What Records Should You Request After a Nursing Home Injury in Illinois?

When a loved one suffers an injury in a nursing home, families are often left with more questions than answers. Was the injury preventable? Did staff members follow the resident’s care plan? Was the facility adequately staffed? Did employees recognize the warning signs of a medical emergency and respond appropriately?

Obtaining the right records after a nursing home injury can be one of the most important steps toward understanding what happened and determining whether neglect or negligence contributed to the harm. Medical records may document the injury itself, but other documents, including incident reports, staffing schedules, medication administration records, care plans, and state inspection reports, may reveal what occurred before, during, and after the incident.

At John J. Malm & Associates, our Illinois nursing home injury attorneys understand the importance of investigating potential nursing home negligence claims thoroughly. Families should not have to rely solely on a facility’s verbal explanation of an injury. A careful review of the available evidence can help establish whether the nursing home provided appropriate care and whether a resident’s legal rights may have been violated.

“When a nursing home resident is injured, families deserve clear answers about what happened and whether the injury could have been prevented. A thorough investigation begins with the records, but it also requires asking the right questions, examining the evidence, and holding negligent parties accountable when the facts support a claim.” — John J. Malm, Naperville nursing home neglect attorney

Why Are Records So Important After a Nursing Home Injury?

Nursing home injuries can result from falls, medication errors, pressure ulcers, infections, dehydration, malnutrition, inadequate supervision, unsafe transfers, and delayed medical treatment. Some injuries are unavoidable consequences of a resident’s medical condition, but others may be connected to failures in assessment, prevention, monitoring, or treatment.

Records help reconstruct the events surrounding an injury. For example, a resident who falls and fractures a hip may have had a documented history of falls, a physician’s order for assistance with transfers, or a care plan requiring staff to use specific fall-prevention measures. Comparing those records with the incident report and staffing records can help investigators determine whether appropriate precautions were taken.

The problem is not merely theoretical. According to a 2025 report from the U.S. Department of Health and Human Services Office of Inspector General, Medicare-enrolled nursing home residents experienced 42,864 falls resulting in major injury and hospitalization between July 1, 2022, and June 30, 2023. The report also found that nursing homes failed to report 43% of qualifying serious falls in required resident assessments. These findings underscore why independently examining the documentation surrounding an injury can be important. Records can help answer several critical questions:

What was the resident’s medical condition before the injury?
Did the facility identify known risks and develop an appropriate care plan?
Were required precautions actually followed?
Which employees were responsible for the resident’s care?
How quickly did staff recognize and respond to the injury?
Did the nursing home accurately document and report the incident?
Did the injury cause additional medical expenses, disability, pain, or loss of independence?

The following records are often important when investigating a potential Illinois nursing home injury claim.

1. Request the Resident’s Complete Medical Records

The resident’s medical chart is usually one of the first and most important sources of evidence. Request the complete chart for the period before the injury, the date of the incident, and the subsequent recovery or treatment period. Depending on the circumstances, earlier records may also be necessary to establish a pattern of declining health or repeated safety concerns.

Rather than requesting only a discharge summary or a few pages of treatment notes, ask for the complete available medical record, including electronic records and relevant attachments. Important documents include:

Physician and advanced practice provider orders.
Nursing progress notes and clinical observations.
Certified nursing assistant (CNA) documentation.
Vital signs and neurological assessments.
Fall-risk assessments and other safety evaluations.
Wound assessments, photographs, and treatment notes.
Records of changes in the resident’s condition.
Physician notifications and orders following the injury.
Hospital transfer documents and emergency response notes.
Discharge summaries and follow-up care instructions.

These documents can help establish the resident’s baseline condition and identify changes after the injury. For example, if a resident developed a pressure ulcer, the chart may show when the wound was first observed, how it progressed, whether repositioning was documented, and whether a physician was notified.

Medical records may also help distinguish between a preexisting condition and a new injury or complication. This distinction can be particularly important when a nursing home suggests that an injury resulted entirely from the resident’s age, frailty, or underlying disease.

2. Obtain the Nursing Home Incident or Accident Report

The incident report is often one of the most important documents to request after a nursing home injury. It may describe how the facility says the injury occurred, when staff discovered it, who was present, what immediate steps were taken, and whether the resident’s physician or family was notified.

