How Audit Trails Reveal Nursing Home Neglect and Cover-Ups
Are nursing homes hiding neglect in plain sight? Electronic audit trails can reveal the truth about what really happens behind closed doors, exposing missed care and falsified records. These digital footprints are powerful tools for holding facilities accountable. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Maria Hagen to talk about how audit trails work, what they can uncover, and how families can use them to prove neglect in nursing home cases.
Hagen:
Especially like with nursing home cases, how many people go into those chart a million, I’m going to format and filter to just that one doctor or one that one nurse, or whatever the case is, and then I’ll concentrate on that. So then that’s also way more cost effective because I’m not trying to go through every single, I literally just filter to who I want and the timeframe that I want.
Schenk:
Hey, out there. Welcome back to the Nursing Home Abuse Podcast. My name is Rob. I’ll be your host for this episode. Today we’re talking all about audit trails. How we can use audit trails to develop the story of our case. Figure out where the nursing home might have gone wrong in the case or maybe gone right?
Sometimes audit trails it’s the opposite. It maybe it’s, it it bolsters the defense, but we’re not having that conversation alone today. We have Maria Hagen. On the show to talk about audit trails. And lemme just say this I, this Maria brought some perspectives that I had not thought about for audit trails and using audit trails in your cases.
As I mentioned, we’re talking about audit trail, but we’re not having that conversation. I. Alone we have the tremendous Maria Hagen on with us this week. Maria is a dedicated emergency room nurse with 13 years of experience caring for patients of all ages patients, I’m sorry, passionate about both nursing and legal nurse consulting.
She takes pride in serving as an expert witness and explaining the complexities of ER care. Maria specializes in interpreting audit trails and uncovering critical case details beyond her profession. She’s a devoted wife and mother of seven. Wow. So that’s like the audit trail of who’s been leaving the refrigerator open for so long balancing her expertise with a deep commitment to family.
Maria, we are so happy that you’ve been able to spare a few minutes with us. Welcome to the show.
Hagen:
Thank you. Thank you so much for having me.
What are audit trails, and how do they work in nursing homes?
Schenk:
So this is like audit trails for most attorneys. And I would imagine the public, it’s like the Sasquatch or like Bigfoot, like it’s just this legend, this mystery thing that people hear about never seen it.
Or they don’t know. They don’t know what it’s, that don’t looks like. Okay. So from a 40,000 foot view, let’s start with the first question, like when we say audit trail, what are we talking about with respect to nursing homes?
Hagen:
So audit trust is they’re like timestamp of everything that anybody does in any medical chart.
Nursing, home, hospital, anything. If anybody access the medical chart, it shows. So any interaction of any kind, if you open it to look at something, if you open it to chart it, if you are looking at results or anything, you can see how many times have somebody opened the chart. What time did they do it?
Did they back chart anything? Did they look at anything specifically? So it is like the the backbone of every single interaction that anybody, and it doesn’t have to be a medical provider, it can be like, like a governor or something. If anybody opens that chart, we can see it with the audit trails.
And that’s obviously something that you cannot see with what the defense attorney give us because it’s not, they’re not gonna give us all that information. So it’s so into detail about what anybody is doing in a patient’s medical charge.
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Schenk:
So what is the, what does the audit trail look like?
Once, once you have it, what are, what is it kinda a progress note and then it’ll say the time that it was made, et cetera, et cetera. Walk, walk us through in general understanding that every system is different, but typically what does it look like?
Hagen:
I’m so glad that you asked this question because I think that this is a mis like attorneys think that you get this information and everything is in there. So I’m so glad that you asked this question because when they give us the audit trail, it is it should be in the Excel form. So then you have columns.
It is like columns, like you usually see the patient’s name, the provider time, like different things like actions, reviews or something like that. And then you have a whole, like thousands of lines that go under like this. So then you have columns, these white and lines, go going down.
And then after that you have to and that’s why it’s so important to know what you’re doing because if you just look at it, you’re just gonna see columns and it’s not gonna mean anything. So once you start, like looking into it, you can see okay, so then this person. Looked at this so many times, but you can’t see exactly what they’re looking at or what they’re doing.
