I had an incident the other day when a CENA was with a resident in LTC and stepped on the peg tubing, ultimately dislodging it from her body while getting her undressed to take a shower. To make a long story short, I was not on the same floor when this happened as the resident is obese and had to go upstairs in the nursing home to a more accommodating area for showers and bathing. After being contacted by the nurse on duty upstairs about the situation, she asked whether or not I wanted a foley catheter to be inserted for patency or for her to be transferred to the hospital. I opted with the transfer to the hospital and contacted the doc and he agreed. When the resident returned to the floor minutes later, I secured the site which had minimal bleeding with a sterile 4X4 gauze, and fully assessed and documented the actions that I took after the event, including vitals,the circumstances leading up to the event, etc. Well, the next day I did not work, but was told the following day by the midnight nurse to watch my back because our boss documented as is she was present the night when the PEG tube became dislodged. Problem is, the boss was not there and my progress notes of the events have disappeared and is no longer in the chart. The nurse who told me about this said that i report that she received about the resident after her return from the hospital was that the resident took the PEG tube out herself which was blatantly untrue. So that nurse then looked in the Chart as she knows that I document very concise and she found nothing but our manager's writing. The nurse then told me that the organization that I work for (only 3 months) are very big on telling nurses what to chart and when to chart in circumstances like these. However, my boss never even approached me about her taking my progress notes out of the chart and replacing them with her own as if she was there. My boss only received report over the phone from me as a standard rule for all transfers. I don't smell a lawsuit in this particular situation but who knows?
Should I run from this job or just start keeping a log and copies of all of my nursing documentation?