Illinois regulations require nursing homes to maintain written reports of incidents and accidents affecting residents when the events are not expected outcomes of the residents’ conditions or disease processes. The regulations also require serious incidents involving physical harm or injury to be reported to the Illinois Department of Public Health (IDPH) within the applicable reporting period. When requesting incident-related documentation, ask for:

The complete incident or accident report.
Any supplemental reports or addenda.
Documentation of the time the incident occurred and was discovered.
Statements or written accounts from involved employees, where available and legally obtainable.
Records showing when the physician, administrator, family, or representative was notified.
Documentation of immediate treatment and subsequent monitoring.
Any related reports submitted to IDPH or another regulatory authority, subject to applicable disclosure restrictions.

Compare the incident report with the medical chart. If an incident report says that a resident was found on the floor at 2:00 a.m., but nursing notes show that staff did not assess the resident until considerably later, that discrepancy may warrant further investigation.

Keep in mind that a facility may withhold certain internal investigative materials or claim that they are privileged or confidential. A resident’s right to inspect and copy clinical and other records does not necessarily guarantee unrestricted access to every internal document. An attorney can help determine what can be obtained through a direct request, a regulatory records request, or formal legal discovery.

3. Request the Resident’s Care Plan and Risk Assessments

A nursing home should evaluate a resident’s individual needs and develop care measures appropriate to the resident’s condition. The care plan can be particularly important when an injury involves a risk that staff knew about or reasonably should have identified.

For example, a resident with impaired mobility, cognitive impairment, or a history of falls may require assistance when walking or transferring from a bed to a wheelchair. A resident with limited mobility may require regular repositioning and skin assessments to reduce the risk of pressure injuries. Request copies of:

The initial assessment and admission evaluation.
All comprehensive and interim care plans.
Fall-risk assessments and reassessments.
Mobility, transfer, and supervision instructions.
Pressure-ulcer risk assessments and repositioning plans.
Nutrition and hydration assessments.
Swallowing evaluations and aspiration precautions, when relevant.
Wandering, elopement, or behavioral risk assessments.
Documentation of care-plan meetings and revisions.
Records showing whether prescribed interventions were completed.

The timeline matters. A care plan created after an injury may not reflect the precautions that were required beforehand. Obtain earlier versions, revisions, and assessments whenever possible. These records may help answer whether the nursing home identified the resident’s vulnerabilities and communicated appropriate instructions to staff. They may also show whether the resident’s condition changed without a timely reassessment.

4. Request Medication Administration and Pharmacy Records

Medication-related injuries can occur when a resident receives the wrong medication, receives an incorrect dose, misses a prescribed medication, or experiences an adverse reaction that is not recognized promptly.

Medication records are especially important when an injury involves dizziness, confusion, excessive sedation, bleeding, low blood pressure, or a fall. Certain medications can increase fall risk, but the specific medication regimen, the resident’s medical history, and the circumstances of the event must be evaluated before drawing conclusions. Request the following documents:

The medication administration record (MAR).
The treatment administration record (TAR), if applicable.
Current and historical medication lists.
Physician orders for medications and changes in dosage.
Pharmacy dispensing and delivery records, where relevant.
Documentation of omitted, delayed, or refused doses.
Medication error reports and related follow-up documentation.
Records of adverse drug reactions and notifications to physicians.
Laboratory results used to monitor medication effects, when relevant.

For example, if a resident suffered a serious fall shortly after a medication change, investigators may need to determine whether the change was properly authorized, whether staff monitored the resident appropriately, and whether the physician was informed of concerning symptoms.

Medication records should be reviewed alongside nursing notes, physician orders, and the incident report. No single entry necessarily establishes negligence, but the records together may reveal an important sequence of events.

5. Obtain Staffing Schedules, Time Records, and Assignment Sheets

Staffing records can help establish which employees were working when the injury occurred and whether the facility had sufficient personnel available to meet residents’ needs. A facility’s overall staffing rating, however, does not establish whether it was adequately staffed during a particular shift. Investigators need to examine the specific circumstances surrounding the injury. Consider requesting:

Daily staffing schedules for the relevant dates.
Timecards and clock-in/clock-out records.
Staff assignment sheets identifying resident responsibilities.
Records of call-offs, absences, and replacement personnel.
Records of overtime or agency staffing.
Staffing levels for the relevant unit and shift.
Relevant training and competency records.
Records identifying the employees responsible for supervision, transfers, medication administration, or wound care.