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So what I do is I look at each person or whatever the case is, and then after that I have to request additional discovery. So it’s not just like a data trails and I have all of the information. Getting the added trails is just the beginning. So like the added trails is just like the treasure box you have, you know that it’s there and you can see the outside of it and then you’re like, okay, I know that inside of there I can see that somebody per se, modified a note or somebody deleted a note or somebody never looked at, this charted for 20 hours yet there’s a note that was back charted for that time.
So you know that. There is like really good information. So then from that you open this treasure box and then you tell the attorney, okay, now I need to request this following information. So once you have that, then you’ll start getting in like the information that is more specific to that case. So let’s say, with a nursing home case and they are, I don’t know, they laid him down while he was eating right and then they had a G-tube and then aspirated.
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That is like a very common thing. Unfortunately, it’s a very common thing. And then, oftentimes they’re like, oh no the patient was sitting up, everything was great. And then I’m looking at, the audit trail. I’m like no. This note was never put in at that time because nobody opened the chart at this time.
So it is impossible that note was put in that time. So then I started looking at kind of the trends, and you’re like, okay, you put this note in two days later. Makes no sense that you’re saying that when he was sleeping at night, you put him up while he was eating. So it is just, the trail is just the beginning is like an Excel form and once you figure out what information you can get out of that, then you open the treasure box and you ask for additional information.
Does that make sense? It is a little bit hard to explain.
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How can audit trails reveal neglect or cover-ups in elder care?
Schenk:
No, it does. And that, that guys is so interesting to me. ‘Cause I guess what I am, what I’ve always thought is audit trail is not correct. So like in a lot of my cases I’ll say, Hey, gimme the audit trail of the chart or whatever, and I’ll get, in some instances I’ll get i’m trying to visualize in my mind, I’ll get like the care plan and it’ll have whatever the objective is and then in italics it’ll be like, updated on this day by this person or in italics, deleted or, and in line throughs. But I guess from my, what you’re telling me, that’s not the audit trail.
I’m just getting something else because the audit trail is basically almost raw data that’s in an Excel spreadsheet format.
Hagen:
Exactly. That is exactly what it is. And a lot of the times the Turner will give it to us in a PDF form, which sometimes you can get that you, you can get some information out of that.
But they, they should be giving us an Excel form because then you can like filter your columns, right? So if you’re just looking at one person, especially like with nursing home cases, how many people go into the chart? A million. I don’t care about every single person that went in there.
So I’m going to format and filter to just. That one doctor or one that one nurse or whatever the case is, and then I’ll concentrate on that. So then that’s also way more cost effective because I’m not trying to go through every single, I literally just filter to who I want and the timeframe that I want.
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Schenk:
So Maria, you’re doing your work. Okay? You’re trying to find coverups weird things, anomalies. Okay. But what are you literally looking at you’re so on one, maybe you got two screens, you’ve got the Excel spreadsheet, and then the chart is, and you’re going from, you’re going you’re looking at the, you’re looking at the audit trail and then putting that against the chart itself.
Is that kind of what you’re doing? I.
Hagen:
Yes, that’s exactly what I do. So I do have two, two screens. So then in one I have the X, the Excel audit trail form, and then I have the chart, and then I’m looking at things that like, that don’t make sense, or sometimes the note is way too perfect.
Or especially what, something happened and they’re explaining why that wouldn’t have happened and it’s eh, that just seems way too fishy that you are charting exactly the opposite of what happened. So then I’m looking at what time things were entered. So that is basically what it is, what time things were entered.
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And sometimes I can tell that things were entered. Let me, lemme try to explain this. So let’s say that an incident happened at 2:00 PM right? And nothing was charting from I don’t know, nine in the morning until two 30. And then at two 30 I can see right after the incident that this nurse was, or doctor or whatever was looking.
Because without, just remember, I can see anything. So if anybody’s looking, just like viewing, not really charting anything, I can see that as well. So I can see that they’re going back and forth with every incident, everything after 2:00 PM right? So then you’re looking at this 20, 30 times before you write this note.
So why did you have to look at everything? To write this note, I said, because you wanna make sure that everything makes sense before you put the note in. If you knew that you were gonna put this note in, why didn’t you just put it in? Why were you looking at results and labs and things to put in something that should have been put in five hours ago?
