On February 23, 2015, the California Court of Appeal published the decision of Lemaire vs. Covenant Care California, LLC. In the case, a resident’s daughter filed a lawsuit against a Covenant Care nursing home alleging that the facility violated her mother’s rights by failing to have nurses’ notes be clear and legible, dated and signed…including narratives [on] how a patient responds, eats, drinks, looks, feels, and reacts in violation of California Code Regs., tit 22 Section 72547(a)(5).
The Court concluded that the failure to maintain accurate health care record posed a risk to patients. Specifically, the court stated, “Here the duties imposed by the regulations that Covenant violated directly affect the patient’s right to proper diagnosis, treatment and care. Failure to maintain complete health care records may lead to serious health and treatment consequences. These regulations set standards for the conduct of the facilities.”
This decision is important in that it makes clear that the failure to keep and maintain accurate health records can effect patient care. Nursing homes often take the position that they provided certain care, even though they did not document it. This is in direct contravention to the nursing school maxim, “if it’s not documented, it didn’t happen.” Now, with the Lemaire decision, nursing homes cannot simply state that they provided care that isn’t documented without being held responsible.