These records can be particularly useful when an injury occurred during a period when residents required assistance with toileting, walking, eating, or transferring. For example, if a resident’s care plan required two-person assistance for transfers, investigators may examine staffing assignments and care documentation to determine whether that assistance was provided.

Staffing records must be interpreted carefully. A low staffing level does not automatically prove that it caused an injury. However, when combined with evidence of missed care, delayed response, or violations of a resident’s care plan, staffing information may help explain how an injury occurred.

6. Request Photographs, Video Footage, and Electronic Monitoring Records

Physical and electronic evidence can be critical when the circumstances of an injury are disputed. Photographs may document bruises, lacerations, swelling, pressure ulcers, unsafe equipment, or environmental hazards. Video footage may help establish whether a resident fell, how long the resident remained on the floor, or whether staff responded promptly. Potential evidence includes:

Photographs taken by staff or medical providers.
Security camera footage from hallways or common areas.
Relevant recordings from authorized electronic monitoring devices.
Call-light system logs.
Bed or chair alarm records.
Electronic access logs, where relevant.
Equipment inspection and maintenance records.
Photographs of wet floors, obstacles, damaged flooring, or other hazards.

Request that relevant video and electronic data be preserved as soon as possible. Some systems automatically overwrite recordings after a short retention period. A written preservation request can identify the incident date, approximate time, location, and specific systems that may contain evidence.

Illinois has an Authorized Electronic Monitoring in Long-Term Care Facilities Act that governs certain monitoring devices in nursing homes. Whether a particular recording exists and can be obtained depends on the device, applicable consent requirements, privacy rights, and other legal restrictions. Families should not assume they have unrestricted access to recordings involving other residents.

If the facility says no footage exists, ask what systems were operating, what retention policies applied, and whether the relevant period was preserved. An attorney may be able to pursue additional evidence through appropriate legal procedures.

7. Obtain Hospital and Outside Medical Records

The nursing home’s records are only part of the evidence. If the resident was transferred to a hospital, emergency department, rehabilitation center, wound clinic, or another healthcare provider, request those records as well.

Outside medical records can provide an independent account of the injury and its severity. They may also document whether the resident experienced a delay in receiving treatment or suffered complications after the initial event. Important records include:

Emergency medical services (EMS) reports.
Emergency department evaluations.
Hospital admission and discharge records.
Imaging studies, including X-rays, CT scans, and MRI reports.
Surgical reports and specialist consultations.
Laboratory results.
Rehabilitation and physical therapy notes.
Wound care documentation.
Follow-up appointments and treatment recommendations.

For example, a hospital physician may document that a resident arrived with a fracture, significant dehydration, or a severe pressure injury. Comparing that assessment with the nursing home’s earlier notes can help establish when the problem developed and how it progressed. Request records from before the injury when necessary to establish the resident’s baseline health and functional abilities. This can help clarify the extent of any new injury and its impact on daily life.

8. Request Nursing Home Inspection Reports and Complaint Investigations

Families should also investigate whether the nursing home has a history of safety violations or similar problems. IDPH regulates Illinois nursing homes and conducts inspections and investigations. Its records may identify deficiencies involving resident supervision, staffing, medication management, infection prevention, or other aspects of care. Useful documents include:

State inspection and survey reports.
Statements of deficiencies, including CMS Form 2567.
Plans of correction submitted by the facility.
Relevant complaint investigation reports.
Enforcement orders and available penalty records.
Publicly available staffing and ownership information.

Illinois law requires nursing homes to retain certain inspection reports and orders for public inspection, generally covering the preceding five years. IDPH also explains its process for accessing regulatory records and obtaining available documents through public records requests.

Prior violations may provide context, particularly if they concern a similar safety issue. However, a prior deficiency does not automatically prove negligence in an individual case. Investigators must determine whether the earlier findings are relevant to the specific injury and whether admissible evidence supports the claim.

9. Preserve Financial Records and Evidence of the Injury’s Impact

A nursing home injury can result in additional medical bills, rehabilitation expenses, transportation costs, and other financial losses. It can also cause pain, emotional distress, reduced mobility, and a loss of independence. Keep records that help document these consequences, including:

Hospital and rehabilitation bills.
Pharmacy receipts and medical equipment expenses.
Insurance explanations of benefits.
Records of additional caregiving expenses.
Documentation of rehabilitation and follow-up treatment.
Photographs documenting visible injuries and healing.
Notes describing changes in mobility, daily activities, or quality of life.
Receipts for other expenses associated with the injury.