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So I can see and that is, there’s a really big part of it too. I can see how many times you were looking at something in order to put that note where if you were just gonna put the note because you knew that you. For example, could, set the patient up? Why did you have to look at all the incidents and all the other things that happened?
Just to put that note. So then you start tying in the whole story together. And then you come up with, I think this is what happened based on the information that I’m, that I’m being given. I can tell you that this nurse did not open the chart for 10 hours or five hours, whatever it was.
And then after the incident, she was. Supporting this chart for, 20 minutes looking at everything else, and then decided to put this perfect note in there. So then I can’t, so then I can see that she was not, or he was not in that chart at all for hours and hours. And then an incident happens and I, and now everybody’s hoarding the chart and then everybody, like you, sometimes you have administration, you have people like everybody looking at the chart and then you, this perfectly magically, lovely note appears explaining how.
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Schenk:.
In my inexperience. I always just considered looking at the audit trail for simple things like you put in this note. Later when you weren’t even in the building or the note you deleted this thing, which would’ve been detrimental to your, to the nursing home side of the story and added something that was detrimental to the plaintiff’s side.
Simple things you’re talking to me about. Looking at a perfect note and then looking at how possibly that came in to be by who was logging in and then what they’re looking at. That’s really, that’s a really interesting perspective. I’ve never thought about.
Hagen:
And then a lot of the times it happened like I just went to court a couple weeks ago and it was like a note that was.
Put in like hours and hours later. And then they’re like, the defense attorney’s he was really busy, and I was like, yes. And I like, I can’t tell, in the ER has, whatever you’re, we’re busy. But then why did he have 52 times, like 52 chances to put this note in if he was so busy, he could have put it in.
52 times before. So then that is another thing, like you can explain yes, I’m not saying that people, that nurses are not busy or doctors or whatever, we are so busy. But if you were so busy, how did you have time to look at this 52 times and put this five words sentence like hours later if you were so busy? Does that make sense?
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Schenk:
It does. And again, that’s another example of there’s so many ways that you can use the audit trail, like it that, like so many ways. I never considered that. If you’re, I was too busy like to chart this, but trust me, I did it well. If you’re too busy, why is it 52 times that you’re in the chart?
Exactly. I never thought about that. That’s amazing.
Hagen:
Yeah, and I think like having a nurse like review these articles is so important because we live through this well, I mean we are in the healthcare, like profession, so we know how things happen. We’ve seen nurses back chart. We have seen him and we back chart all the time.
Like I’m not saying that we shouldn’t back chart. That is unrealistic, but. When you are charting six or seven hours after a patient died, and then you’re like going back and look at things, I know what they’re doing. Like I, I live in these hospital walls and, nursing home walls. It’s I know that, so it’s it is very interesting and it like, it opens like a whole new world, but how to look at medical records, like I was looking at medical records be before I took the audit trail, the class, and then afterwards I was like.
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Oh my gosh. How was I even right about these other ones that I did? Because. There is so much information that I had no idea that it was there. Now that I know that I can get it, it’s like I can never look at a medical chart again without auto shows. Never. I can’t. I’m always like did this really happen?
Or what? What was happening with this and that?
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Why are some nursing homes reluctant to share audit trail data?
Schenk:
Tell me about. So it seems to me that you described like a first pass. So you get the audit trail and then it’s, yeah. I think you said it’s just the beginning of the treasure box. Correct. What are some of the things that you might see that you might then have to go back to the attorney and go, Hey, request this, and this.
What is that? What is the, what are you looking forward to get in that second pass typically, or give you some examples?
Hagen:
So like some examples are like when I’m, when I see that there was a note or vitals let’s go, vitals, I see that there’s vitals put in at, every hour, right?
And then all of a sudden patient didn’t do good and then COVID, and then I’m looking that nobody opened this chart at all. And then I’m seeing like nobody was in here, so this vitals couldn’t have been put in at that time. So then I have to, but then I look like, five hours later or whatev whenever it was that this one nurse or PCT or whatever was in the chart, and it’s it shows modified.
So like they’re doing something to the chart, right? So what I request is I request every single modification that nurse or that doctor, whoever you’re thinking about, that. In that specific time, so once they were in the chart, they were like interacting with the chart. I wanna see exactly what they did.
