Made to Falsify Documentation :(

Specialties Geriatric

Published

Ok...so I'm just learning the ropes as a new CNA on board and charting is one of the tasks. We are supposed to check and change (if needed) everyone on our team (20 people) every 2 hours for incontinence as the single CNA. Our floor is heavy and there's no possible way. Yet, at the end of the shift we are expected to write the times in perfect 2 hour increments that we checked each person, and our initials. I have a problem with this. Problem #1 The resident isn't getting the care (s)he deserves obviously! Problem #2 There's no way I can do this all by myself and the nurses say there's nothing they can do and pass the buck. Problem #3 Those are my initials on there and that means that my integrity is on the line. I take that seriously.

The same of the above goes for ambulation which rarely gets done for those residents who cannot walk to meals or the toilet. Lots of other stuff gets fudged too. I doubt it's the facility that I am working at because it's really one of the nicest ones around. All of the CNAs do this and they care but they say there is no possible way that things can be done properly as they would like to.

Does everyone do this? Is it commonplace to lie on charts for the files just in case the state comes in to check?

Thanks,

Shel

Get over yourselves. I refused to alter documents...refused to sign if I didn't personally do something. I didn't get fired. I got promoted.

Get over yourselves? Huh?:confused: I'm just a reporter here telling what happened at my old LTC. I think that it nice that you got a promotion instead of getting fired. I think it is more likely in most LTC's that one will get fired rather than getting a promotion.

Everyone talks about state coming and getting in trouble for false documentation. I don't think state cares because this goes on constantly and all they would have to do is investigate on sites like this. If state cared they would be up at the state house demanding more staff in LTC facilities but they just keep playing the game so they can get their paper work done and get out of there. As for a LTC going bankrupt........don't bet on it. These places make sooooo much money and those at the top are living high on the patient's misery(and nurses). It is a big business to get into today and that is why we are getting all these assissted living facilities$$$$. Government knows too but as long as people need jobs....they will count on us being there to get used and blammed. I need a job bad!!! and I will be one of those who leave everynight sad for my residents feeling exausted and having no control. If not, I don't feed my family. I hope soon someone will have the organization to go to the government and demand justice for our residents and ourselves.:crying2:

Specializes in Pediatric Private Duty; Camp Nursing.

When the state came to my place, I was sure they'd find tons of the types of problems that occur from chronic understaffing, but we did rather well. The major tags came when someone blatantly did something stupid right in front of them, like a nurse gave meds via tube w/o gloves on. Even holes in the CNA book were hit as documentation errors, not neglect. When they did dig into the residents' charts, the only thing they came up with was our doctors and psychiatrist not following up on referrals or signing monthly orders. I came away that experience totally disillusioned that the state really was not trying to sniff out any underlying major problems. They are not our advocates.

Specializes in LTC.
The major tags came when someone blatantly did something stupid right in front of them, like a nurse gave meds via tube w/o gloves on.

Ew. Even when I'm not being watched I don't touch a g-tube without putting gloves on. Its just something about stomach contents that skeeve me.

Ok...so I'm just learning the ropes as a new CNA on board and charting is one of the tasks. We are supposed to check and change (if needed) everyone on our team (20 people) every 2 hours for incontinence as the single CNA. Our floor is heavy and there's no possible way. Yet, at the end of the shift we are expected to write the times in perfect 2 hour increments that we checked each person, and our initials. I have a problem with this. Problem #1 The resident isn't getting the care (s)he deserves obviously! Problem #2 There's no way I can do this all by myself and the nurses say there's nothing they can do and pass the buck. Problem #3 Those are my initials on there and that means that my integrity is on the line. I take that seriously.

The same of the above goes for ambulation which rarely gets done for those residents who cannot walk to meals or the toilet. Lots of other stuff gets fudged too. I doubt it's the facility that I am working at because it's really one of the nicest ones around. All of the CNAs do this and they care but they say there is no possible way that things can be done properly as they would like to.

Does everyone do this? Is it commonplace to lie on charts for the files just in case the state comes in to check?

Thanks,

Shel[

It's not commonplace in all hospitals. But the ones who do it have no intention of changing. You can't change it. You can only chart what YOU DID and walk away.

I was a PCT before I was an RN so I have been on both sides of the story.

So i suggest you do what you can do, chart the hell out of it, and move on. Can't worry about other people. If you find that situation unbearable, you have no choice but to leave. But don't leave until you HAVE ANOTHER JOB SET UP. Too many of us old timers made that mistake.

I knew an LPN at my old job who said that he was not going to lie about doing the treatments. He said he didn't have time to do all of the 20 treatments required on his shift. The supervisor told him that he had to initial all of the treatments whether he actually did them or not. He was not willing to lie. He was fired for refusing to lie.

Im a brand new LPN working in LTC. I have had at least one Nurse tell me to sign everything in the treatment book whether I did it or not. Her reasoning is that she had gotten into hot water with management in the past for failing to sign her inititals. Everyone keeps talking about how you can get yourself into trouble for signing off on things you didnt do. What about the problems you can get into for failing to follow thru with your assignment? How about negligence for failing to do a treatment? I think its great that some of you experienced Nurses can run circles around me caring for 40+ residents. My preceptor and I had 36 one night and No we never did get to the treatment book, she also did not sign off on it, which I think can be more than enough fuel for a lawsuit to see that treatments are not done. Do you think anyone is going to care if you ran out of time on an 8 hour shift and had 50 people you couldnt do treatments on? Im sure the outcome will be the same whether you falsly document or whether you fail to get all your work done on your shift. Seems like a no-win situation to me and I am already rethinking working in LTC.

Specializes in Pediatric Private Duty; Camp Nursing.

In my old SNF, often CNAs ended up doing some of the treatments, like medicated powders and creams, right after they'd give them their shower and they were undressed anyway. It was technically a no-no but it saved a ton of time for the nurses and really wasn't more than a short extra step for the CNAs.

But yes those tx were awful to try to rush through and complete. I have to admit that to survive and not get in trouble, I'd do all the ones first that had bandages or sponges that needed to be dated daily. That was an easy way to get busted for not doing a tx, they could just check the date. Unfortunately it wasn't checked enough by management. I would get disgusted when I'd take off a bandage dated three days prior, but was signed for every day. Then I'd go back and do tx that couldn't be signed (like wiping somebody's eyelid with a special cleanser). Usually I'd get them all done, but we weren't allowed to stay late so sometimes I'd leave that place hanging my head in secret shame. I'm better than that, so I got out of there first chance I could.

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