Ethical dilemma r/t documentation - page 2

I am a new nurse and I work as an LPN in a LTC facility. A few days ago, we had a readmit. With any admit or readmit, we have to do an admission assessment (I'm sure this is all common knowledge for... Read More

  1. by   Murse901
    Thanks for the advice everyone. At least I know I'm not just being stupid about it.

    The only thing that would be falsified on the document would be the date, making it appear to be the original document. That would put my *** in a sling if the originals were found during a state inspection. They have gone through all the charts, and I went through all the charts last night with another nurse -- nothing.

    I will talk with the DoN today about writing it as a late entry with a notation of the original documents not being found, and filling out an incident report. That would make me a LOT more comfortable than just blindly writing a new admission assessment dated for several days ago.

    To the poster that asked for clarification on the 16/24-hour time frame, it was over 48 hours when I was asked to rewrite the documents, so I don't think it would have necessarily mattered in that case.

    Thanks again, everyone. At least now I have some options instead of just telling the DoN that I'm not going to rewrite it. They will just have to deal with it being written as a late entry with a notation of the originals missing. I'll be sure to try to word that to be neutral, but I also need to make it clear on that wording that *I* didn't lose the documents.

    I'm hoping that they will just find the paperwork by the time I get in today. It has to be somewhere.

    I will try to write an update tonight to let everyone know how it went.
  2. by   TazziRN
    Not a thing wrong with redoing them.....as long as the second one is clearly marked as a rewrite. Date them properly and indicate that it is a rewrite for the original one.
  3. by   Simplepleasures
    Quote from canoehead
    It's not an issue if someone wants you to rewrite anything. Just note that you are rewriting, and what happened to the original. The issue would be if they asked you to falsify the rewrite- that would be something to stand your ground on.
    PRECISLEY! This is what happened to me , I refused to rewrite without the "rewritten" and I refused to falsify the original wording, guess what, I was FIRED. Am now in the appeals process in a lawsuit. Luckily found protection under our state law Wisconsin Healthcare Worker Retaliation Protection Act.I would seriously get the advice of an employment attorney. Good Luck.
  4. by   Antikigirl
    OH heck..I could have re-written it and still saved my hide! Of course management proably would not have liked it..LOL!

    I would have put the first paragraph in as stated: "original assessment forms done by me can not be found and I have been asked to re-write this assessment by my managment(I would proably put in the name of whom asked me!!!). The following is strictly from memory from the date ____, and what I can recall from that assessment and in no means overrides or takes place of the original assessment I did on ______ at ____."

    That covers my hide, tells the truth of the story, points to the responsible party for the loss of documents and me having to write this, and also reminds of the date you did the orginal assessment!

    Go figure I too have had to do this before !
  5. by   Simplepleasures
    Quote from starbin
    As a LTC care nurse, I have been requested to rewrite, rephrase and sometimes even add few sentences to the previously written notes..the notes they were written months ago. These activities are specially intensified when it is time for annual State survey. I refused to rewrite and next day I found out that someone else had scribbled my part. I didn't say a word, it is not my name/ signature ....why bother. I have even witnessed some notes being lost, missing........after a couple of months..because the note shows that the facility failed to maintain the standard of care in one way or the other. The unit managers and MDS co-ordinators and all those heads spend more time in reviewing and fixing the charts than doing anything else. Sometimes we joke- "we have more meetings in here than in white House". They lack adequate staffing and overload the nurses with paperwork and hire more people to fix the documents so that they will not loose the license to run the nursing home.
    This practice of forcing staff to "rewrite" add info or outright falsify legal documents is highly illegal, unethical and RAMPANT in LTC. Nurses who refuse to engage in this practice are fired and if they report this to the state, they will MOST CERTAINLY be fired. The charges by their employers will be trumped up ones, called pretextual, but they will get rid of you. There are state laws that can and do protect heatlhcare workers from this type of retaliation.My bottom line is until we nurses get together to get all states or better yet, FEDERAL protections against such dispicable practises, it will continue and nurses will continue to be put on the hot seat or outright fired.I am involved in a lawsuit right now that addresses EXACTLY such issues, I hope my case can be won and set a precedent, as the LTC corporations know, its money that speaks.
    Last edit by Simplepleasures on Feb 1, '07
  6. by   Simplepleasures
    Quote from TriageRN_34
    OH heck..I could have re-written it and still saved my hide! Of course management proably would not have liked it..LOL!

    I would have put the first paragraph in as stated: "original assessment forms done by me can not be found and I have been asked to re-write this assessment by my managment(I would proably put in the name of whom asked me!!!). The following is strictly from memory from the date ____, and what I can recall from that assessment and in no means overrides or takes place of the original assessment I did on ______ at ____."

    That covers my hide, tells the truth of the story, points to the responsible party for the loss of documents and me having to write this, and also reminds of the date you did the orginal assessment!

