LPN :Documenting noncompliance in home health setting

AMN74 · Mar 4, 2012

I guess I don't understand. I've been a home health nurse for 18+ years. What are you not supposed to document? If I had a patient that got 60 percocet 3 days ago, and I looked in her pill bottle and now there is only 22 pills and to take them q 6 hours . I first asked the patient what happened to the rest of the pills and I document #60 percocet (whatever dose) dispensed by pharmacy on x day, today is y day (3 days later) and patient says she dropped pills in the floor and vaccuum cleaner sucked them up (I even went so far as to ask if I could see the vaccuum cleaner bag and cut it open to see if the pills were there, but conveniently she had thrown that bag away yesterday AFTER the pills got missing (documented that too), I then call the doctor and tell him she is short, wh at her excuse is and let the patient know she has to sort it out with the doctor when her pain becomes unbearable because he says he is not giving more.

I had a really nice guy once in a really bad neighborhood. He has heart failure due to crack problems. On my first visit there was a burnt up lighter on the kitchen table in an ashtray. I just saw it and even made mention of it in my note. Second visit he wouldn't come to the door. Third visit he was so jolly and happy..I went in, sat my bad down on the table and low and behold there was a crack pipe and the burnt up lighter. I politely told the patient that I enjoyed taking care of him, but if he didn't have enough respect for me to keep his drug paraphanelia out of my sight during my visit then I would not come back. It was not safe for me to be there. I got to my car, called my supervisor, documented everything, called the md and told him of our discharge.

What are you not supposed to document? YOu need to be able to paint a clear picture with each and every single nurses note that you write in home health, and most of all you need to be able to cya and document so that if in 10 years you end up in court you can recall what happened and it is already documented for you.

EDIT

I just read the no md backing thing. You should call the MD and tell them what is going on. Write in your notes "Called Dr Jones at 315pm on 2/22/12 and left message with Kathy his nurse about xyz, awaiting further orders" If you don't hear back from them do it again the next day, and on the 3rd day I discharge. NO doctor, NO orders, NO leagle reason for you to be there!!! If it is non compliance that is one thing, if it is patient safety that's another, I try to get social work involved and/or call aps.

Good luck

legalbeagle2 · Mar 6, 2012

My clinical manager says not to put narcotics counts in nurses notes...goes against everything I thought I knew about documenting.My shift is a night shift,so I look to cm to call MD - she refuses.As far as pt safety,neither my cm nor the director will do anything but 'talk' with the client and family...about smoking around the O2 tanks,incorrect narcotic counts,domestic violence.....

AMN74 · Mar 6, 2012

I don't understand why you are not supposed to document these things. First of all it sounds unsafe. You need to document about teaching 02 safety and smoking, if the patient refuses to comply notify the MD. I understand you work nights, but if your cm and director do not call during the day it might be worth your effort to place a call to the MD during the day yourself and document everything. Sounds like there is big problems with this case. Domestic violence also needs to be documented. I would insist that a contract be drawn up between patient and agency about home safety and if patient breaks contract you notify the MD and discharge. Just my opinion. I do not do single "shift" cases, I do intermittent skilled visits and that's what I would do to handle the situation. But your safety is in jeopardy if the patient is smoking with oxygen on while you are there, or domestic violence. I'd probably have a serious talk with the cm and director and then refuse the case if they are not going to do anything about it. If you allow the behaviors to continue you are an enabler.

caliotter3 · Mar 6, 2012

When they tell you not to document situations that you know require documentation, time to start looking for a new employer. The narcotics count belongs on the narcotics count log. If there is none, then create one. If your manager does not want a log, then she is setting you and the other nurses up for problems. In that case, I would document the count in my notes. If she does not like it, then the manager can provide the log for that purpose. Any discrepancy should be documented in a communication note/incident report to be sent to the office. Sounds like you have lazy managers. At problem time, though, I'll bet that they have no problems with assigning blame. That does not take much effort on their part.

legalbeagle2 · Mar 7, 2012

Narcotic count sheets are in place and I have been documenting correct/incorrect in my nn...I have consistently documented pt health education and the outcomes are apparent when I have to document repeating the same education nearly every shift,I think.This case shld be discontinued, but administration has failed to do that - I think in part because it's ins paid and because they have not had any new cases for several months.I have taken myself off the case and my home office has no work for me....now I am looking at travelling many many miles to work within the company until I can,as an LPN,get another job - which there seems to be very few requests for LPN's where I am located.But I just have a sick feeling about this case!

legalbeagle2 · Mar 7, 2012

I have done the calling and clear documentation...having heard nothing from cm,I call her to request feedback - she says,every time"I haven't heard anything - you can"t make the family do anything,all you can do is teach."Unacceptable,I am not on this case now...but I think lines were crossed and makes me very uncomfortable...I'll move on and get over it,but I feel that trying to do the right thing didn't get me anywhere,esp with lack of support from clinical mngr/administration!I appreciate your feedback.

AMN74 · Mar 8, 2012

Time to find a new job, honey.... You are risking your nursing license. I hope you have malpractice insurance!