the Facility
Any time you interact with the nursing home about concerns, keep a record. That includes:
- Emails to and from staff or administrators
- Text messages (take screenshots and save them)
- Voicemail messages (keep them and, if possible, back them up)
When you talk on the phone, follow up with a brief email summarizing the call:
“Thank you for speaking with me today about my mother’s fall on 2/3. As we discussed, you stated she fell in the hallway and that she will now be checked every 30 minutes. Please let me know if I misunderstood anything.” This does two things: it shows you raised the concern and it locks in what the facility claimed at the time.
STEP 6: Track Medical Visits and Hospitalizations
Neglect often shows up in the form of hospital trips and worsening health. In your documentation, keep a clear timeline of:
- ER visits and hospital stays (with dates, diagnoses, and reasons)
- New diagnoses (infections, dehydration, malnutrition, fractures, sepsis)
- Changes in medications related to injuries or declines
- Referrals to wound care clinics, specialists, or therapists
Whenever your loved one goes to the hospital:
- Ask for copies of discharge paperwork.
- Note what doctors say about your loved one’s condition—especially if they mention bed sores, dehydration, recurrent infections, or “failure to thrive.”
- If a doctor hints that the condition “should have been caught earlier” or “should not have happened,” write their exact words down as soon as you can.
Later, an attorney and medical experts can connect these events back to the nursing home’s conduct, but your notes help them see the big picture.
STEP 7: Listen to and Record Your Loved One’s Story
If your loved one can communicate, their words matter.
In your journal, write down:
- Things they say about how long they waited for help
- Whether staff respond to call bells
- Whether they are helped to the bathroom or left in soiled clothing
- Whether they’re being turned, repositioned, or helped to walk
- Any reports of rough handling, yelling, threats, or inappropriate touching
Try to keep their wording as close to exact as possible. For example:
“Dad said, ‘I press this button and no one comes for an hour.’” If it feels appropriate and your loved one is comfortable, you may record audio or video of them describing their experiences. But never push them to talk if they don’t want to or seem distressed.
STEP 8: Note What Staff Say and Do
You don’t need to interrogate staff, but paying attention to their comments and behavior can be important.
Record in your journal:
- Names and roles of staff you interact with (write them down from name tags if needed)
- What they tell you about staffing levels (“We’re really short today,” “There are only two aides on this floor”)
- Their explanations for injuries or bed sores
- Whether you see them responding quickly to other residents or ignoring call lights
Again, your goal is not to start a fight; it’s to build a picture of what everyday life looks like inside the facility.
STEP 9: Consider Reporting Concerns to Authorities
Documentation isn’t only for a future lawsuit. It can also support complaints to:
- State health departments
- Long-term care ombudsman programs
- Adult Protective Services (in some situations)
When you make a formal complaint, write down:
- The date and method of the report (online, phone, mail)
- The name or ID number of the person you spoke with
- Any case or reference number you’re given
Keep copies of any written complaints you submit and any response you receive. These records can show that you tried to get help through official channels. (If you’re unsure where to report in your state, a nursing home neglect lawyer can point you in the right direction.)
STEP 10: Get Organized Before You Talk to a Lawyer
If you reach the point where you’re ready to speak with a nursing home abuse and neglect attorney, being organized will make that first consultation much more productive.
Try to have:
- Your journal or timeline (even if it’s messy—that’s okay)
- Key photos and videos (you don’t need to send everything at once)
- Hospital discharge summaries and major medical records
- Any incident reports or written communications from the facility
- Basic information about your loved one (age, conditions, how long they’ve been in the facility)
You don’t have to have everything perfect. A good nursing home neglect lawyer will help you figure out what else is needed and how to obtain additional records, including full nursing home charts and medical records.
Practical Tips to Make Documentation Easier
- Keep everything in one place. A simple binder or a shared digital folder can make a huge difference.
- Use dates consistently. Always note month/day/year and time when possible.
- Don’t edit out “small” things. Minor issues become big when they repeat over time.
- Involve trusted family members. If others visit, ask them to write down what they see too.
- Don’t worry about being “too detailed.” When it comes to neglect, more detail is almost always better.
When in Doubt, Ask for Help
You shouldn’t have to become an investigator just to keep your loved one safe. But clear documentation can:
- Push a facility to take your concerns seriously
- Help regulators and inspectors understand what’s really happening
- Strengthen any future bed sore, fall, or neglect lawsuit
- Give your loved one a voice when they can’t always speak for themselves
If you’re worried that a nursing home in New York has neglected or abused a loved one, you don’t have to figure it out on your own. The Law Office of Jesse D. Capell, PLLC can review your notes, photos, and records, explain your options in plain language, and help you decide what to do next.
You can reach out for a free consultation to talk through what you’re seeing, whether it may be neglect, and how to protect your loved one going forward.
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