Manager wants me to alter documentation on expired patient

[All4NursingRN]

I recently took care of a very critical patient who was not expected to survive (septic shock, DIC) who was to receive multiple units of blood products. The patient expired before the transfusion was complete so on the form I checked off the 3/4 box as that the transfusion was about 75% complete and indicated that patient expired before transfusion could be completed.

my manager does chart review and approached me and says that it was inappropriate to chart this and that I should have wrote all vital signs as "0" on the form and wants me to retrieve the chart from medical records and change it.

i recently took a course in critical care nursing and nursing documentation and approached the speaker who is a legal nurse consultant and has sat on numerous legal cases and asked her opinion.

she said that there is nothing wrong with what I wrote, it is accurate and I cannot document v/s as "0" if I coded the patient because not v/s were taken! It was a code! She was adamant I do not alter my documentation.

how do I now approach my manager?

[Tenebrae, BSN, RN]

if something were to go wrong, your manager wont hesitate to throw you under the bus.

[ProperlySeasoned]

Agree that this is very strange. Every major hospital has a compliance hotline, where people can report anything from stealing office supplies to the kind of situation you described. You can even report anonymously. If this was a Medicare patient, you have additional reasons not to change the charting.

[KatieMI, BSN, MSN, RN]

Ask if your manager and the hospital's risk manager can meet with you to discuss this situation. Explain to the risk manager that you do not think it looks good from a legal perspective to pull the chart from health records

THIS.

I am pretty much sure that it is an issue of "every square must be marked" and, maybe, it would be fine to write like "N/A", then in comment section "patient coded at (time), please see code paperwork" before the chart was filed. But is the manager wants to change the chart notes post factum, let QA and risk management people educate her about what it can lead to, that's what they are paid their salaries for, after all.

I was in similar situation once (not filling a piece of "internal protocol" paperwork d/t patient coding and dying), I just told NM that I was OK with doing that as long as she would be OK with signing the paper like that: the note was changed at (date, time) by KatieMI, RN, according to my order, her signature and credentials. That brought the issue to screeching stop.

[Guest374845]

The form your manager is hung up on: is it a transfusion form or just another part of the vitals record? To ask you to make those changes is spineless, but if you can get to the root of their concern you can push back more easily.

[All4NursingRN]

Thanks for the responses. It is the transfusion form of itself that the manager wants me to pull from medical records and alter. Also on our transfusion forms we have 4 check off boxes on the bottom indicating how much was ultimately administered 0, 25%, 50%, 75%, or 100%.

Like someone else alluded to, our lab reviews all transfusion forms and does not want to see any blank spaces but to write "0" as a temp, HR, or BP seems inaccurate and false to me.

[Guest374845]

Now we're getting somewhere... do you know if the lab audited the form and reached out to your manager (who, again, must be spineless if he going to cow to the blood bank or whatever) or if this is coming from your manager directly, with no other department raising any concern?

Can you review some applicable facility policies as well? This is clearly a case outside the scope of normal transfusion documentation, so this is a silly expectation if your side of the story is accurate.

[Richard Wolfe, RN]

The fact that your patient died while receiving a blood product raises many questions. Was it the first unit? Was the code witnessed? What was the infusion rate? Did you follow hospital policy for blood product transfusions? Was there a trend that a reasonable and prudent nurse would have recognized? Did you disconnect the blood before, during, or after the code? What other medications were running at the time? etc. and so forth

[catsmeow1972, BSN, RN]

And if that chart was ever brought up in court you know some lawyer would zoom in on that one. Right before I got my license years ago a lawyer had deposed all the nurses for in the chart. The questions asked had nothing to do with the outcome of the patient. He was digging for something, they just had no idea what.

We just don't check body temps on dead people. It's irrelevant to their care, as would be physically checking BP and pulse at that point.