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So then I, request that and then you get like a whole. At that point, it’s like a PDF file. And then document. I’m sorry. And then he tells you like, okay, so at this time he clicked on this, he opened this, he looked at this, he charted this. He went back and did that was not a good example.
I’m sorry. Let me tell you about a doctor. So doctors put in notes and then signed them three or four days later, right? That is not, that’s it’s not unusual. What they can do between that four or five day period, they can go and modify it and they can add, delete, whatever. All you get is that final draft that the doctor did.
You don’t have anything in between, right? With the medical chart like it was started this time and sign in this time. Okay. What I can do with the audit trail is I can request that specific note and see every single modification, deletion, edition, whatever they did. I can see exactly what steps they took if they were pending that note.
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Let’s say that they started chart a patient was doing great, like all the medications we’re giving, like good. And then. The next day, they’re like, maybe I’m thinking about changing this medication or this tooth feeding. And then the next day now I added this.
And then three days later you have this perfect note saying oh, patient was doing wonderful, blah, blah, blah, blah. And then all the sudden the medications were not changed. But then you can go back and be like, no, but you we’re thinking about that this was, that this was happening.
So then you can again, you can get a full story of what’s happening just to see what that doctor was doing in their, changing things, addition, modifications, or, sometimes these notes can be nothing, right? But eh, when there’s a bad outcome, unfortunately. You do see some kind of documentation changes one way or the other.
I don’t know if that kind explains what you asking.
Schenk:
No those are perfect examples.
Hagen:
It’s hard to it’s hard to explain, but like once, I don’t know, have you ever had anybody, like in your, do an audit 12 for you, like actually do it?
Schenk:
I’ve only done it one. I’ve only done it one time and this was years ago.
So like I’m, as I’m assuming things have changed since then,
Hagen:
Yeah, so once you get like that first audit trail and then you see the initial, like what I was talking about, like the initial charge back and then you start seeing like how everything starts evolving and how every, like how all the information you start to get, then it just makes so much more sense.
It’s hard to explain.
Schenk:
Yeah.
Hagen:
Without, like really seeing one, but it’s just there’s so much information. So much literally is the treasure box.
Schenk:
So what you’ve been describing do you have any is it same, is it the same for PointClick Care, for example? And I know that PointClick Care is probably one of the more prominent medical record systems for nursing homes in the country.
Hagen:
I think like audio trends in general, like the idea is the same with every, with every one of ’em. With different type of EMR or point of care click or whatever, all you have to do is just know how that one works. And, but once you start doing them, then you, it’s like the same thing, like when they were in, when they were not, when they were clicking, not clicking. I think once you have done a few. You get like a really good idea of how to do things and then you just go back and forth, just figure out how that specific system, does it or Right.
What it has.
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How can audit trails help prevent future neglect in nursing homes?
Schenk:
What advice would you have for any attorney that might be on the fence about audit trails in a particular case?
Hagen:
I think that if you’re on the fence about getting audit trouble and having somebody look at them you have to do it. You will never look at a medical record the same way.
Like at least if you didn’t, because some, sometimes you’re not gonna find anything. I’m not gonna say you’re always gonna find something, but at least if you didn’t find something, you know that you still got the full story of that case. Versus if you don’t know. If you didn’t get it, you don’t know.
You could have had that one note that was like, that made your, case that much stronger or like just something that is, it is so good and it is, and it’s there. And by law these places have to, they have to give it to us by law. And that is another thing, if you’re having problems getting this I can help you or, some other people that have been through that class, they can write that email for you saying according to the A STM. You have, people, these nursing homes have to.
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Schenk:
It’s a part of your, it’s part of your record. Yeah.
Hagen:
Yes it is.
Schenk:
Maria, thank you again so much for coming on the show and sharing your knowledge with us.
Hagen:
No, you’re welcome. Thank you so much for, for having me here, and I really hope that attorney start to get these audit trails and just get the full story of every case that you have.
Schenk:
Very good. Folks, I hope that you found this episode. Educational. If you have any ideas for topics that you would like for me to talk about, please let me know. If you have any ideas for guests that you would like for me to talk to, let me know that as well. As always, please for the love of God. Get a nursing home abuse podcast mug so that I don’t have these taken up space at my house anymore.
New episodes of the Nursing Home Abuse podcast come out every single Monday. And with that folks, we’ll see you next time.
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