Incident Report Turmoil (somewhat long)

[TheCommuter, BSN, RN]

I am a new LVN at a nursing home and am responsible for treatments, medication passes, and charting on 30 patients. I have only been on the job for 1 month.

A few days ago I left the facility during my lunchbreak and the other nurse on duty agreed to take care of my patients while I was gone. I returned to find out that one of my patients suffered a fall while I was on break. She suffered a laceration to the scalp that was bleeding. I and the other nurse grabbed wet wash cloths and cleaned the site of the wound to see what we'd be dealing with. Keep in mind that this is my first incident report.

The other nurse, a temp, called the family and told them that the scalp laceration was half an inch long. I prepared an incident report with information provided by this other, more experienced nurse. The next day I went to work and discovered that the laceration was drastically larger than originally reported. My documentation stated half an inch, but the laceration was re-measured at 5 centimeters. The family of the patient demanded that their mother be sent to the hospital. She did go to the hospital and received 5 staples to the laceration.

The DON of this facility has asked all involved employees to prepare a written statement of what they observed and/or how they measured the wound. I do not care if I am written up or terminated, just as long as the patient is in stable condition. I have accepted another job offer closer to my home. I simply want to know if I could possibly lose my license over this situation. I am aware that I made some major mistakes in measurements, documentation, and basic judgment. How do I make my written statement of the incident to the facility DON that would be defensive and truthful at the same time? Also, I'd like some advice on how to cover my behind in the future. Patient safety comes first, and I do care about the safety of the involved patient. Thanks.

[LPN1974, LPN]

For scalp lacerations, I always make sure I thoroughly check the wound myself to see if it is gaping open, if it is, to see how deep and long it is.

Get a ruler if you must and measure it. If it is gaping, no doubt it is going to need sutures or staples. However, even if it doesn't need closing, you could still have a severe head injury, so be careful of not doing anything for a head injury just because you think it doesn't look bad.

You must also do neuro checks and vital signs.

Call the doctor and the family immediately. If a head injury is severe enough that the patient should deteriorate you could really be in trouble, so you must notify the doctor and hopefully he gives orders to transfer to the ED for evaluation, and of course the family needs notification because they will most surely want to go to the ED to check on their loved one.

You will never go wrong by notifying the doctor and the family immediately.

IMO, don't go by what someone else says...check yourself, however, another nurse is always helpful, in most situations. But when you sign your signature with LPN behind it on the bottom line of that incident report you are saying that you checked this person for injuries.

And this goes for all falls. If someone falls, and all you see is a scraped knee, still check that person over thoroughly, from head to toe, and especially for head injuries, check for range of motion of all limbs, and ability to amubulate without pain, look for bruises, any bleeding wounds, or skin tears, do your vitals and neuro checks.

And notify the family, and the doctor of any falls, no matter how minor you think it might be. It could come back to bite you in the butt if you don't.

Best thing to do is just don't take any chances. Send em out.

And another thought......if you are unsure about something.......call your DON. Even if she's not at work......get yourself an RN supervisor on the telephone and get her/his advice on what you should be doing in certain situtations if you don't know.

LPN's work under the direction of an RN or a physician, and that's what they are there for, so CALL THEM if you don't know what to do.

Before long, incidents like these, you will be very familiar with and know exactly what to do, but in the meantime don't be afraid to ask your DON for any assistance. I will call my RN supervisor over a temporary nurse any day.

As far as your statement to the DON.....tell the truth. You're going to have to tell the truth. The patient's well being depends on it.

I would just tell her that for lack for better judgment, you failed to check the patient for injuries, only going by what the other nurse said, and documented what you were told.

The other nurse should have done the incident report since it happened while you were gone, and she called the family. YOu didn't say if she called the doctor...did she?

