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

We have a restorative department. They work during the day individually with the residents. Our LTC is also a rehabilitation center that has its own therapy department at the facility. However, I work 7p-7a so I am one of those night shift ppl. There have been occasions where R have been left up. As long as they are dry or as dry as can be expected and dressed for bed, then no I don't scream bloody murder. I just think that its an issue of time management and learning the ropes. The things I do get p-o'd about is when ice doesn't get passed or residents are put in bed still dressed or bed check has not been done. There are certain things that can be overlooked (we all have good and bad days) however, letting R go thirsty or having them have their feet touching the edge of the bed and them lying completely on their back or them being a total bed change is something I don't tolerate and I let ppl know.

Julee

I never put my residents to bed dressed. I always get them water or pop or juice throughout the night. I potty every one of the ones that request it as soon as I can. The 3 I put to bed before dinner get changed when I put them to bed, at PM care and at last rounds. I never put the incontinent ones to bed and leave diapers on them. All get washed at bedtime. I can't stand it when they are slumped way down in the bed either and if I can't pull them up higher myself I get someone to help me.

I have done the best I can regarding time management but we are dealing with humans here and I can't expect them to comply with my Day Timer.

We don't have a restorative department in the evening. It's up to the aids and there are less aids on 3-11 than day shift.

This is part of the reason I decided to leave LTC work. I couldn't stand having to chart things that I didn't do. We were told that we were to get restorative done as it was shown and that was it, non-negotiable.

However, I'm glad that someone brought this problem up. I'll be going to the hospital to work and if anyone hints that I should lie on my paperwork, you all have given me good suggestions on how to approach it if perhaps I have a real busy day and can't get everything done.

Specializes in Med Surg/Tele/ER.
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

I do not mean to start a argument but no one can MAKE you lie. You either do it or don't. I see you are upset and you know its not right so just don't do it. Report this place to Medicade/Medicare. I worry about the residents if you don't help them who will? This could be your mother, father, sister or other family being treated this way. Each person has the right to be teated well and have decent care given this is just plain negligence. I urge you don't be a part of this crap and get those people the help they need. Good Luck and God Bless CRB613

Specializes in Gerontological Nursing, Acute Rehab.

It seems that you have just been formally introduced to the wonderful world of LTC nursing!

The thing that you have to understand is that LTC is SO regulated, even more so than a nuclear power plant. There is no possible way that the staff, no matter how dedicated or how caring, can do all the things that the state regulates us to do. We spend so much time on care plans, documentation, charting and books, because that "proves" to the state that we are doing what we are supposed to do (according to them, at least). I understand your frustration, and things may go more smoothly as you gain more experience and your time management skills improve. It may not seem like it now, but you will be surprised at how well you can do things if you give yourself a chance to grow.

My personal opinion is that the state doesn't care all that much whether or not the work is actually being done, as long as it is documented in the care plan or the CNA books. Is this right? Of course not. Do I suggest that you do that? I'm not suggesting anything, but I have worked LTC for over 9 years and I know how it works. And I also know that if the state TRULY cared about our elderly and wanted them taken care of properly, they would change the laws and increase our nursing hours and staffing.

Please don't give up on LTC nursing. I never wanted to work in LTC when I was in school, but now I don't think you could double my pay to get me in the hospital. They have their own sets of problems, too. If this facility isn't working out, then look for another one. I've moved around quite a bit, but the place I work now is beautiful, well staffed and well run. Sure, it has it's problems, but I'm really happy there.

Do what you feel is right, but be prepared for backlash. Care plans are meant to be written for the state mainly, and if you can do it, great. If not (as is the case a lot of the time), then I doubt you will see everyone in a tizzy over it. It's sad, because our seniors deserve a lot better, but until the state changes the staffing regs, it's not going to get any better.

Good luck to you!

LTC is a lose-lose business proposition. Sooner or later it's going to collapse under the weight of costs, state regulations and staff that give up on it.

We all better start remodeling our homes so we can care for our parents ourselves.

You are absolutely correct.

And I also know that if the state TRULY cared about our elderly and wanted them taken care of properly, they would change the laws and increase our nursing hours and staffing.

The majority of states have no staffing laws and have nothing to do with staffing nursing homes. The mgmt and administration of the nursing homes determine staffing. It is what the market will bear. As long as nurses are willing to put up w/ poor staffing, facilities will be able to staff however they wish.

Specializes in Gerontology, Med surg, Home Health.

We've changed our care plans -- they used to read "toilet q 2 hours"...yeah, right. So since we didn't want the state surveyors standing there with a stop watch, we now write "toilet after meals and prn" or before meals depending on the resident's preference. No one at this place has ever asked us to falsify documentation. If there are blanks on the CNA flowsheets, one of the supervisors tracks 'em down and they have to fill in for the shift they worked.

Specializes in Geriatrics/Oncology/Psych/College Health.

Here's my experience:

A lady I cared in the community for went into a nursing home. Later found out that it was dutifully documented that she was being ambulated x number of feet daily and eating 100% of meals and snacks when all the while she was losing weight, not walking, developing bedsores on her heels, and had snacks sitting uneaten next to her on visits. Her family member who is a dear friend was keeping a journal of events just for her own sanity as she watched her loved one decline despite her best efforts. Ultimately, the sheer hideous quality of care and lying on the part of the ECF staff coupled with the lady's precipitous decline in condition (a matter of a few weeks until she was nearly completely incapacitated) lead to a lawsuit. It was clear based on the family member's documentation and my deposition that the documentation was false.

So no, it's not just initials on a piece of paper and it can come back on you.

every state has state inspections,,,they will accept anonomyus reportsse and they will pop in without notice and they can scare the living h out of admin/don etc

I'm a PCT/CNA, whatever you want to call it. Anyway, you should never lie on any medical documentation forms. Are you crazy! I some states they will yank your certification. Ya see, people think that a certi/means nothing. But in you cannot work without one in an acute care hospital. Protect your integrity and your certification. In addition, your RN that you are working under should know better. CNA's get called into court too. You better believe it!

I've been asked by my superior to falsely document lies concerning a residents fall -- that the V/S were within normal range, there was no pain, no injury, etc., etc. I was yelled at -- "we have a duty to protect this company!!!!".

I refused to do it. When I became a nurse I took an oath to be honest and cause no harm; my license is important to me and finally it's ethically wrong; if this was done to my own mother I would be furious.

The results for refusing -- I was demoted, belittled, attempts were made to set me up, and eventually I was fired "at will".

I was hurt to the point of considering giving up nursing; then, one early morning I received a call from a client on her death bed that wanted to speak with me. She could see what was being done to me and she demanded that I keep my head up and become an RN. She stated, "I will be looking over you dear and I will be there to greet you when you cross over -- don't be afraid".

I did get an attorney to send a letter of the seriousness of whistle-blowing retailiation. After that, they left me alone. I now have monetary compensation and I'm going back to school for my RN.

My point is, stay honest, stay true, and love your clients as though they were your own. This is your greatest protection. Yes there will be those that will be jealous of you but thats their problem.

Remember one thing. A good honest nurse is a gift that many would give their right arm to have. Wouldn't you want such a nurse to care for your loved one?

This is an old thread. I am so glad that I no longer work LTC. There were a few nurses at that LTC who refused to lie . When they refused to lie about doing treatments etc. they were all fired. :crying2:

Specializes in Gerontology, Med surg, Home Health.

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.

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