Several years ago i sat jury duty for a vehicle vs motorcycle, tort personal injury sort of thing case. The defense lawyer was up there describing his client's injuries with all kinds of theatrics (complete with power point slides) like "THEY PUT A 16 FRENCH FOLEY CATHETER IN HIS BLADDER!!!! I had to remind myself to not chuckle as his absurdity. i know he was trying to appeal to the lay people on the jury. In deliberations, I was able to tell them that the treatment he got was SOP for those injuries. We awarded a decent figure but not nearly the 7 figures they were trying for. I've always wondered why they put a trauma surgery nurse on that jury.

[missmollie, ADN, BSN, RN]

The fact that your patient died while receiving a blood product raises many questions. Was it the first unit? Was the code witnessed? What was the infusion rate? Did you follow hospital policy for blood product transfusions? Was there a trend that a reasonable and prudent nurse would have recognized? Did you disconnect the blood before, during, or after the code? What other medications were running at the time? etc. and so forth

THIS is why I love reading these forums. I'll be honest Texas, I didn't even think about the fact blood products were going in and that may have caused an issue the nurse should've recognized. I won't forget that lesson. Regardless, I don't think the OP should change their charting. No one can do that but them, and you don't go back and change what you did.

[JKL33]

Thanks for the responses. It is the transfusion form of itself that the manager wants me to pull from medical records and alter. Also on our transfusion forms we have 4 check off boxes on the bottom indicating how much was ultimately administered 0, 25%, 50%, 75%, or 100%.

Like someone else alluded to, our lab reviews all transfusion forms and does not want to see any blank spaces but to write "0" as a temp, HR, or BP seems inaccurate and false to me.

Avoid this in the future by placing a line through boxes that can't be completed in the usual way and write something to the effect, "CPR in progress, please refer to resuscitation record."

It's true that we don't alter our records, but being accurate and clear in the first place is important. I once had someone just leave blank the "rhythm" section on a resuscitation record because "they had no rhythm." I discovered this at the end of the code (i.e. immediately). I asked the person to "please fill in 'asystole' - that is the rhythm." Person refused to "alter" the document. Well - - I guess it's more ethical that it looks like no one even made effort to monitor the rhythm the entire time??

Blanks that are usually filled in on every patient become significant when they're not filled in and there is no clear explanation.

I would not put zeros in the boxes. That is also not accurate. I would tell manager that you will write a note in the chart if she insists but will not fill in zeros. You can write a note, "Addendum 10/25/17: Please refer to resuscitation record for vital signs during the transfusion of PRBC unit # ____________." That's all I personally would be willing to do.

[BeckyESRN]

I had a very similar situation a few years ago. A patient of mine was ordered 4 units of FFP. Unit #3 was finished, took vitals, docs came in so I waited a few moments to hang unit #4, docs left the room(maybe 10 minutes later), I was spiking the bag for #4 and heard the patient gasp. No pulse, no respirations, dead as dead could be. We got a pulse back, moved him to ICU where he died about 2 hours later. My manager just could not understand why the FFP was hanging, but not infused and why there were no vitals. She kept calling and calling about it, finally the ICU manager got sick of the "but the box must be checked" nonsense, grabbed a different blood bank sheet and wrote DEAD in big red letters across the vitals section(not the sheet going in the patient's chart, he was just proving a point) and gave it to my manager. I swear she still could not understand why I would not have put vitals on that damn paper. Weeks later she was still asking me why I hadn't put pre-transfusion vitals on the sheet, I asked if she wanted me to count his heart rate with compressions or without...

All that to say, do not change your charting. The patient died, "0" is not going to change anything.

[Been there,done that, ASN, RN]

This is just a shot in the dark, but I'm thinking there may be some QA tool that flags every infusion that doesn't have post infusion vitals and then it goes on some "naughty list" or something and she doesn't want one for her department on it. I've seen how these excel reports are generated and then reviewed. Now, it would be nice if they went back and looked at additional notes charted that may explain why they were not documented.

Yes, the pulse and b/p will be 0 for eternity ...but the temp? No room is that cold. Okay, now I'm being a wise ass but I just cannot stand some of the stuff that comes out of chart reviews that could easily be waved if they actually REVIEWED the chart.

Not a shot in the dark. NM wants the transfusion record buffed.