What do you do when you know a nurse is making false statements in the chart?

  1. I work on a Med/Surg floor. We use a 24 hour flow assessment sheet for the patients. The sheet is nothing more than a check list of the systems: Lungs--clear Skin---moist AP--regular, etc.

    The problem we're seeing is with a nurse who never wears a stethoscope. She doesn't borrow one, nor do we have stethoscopes in the patients' rooms. I don't think the patients bring one from home with them either.

    So the question is: How can she assess her patients without a stethoscope? But everyday her flow sheets are filled in. Positive bowel sounds, lungs clear, and the AP is regular. How does she do that and get away with it?

    We've also heard her ask the CA to teach a patient how to change her colostomy bag. Then this nurse documented on the nursing education sheet that the patient and family have been instructed on how to care for the colostomy. She even wrote a note in the progress note section verifying the teaching.
    She went further to say how the patient demonstrated the technique back to her. How the hell would she know that? She wasn't there and she sure wasn't doing the teaching as she so documented.

    The problem gets more complicated because the nurse happens to be the ANM of the floor. We can't go the the NM becuase they are boosom (spg?) buddies. What recourse do we have. Someday a patient's condition is going to change for the worse and her documentation isn't going to support the proper plan of care.

    What can we do? Who will listen and take our concerns seriously? Please advise soon. We are very worried and don't really know what to do about this situation.

    Thanks for your help. Deb
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  2. 11 Comments

  3. by   sile
    The answer to your dilemma is very simple. You have a responsibility to report this nurse to your professional body. the complaint you are making comes under the heading 'fitness to practice'. Anyone can make a complaint to a professional body/nursing board of your country. It is then the responsibility of the Board to assess the 'bona fides' of a case and to proceed from there. Good luck!
    Originally posted by Deb2300:
    I work on a Med/Surg floor. We use a 24 hour flow assessment sheet for the patients. The sheet is nothing more than a check list of the systems: Lungs--clear Skin---moist AP--regular, etc.

    The problem we're seeing is with a nurse who never wears a stethoscope. She doesn't borrow one, nor do we have stethoscopes in the patients' rooms. I don't think the patients bring one from home with them either.

    So the question is: How can she assess her patients without a stethoscope? But everyday her flow sheets are filled in. Positive bowel sounds, lungs clear, and the AP is regular. How does she do that and get away with it?

    We've also heard her ask the CA to teach a patient how to change her colostomy bag. Then this nurse documented on the nursing education sheet that the patient and family have been instructed on how to care for the colostomy. She even wrote a note in the progress note section verifying the teaching.
    She went further to say how the patient demonstrated the technique back to her. How the hell would she know that? She wasn't there and she sure wasn't doing the teaching as she so documented.

    The problem gets more complicated because the nurse happens to be the ANM of the floor. We can't go the the NM becuase they are boosom (spg?) buddies. What recourse do we have. Someday a patient's condition is going to change for the worse and her documentation isn't going to support the proper plan of care.

    What can we do? Who will listen and take our concerns seriously? Please advise soon. We are very worried and don't really know what to do about this situation.

    Thanks for your help. Deb
  4. by   Nancy1
    Standards of practice need to be upheld by all nurses. It is sad that you feel that the NM would not listen to you, but you do need to reprt to someone.
    Talk to one of the supervisors about your concerns.
    Do you want your family member cared for by that nurse? NA
  5. by   monica f
    Our hospital has an tip line that you can call. I would probably report what I knew that way and give it a week...if nothing was done about the problem, I would contact the state board of nursing. (I'm sure that hospital administration would like to know that they have a nurse not assessing her patients. They don't want any disipline from Joint Commission or a law suit from a family.)All the nurse would have to do is chart that she checked something and if a restraint or something similar was marked she would be caught and the hospital would have a mess on their hands.
  6. by   mosyoks
    I am not a nurse however I worked at a nursing home for 3 1/2 yrs and you wouldnt think that I would know as much as I do about what nurses do in a nursing home but things go on like that all the time in the nursing home I just resigned at and I have the same complaint you do you go to tell their supervisors and even in our case our coporate officers and things dont happen until you do something like have to call state not that I have only once that I know of a nurse has been let go from there for improper nursing care and it is very upsetting whenever there is a problem it needs to be addressed and not put off till later.
  7. by   Alma
    Hi,
    Have you asked her/him directly about their actions? I would ask first, then I would report to the NM, if that doesn't work go over her head. Your first responsibility is to the patient and their care, if its not getting done your patients are in danger and by it not being addressed your shift could take the blame. Ethically, it needs to be reported.
    Originally posted by Deb2300:
    I work on a Med/Surg floor. We use a 24 hour flow assessment sheet for the patients. The sheet is nothing more than a check list of the systems: Lungs--clear Skin---moist AP--regular, etc.

    The problem we're seeing is with a nurse who never wears a stethoscope. She doesn't borrow one, nor do we have stethoscopes in the patients' rooms. I don't think the patients bring one from home with them either.

    So the question is: How can she assess her patients without a stethoscope? But everyday her flow sheets are filled in. Positive bowel sounds, lungs clear, and the AP is regular. How does she do that and get away with it?

    We've also heard her ask the CA to teach a patient how to change her colostomy bag. Then this nurse documented on the nursing education sheet that the patient and family have been instructed on how to care for the colostomy. She even wrote a note in the progress note section verifying the teaching.
    She went further to say how the patient demonstrated the technique back to her. How the hell would she know that? She wasn't there and she sure wasn't doing the teaching as she so documented.

    The problem gets more complicated because the nurse happens to be the ANM of the floor. We can't go the the NM becuase they are boosom (spg?) buddies. What recourse do we have. Someday a patient's condition is going to change for the worse and her documentation isn't going to support the proper plan of care.