On our incident reports at my job, I can do an incident report for another nurse, but the questions are designed in such a way that it shows who exactly did what. It asks who called and notified the family, the doctor, the supervisor, who made arrangments for transfer, and so forth, and then it asks for the signature of the preparer of the report. Then the nurse who checked the person and evaluated for injuries will do the nurses note, but another nurse can always assist with the actual incident report. I like the way that ours are done, because it gives us the freedom to have another nurse help with paper work and telephone calls.

[superbratnurse]

Hi commuter,

Ok, first off, and I know this doesn't help much...NEVER state or chart a measurement that you haven't measured yourself, don't trust YOUR liscense to anyone else! That's just to keep your behind covered...

Secondly, everyone makes mistakes...we are all human!

I don't know how Texas is, but here in Arkansas, if you are charged with neglect (worst possible case scenario) and found guilty, you can lose your liscense.

But from what you said, this nurse was assisting you in treating this patient, and you took her word for it when she told you how long she thought (probably) the laceration was. I would put that in my statement, and would also put that she is the one who informed the family. Basically be truthful with your DON, that is all you can do. You can only learn from your mistakes.

Usually, I have found, that with a head laceration, the best thing to do is call the doc and get an order to transfer to the ER for an evaluation, because it is hard to tell when someone may have a subdural hematoma, especially if they are already confused (as alot of nursing home patients are) because their pupils don't always blow, and you can't always tell a change in LOC if they are already confused and agitated to begin with.

I don't know your facility's policy on I&A reports, but all of the ones I have worked in, you have to inform the MD of any injury or fall. If you doubt the severity of the injury, ask if you can transfer the resident to the ER for evaluation...Better safe than sorry, there are too many money hungry folks out there looking for any reason to sue...

I have been a nurse for 16 yrs and working in nursing homes for 14, and I have made more than my share of goof-ups, just hang in there, and keep doing your best! Don't beat yourself up! :selfbonk:

Just my

~Brat

[Tweety, BSN, RN]

Good advice. Always check the patient yourself and do your own assessment, rather than rely on others. I understand you have a lot of patients in your care, but that should have been a priority.

Make your incident truthful, sticking to the facts, without getting defensive, even if it makes you look bad, the truth comes out the same every time. A simple "measurements and assessments provided to me by Nurse So and So, dressing was noted to be dry and intact, but wound not assessed by myself" is truthful without being accusitory.

Patients/residents unfortunately fall, and hopefully the delay in treatment will not have any negative outcome, and I doubt your license is in serious jeopardy.

You live and learn. Good luck in your new job.

[LoriAlabamaRN]

I'm so sorry you are goign through this. What an awful situation. It's a hard way to learn never to trust the judgement of another nurse to the point you sign your name to it, no matter how much you trust them. I would emphasize the lesson learned to your DON when you speak to her, and basically admit your culpability. If she is satisfied with the explanation you give her and the fact that it will never happen again, she is less likely to report the incident to the BON. I just hope for your sake that the family doesn't. Keep us posted!

[CoffeeRTC, BSN, RN]

Yep...what they all said!

What did the doc say about the incision? Heck, half the time their first response is to always send the pt to the hospital, esp with head wounds.

Always use an appropriate measuring tool when measurinng wounds and lacerations or skin tears.

Chart, chart, chart!

Remember to follow basic first aid when your are treating and assessing a resident that has fallen..ie. Don't move or transfer the resident until you complete your assessment.

[snowfreeze, BSN, RN]

confused patients trying desperately to injure themselves and us trying desperately to stop them. with one of us watching 30 of them, it seems most of the time they will win. such a thankless job at times. most of the time though it is so rewarding, makes the bad days fade quickly. follow a basic attack to injuries, dont move them until fully assessed, call family and doc, send out head injuries for further evaluation. possible broken bones need an x-ray and a weeks follow up for possible hairline fractures that will worsen. make notes of how the injury happened and how you found the patient, sitting, laying, splinting a body part, holding their head, rubbing a body part etc. bruises may appear in a day or two that will need to be accounted for.