Family members may also keep a dated journal documenting observations, conversations with staff, changes in the resident’s condition, and the effects of the injury on daily life. Record facts as accurately as possible, distinguish personal observations from what others reported, and preserve original documents. These materials can help establish the scope of the losses and provide context for the medical evidence.

How to Request Nursing Home Records in Illinois

Under Section 2-104(d) of the Illinois Nursing Home Care Act, a resident, the resident’s guardian, or a parent when the resident is a minor may inspect and copy clinical and other records concerning the resident’s care and maintenance kept by the facility or physician. A reasonable copying fee may be charged.

If you are requesting records for a family member, the facility may require proof of legal authority, such as a valid healthcare power of attorney, guardianship documentation, or an appropriate authorization. The applicable requirements can differ depending on whether the resident is living, deceased, or legally unable to act independently. A practical approach is to:

Identify the incident. Provide the resident’s name, facility, relevant dates, and a concise description of the injury.
Make a written request. Specify the categories of records you need rather than asking only for the “medical chart.”
Request electronic copies when available. Ask for records in their original electronic format when appropriate, including relevant audit trails or metadata if necessary.
Keep a copy of your request. Save emails, letters, delivery confirmations, and responses.
Follow up on incomplete responses. Identify missing dates or categories and ask whether additional records exist.
Seek legal assistance if necessary. An Illinois nursing home abuse attorney can evaluate the scope of the request and pursue records that require formal discovery or additional legal authority.

Do not assume that receiving some records means the production is complete. If a facility provides only a brief summary, ask whether the underlying progress notes, medication records, assessments, and incident-related documentation are available.

Frequently Asked Questions About Nursing Home Injury Records

Can a nursing home refuse to give a family member medical records?

A nursing home may require proof that the requester is authorized to obtain the resident’s records. A family relationship alone does not necessarily provide unrestricted access. Illinois law expressly provides inspection and copying rights to residents and certain authorized representatives, subject to applicable confidentiality and legal requirements.

How far back should I request nursing home records?

Start with records covering the period before the injury, the incident itself, and the subsequent treatment and recovery. Depending on the allegations, it may be necessary to obtain months or years of earlier records to identify recurring falls, prior complaints, medication changes, declining health, or failures to implement care plans.

What if the nursing home says it has no incident report?

Ask for a written explanation and request related nursing notes, assessments, physician notifications, staffing records, and any reports submitted to regulators. Illinois regulations require documentation of certain resident incidents and accidents, but whether a particular event was subject to a reporting requirement depends on the facts and applicable rules.

Can I obtain records from the Illinois Department of Public Health?

Yes. Certain inspection, deficiency, enforcement, and complaint investigation records may be available through IDPH, subject to applicable disclosure rules and confidentiality restrictions. Start with the department’s nursing home regulation resources and follow its procedures for requesting records.

Do these records prove nursing home negligence?

Not necessarily. Records may reveal inconsistencies, missed care, delayed treatment, or departures from appropriate practices, but a claim requires a fact-specific legal and medical analysis. An attorney may consult qualified experts to assess whether the care fell below the applicable standard and whether that failure caused compensable harm.

What should I do if I suspect that records may be altered or destroyed?

Preserve the documents already in your possession, keep copies of correspondence, and promptly seek legal advice about a formal preservation request. Do not alter original records or attempt to access restricted systems. An attorney can evaluate appropriate steps to preserve relevant paper records, electronic data, and video footage.

Contact the Award-Winning Illinois Nursing Home Injury Lawyers at John J. Malm & Associates

If your loved one suffered a fall, fracture, pressure ulcer, medication error, infection, or another preventable injury in a nursing home, obtaining the right records can be an important first step toward understanding what happened. Medical charts, incident reports, care plans, medication records, staffing documents, video footage, and state inspection reports may help reveal whether the facility recognized known risks and provided appropriate care.

At John J. Malm & Associates, we represent injured individuals and families pursuing answers and accountability for suspected nursing home negligence. Our attorneys can help evaluate the circumstances of an injury, identify relevant evidence, and determine what additional records may be necessary to investigate a potential claim. Because electronic records and video footage may be subject to retention limits, it is important to act promptly.

Contact John J. Malm & Associates for a free consultation if you believe a nursing home’s failure to provide appropriate care contributed to your loved one’s injury. Our team will listen to your concerns, discuss your options, and help you understand the next steps toward protecting your loved one’s rights.