    What can we do? Who will listen and take our concerns seriously? Please advise soon. We are very worried and don't really know what to do about this situation.

    Thanks for your help. Deb


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  8. by   tls773
    I am a future nurse and am about ready to graduate in May. I can't believe what I read about this nurse documenting on a legal document stuff she hadn't checked out herself. Has she forgotten everything she has learned from her studies? Aren't we taught assessment from the very beginning and then it is drilled in our minds until the day we aren't nurses any longer. Assessment is how we get to know the patient and if we aren't doing one then you have no understanding of what this patient is going through or what they might need. She sounds to me like she may be just going through the motions and may have to be asked if she is doing what she loves or wants to do. If I were in the same situation, I would have to confront that nurse first and give her a chance to explain herself, although there is no excuse for negligence, and if you still don't feel like you have gotten proper results take the next steps until you do.
    Originally posted by Deb2300:
    I work on a Med/Surg floor. We use a 24 hour flow assessment sheet for the patients. The sheet is nothing more than a check list of the systems: Lungs--clear Skin---moist AP--regular, etc.

    The problem we're seeing is with a nurse who never wears a stethoscope. She doesn't borrow one, nor do we have stethoscopes in the patients' rooms. I don't think the patients bring one from home with them either.

    So the question is: How can she assess her patients without a stethoscope? But everyday her flow sheets are filled in. Positive bowel sounds, lungs clear, and the AP is regular. How does she do that and get away with it?

    We've also heard her ask the CA to teach a patient how to change her colostomy bag. Then this nurse documented on the nursing education sheet that the patient and family have been instructed on how to care for the colostomy. She even wrote a note in the progress note section verifying the teaching.
    She went further to say how the patient demonstrated the technique back to her. How the hell would she know that? She wasn't there and she sure wasn't doing the teaching as she so documented.

    The problem gets more complicated because the nurse happens to be the ANM of the floor. We can't go the the NM becuase they are boosom (spg?) buddies. What recourse do we have. Someday a patient's condition is going to change for the worse and her documentation isn't going to support the proper plan of care.

    What can we do? Who will listen and take our concerns seriously? Please advise soon. We are very worried and don't really know what to do about this situation.

    Thanks for your help. Deb


    [This message has been edited by tls773 (edited April 26, 2000).]
  9. by   than5
    I am soon to be an RN graduating next month. Although it is hard to believe that someone would actually do this, I believe it is probably a problem everywhere. Why would someone become a nurse if they don't have the care and compassion that must go along with the profession? This must be brought to attention before some serious harm comes to the patients. The first step I would take is to write up the situation and have other co-workers do the same, if this doesn't help I would take it to the state board of nursing, and even beyond that if necessary. Someone who would do this doesn't deserve to have a license to practice. Assessments are very important and that is how the entire patient care is determined. There must be a baseline formed and how will that be done without properly performed assessments? I wish you luck on solving this problem.
    Originally posted by Deb2300:
    I work on a Med/Surg floor. We use a 24 hour flow assessment sheet for the patients. The sheet is nothing more than a check list of the systems: Lungs--clear Skin---moist AP--regular, etc.

    The problem we're seeing is with a nurse who never wears a stethoscope. She doesn't borrow one, nor do we have stethoscopes in the patients' rooms. I don't think the patients bring one from home with them either.

    So the question is: How can she assess her patients without a stethoscope? But everyday her flow sheets are filled in. Positive bowel sounds, lungs clear, and the AP is regular. How does she do that and get away with it?

    We've also heard her ask the CA to teach a patient how to change her colostomy bag. Then this nurse documented on the nursing education sheet that the patient and family have been instructed on how to care for the colostomy. She even wrote a note in the progress note section verifying the teaching.
    She went further to say how the patient demonstrated the technique back to her. How the hell would she know that? She wasn't there and she sure wasn't doing the teaching as she so documented.

    The problem gets more complicated because the nurse happens to be the ANM of the floor. We can't go the the NM becuase they are boosom (spg?) buddies. What recourse do we have. Someday a patient's condition is going to change for the worse and her documentation isn't going to support the proper plan of care.

    What can we do? Who will listen and take our concerns seriously? Please advise soon. We are very worried and don't really know what to do about this situation.

    Thanks for your help. Deb
  10. by   mcrow
    I agree that you should talk with this nurse, express your concerns. Surely she realizes that she could be missing a really important detail about the patients condition by not actually performing her assessments and documenting accordingly. If she does not respond to your concerns, I think you have a responsibility to report it higher up. Just make sure all your facts are straight before you report her and document that you did report your concerns.
  11. by   bunky
    There is something in this story that we overlook here too. The use of these 24hr flow sheets. I feel that using these sheets sometimes sets us up. How many times have you walked into a room for the first time and found a big huge IV infiltrate? Yet on our flow sheets it is ticked off that the last nurse saw the site 2hrs ago and that it was OK? If the fluid was set at TKO, you know it took a lot more than two hours to get that much swelling. Sometimes it seems as though they want ICU observation but on a firstaid stand budget. And we are expected to sign our names to this. It looks very pretty but I feel that it is unfair to use these flow sheets to set us up for a level of care that we are not adequately staffed to provide.
  12. by   lynn allen
    Do you have an ethic's committee? If so, try going to them. Also you might try going directly to that person, but be ready...it might get sticky, but if that person is aware that you have noticed; they might at least wear their stethoscope.
  13. by   nursebeady
    We want premium pay, more respect, efficiency in the work place, but we are reluctant to speak up about practices that could harm our patients or that are unprofessional.
    Early on you have to decide what your own personal path will be. Our professional ethics are clear.
    Good luck with your choice. I know it's diffcult, But you have got to believe in someting !!!!!!!

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