    Go figure I too have had to do this before !
    Triage RN, if it was LTC and you did as you stated above , I guarantee you would have found yourself in my shoes, FIRED and in a lawsuit. I dont know if hospitals have a different ethical code, but this does not seem to happen as often as it does in LTC.
    Last edit by Simplepleasures on Feb 1, '07
  7. by   Antikigirl
    Quote from ingelein
    Triage RN, if it was LTC and you did as you stated above , I guarantee you would have found yourself in my shoes, FIRED and in a lawsuit. I dont know if hospitals have a different ethical code, but this does not seem to happen as often as it does in LTC.
    This was in LTC/ALF...and thankfully they put up with it because they couldn't afford to loose a nurse, and well...I had asked a nurse associate that works for the BON what I should have done in that situation and she said it was certainly "pass the buck"...but better to have the buck thrown back at the party at fault than you since you did no wrong! I agreed!

    She said it was like a 'late entry', but told the story of why it was a late entry (which is legal!), and that I admit to doing it by memory not hands on assessment of that particular time. I also put the entry in past tense, and did do a re-assessment (in present tense) of how the patient was doing currently.

    If I had told my admin "NO", then they would have fired me big time, even if they needed me (it was a fraternal organization that owned the LTC/ALF and they didn't STAND for WOMEN to speak up for themselves...I found that out too many times and have posted threads about it...). But since I worked with them, and did quote my references for doing it (that scared the caca out of them I assure you! ...oh boy do I do CYA well...if I don't know..I made sure I knew someone at the BON to talk to! Thought that was a great idea! Paid off..still does!). I stayed there for a few more months and left for the hospital job...four long years at this LTC/ALF and I had had more than enough! (it was the pts...I did worry about if I was gone what would happen...and well, things went horribly wrong after I left and many have passed in the year I have been gone ....).
  8. by   Simplepleasures
    Quote from TriageRN_34
    This was in LTC/ALF...and thankfully they put up with it because they couldn't afford to loose a nurse, and well...I had asked a nurse associate that works for the BON what I should have done in that situation and she said it was certainly "pass the buck"...but better to have the buck thrown back at the party at fault than you since you did no wrong! I agreed!

    She said it was like a 'late entry', but told the story of why it was a late entry (which is legal!), and that I admit to doing it by memory not hands on assessment of that particular time. I also put the entry in past tense, and did do a re-assessment (in present tense) of how the patient was doing currently.

    If I had told my admin "NO", then they would have fired me big time, even if they needed me (it was a fraternal organization that owned the LTC/ALF and they didn't STAND for WOMEN to speak up for themselves...I found that out too many times and have posted threads about it...). But since I worked with them, and did quote my references for doing it (that scared the caca out of them I assure you! ...oh boy do I do CYA well...if I don't know..I made sure I knew someone at the BON to talk to! Thought that was a great idea! Paid off..still does!). I stayed there for a few more months and left for the hospital job...four long years at this LTC/ALF and I had had more than enough! (it was the pts...I did worry about if I was gone what would happen...and well, things went horribly wrong after I left and many have passed in the year I have been gone ....).
    TriageRn, It was very fortunate that you had an associate in the BON, alot of nurses dont have that option. It was also very fortunate they did not ask you to falsify the new "rewritten" document as they did in my situation. I had stated to them that it would be nessessary to contact the BON for direction and that is what infuriated them to begin with! Some LTC facilities have alot of ball* and feel they must set an example of the nurse, or else all the nurses might actually mutiny and do the right thing. I am glad things turned out well with you, I just wish that other nurses would be so fortunate.
  9. by   Keysnurse2008
    I wouldnt put yesterdays date on it.....are you sure that's what she asked you to do?

    What I would do...is note the document with a star/asterick signifying a notation with the date listed as late entry for yesterday's date....like
    " **Late entry /Duplicate copy 2-1-07 1400 XX RN
    for admission date of 1-31-07 1120 XX RN

    Are you sure she was specifically asking you to stick yesterdays date on it??
  10. by   Murse901
    At the time I was originally asked, they wanted me to put the original date on the "new" document.

    I talked to them about it today. They said to date it for 1/31 and not the original readmit date (which I'm mostly okay with, since I was supposed to rewrite it yesterday), but they said to put "Second Copy" on it if I'm worried about the duplicate documentation issue.

    I didn't really want to argue with them at the time, because I knew it wasn't going to turn out good, but "second copy" to me does not indicate that there is an original out there that is missing.

    So, I put "Second copy, original document was dated (whatever the date was.. can't remember now but got it off my NN's)". At least that will show that there was another document from the original date. This probably won't make them happy, but "Second copy" to me means that I hand wrote a direct copy from the original, which I did not.
  11. by   lilypad2424
    also, send yourself an unopened letter with notes on this whole fiasco. That was advice from an instructor of mine. That way, the postmark proves the date.

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