The most important proof of neglect may never appear in a single chart. It can be scattered across care notes, medication entries, hospital records, family photographs, staffing systems, and video that gets overwritten on a routine schedule.
Families often start by requesting medical records, but knowing how to preserve nursing home records after suspected neglect means protecting what lives outside the resident medical record, too. Since 2005, we’ve represented people harmed in long-term care settings, and Attorney Dusti Harvey’s past work as in-house corporate counsel and a mediator for a national nursing home chain gives our team direct insight into how facilities investigate and respond to allegations.
Put the Resident’s Safety First
Medical care and immediate safety come before evidence collection. If a resident has a serious injury, unexplained decline, dehydration, signs of infection, medication concerns, or is in immediate danger, seek appropriate medical attention and consider whether a safer care setting is needed.
Document what you can observe without reaching for a legal conclusion. Write down the date and time of each visit, the resident’s condition, what staff members said, changes in appetite or mobility, missed hygiene, unexplained bruising, and any hospital transfer. A clear timeline built in real time is far more useful than notes reconstructed from memory weeks later.
Start a Dated Log
Use one notebook or digital document for observations, calls, meetings, and messages. Include the names and job titles of staff members when known, the room or location involved, and the specific steps the facility said it would take.
Request Records in Writing
A written request creates a record of what you asked for and when. Identify the resident, the date range, your authority to receive records, and whether you want paper copies, electronic files, or both. If you aren’t the resident or an authorized representative, the facility may require consent or other authorization before releasing protected information.
Ask for the complete available record rather than only a discharge summary or a few recent notes. New Mexico long-term care rules require resident records to contain dated and authenticated entries, accident and injury documentation, medical and dental appointments, observed changes, and follow-up information.
Records to request:
- Care Planning Materials: Care plans, assessments, individualized service plans, physician orders, and progress notes.
- Medication Documentation: Medication administration records, commonly called MARs, which show medications scheduled, administered, refused, or omitted.
- Injury & Treatment Records: Wound assessments, skin treatment records, fall documentation, therapy notes, and incident reports.
- Transfer & Outside Care Records: Hospital transfer paperwork, emergency department records, ambulance records, appointment records, and discharge instructions.
- Daily Care Documentation: Dietary records, bathing and repositioning records when available, vital signs, and billing-related care documentation.
Keep the request itself, proof of delivery, every response, and a running list of missing materials in a separate evidence file. A facility may not produce every item immediately, but documenting follow-up requests establishes what was sought and what was provided.
Preserve Evidence the Chart May Not Show
The chart reflects what was entered into the facility’s system. It may not capture the resident’s full condition, what family members observed, whether a call light went unanswered, or what happened before an incident was documented.
Protect Original Family Evidence
Take clear photographs and videos of visible injuries, unclean conditions, damaged personal property, or concerning changes in the resident’s condition. Keep the original files on the device or in secure storage with their original date and time information intact. Make copies for sharing, but don’t crop, annotate, filter, rename, or otherwise alter the originals.
Save texts, emails, voicemails, call logs, complaint letters, receipts, discharge papers, and notes of conversations with staff. For each conversation, record who participated, the date, and the substance of what was said as soon as possible afterward.
Ask the Facility to Preserve Electronic Evidence
Some evidence isn’t ordinarily included in a family’s copy of the resident medical record. Send a prompt written request asking the facility to preserve surveillance footage, staffing and payroll records, call light data, access logs, internal messages, and electronic health record audit trails. An audit trail is a system log that shows when an entry was created, viewed, changed, or deleted.
A preservation request differs from a request for copies. It alerts the facility that specific material may be relevant and shouldn’t be overwritten or discarded while concerns are under review. Don’t secretly record private conversations without first considering applicable law, and don’t confront staff in a way that could affect the resident’s care.
Use New Mexico Complaint Channels
New Mexico regulations require current resident records to be maintained on-site in an organized and accessible manner, and facilities must safeguard those records from loss, destruction, and unauthorized use. For assisted living facilities, records for discharged residents must be protected for at least five years. Retention obligations vary by facility type and record category, so families should act promptly rather than assume records will remain available indefinitely.
The New Mexico Long-Term Care Ombudsman can investigate complaints involving long-term care residents. During an investigation, the Ombudsman may access medical, personal, financial, administrative, and other relevant records, subject to resident consent and applicable rules involving a surrogate decision maker or authorized representative.
When filing a complaint, preserve a copy of what you submitted and note the date, recipient, response, and any reference number. Use the same approach for concerns reported to the facility, Adult Protective Services, a New Mexico oversight agency, or law enforcement.
When to Seek Legal Help with Preservation
A preservation letter, sometimes called a litigation hold, is a written notice asking an organization to retain identified evidence that could be relevant to a potential legal matter. It can identify the facility, owner, management company, insurer, relevant dates, and the records or electronic data that should be kept.
Legal guidance may be worth seeking when a facility delays records, offers inconsistent explanations, produces chart entries that appear incomplete, can’t locate an incident report, or says surveillance footage is no longer available. Worsening pressure injuries, repeated falls, unexplained weight loss, medication concerns, and sudden hospitalizations can also warrant a careful review of what records exist and what may be missing.
Families don’t need to prove every fact before asking for help. Protecting the resident, preserving original materials, and building a clear record of the facility’s actions while information is still available is where a meaningful case begins.
Keep Next Steps Simple
Protect the resident first. Request records in writing, preserve original photos and messages, track every communication, and act quickly when video or electronic data may disappear.
If your family needs help evaluating what to preserve, our team at Harvey, Foote & Baker Law Firm offers free consultations and handles these matters on a contingency fee basis. We provide representation in English and Spanish, and you can reach us at (505) 295-2245.