Altered and removed charting

[Xtreme1]

I came to work and while making rounds, a pt, 75, who was 5 days post-op from a pacer install told me that 24 hours earlier that he had been given a wrong med, Ditropan XL 5mg p.o., which was another residents RX. He also told me about how the aide tried to talk him into letting her stick her finger down his mouth to induce vomiting!

I had heard about this, so i knew that it had happened. When I checked, there was nothing charted...nothing! I charted..by hand, what the pt told me and that I could not find any documentation anywhere, so i referred it to the RN in charge on a.m.'s. She left me a voice mail saying that I should not have written any of what I was told. When I came to work last night, the RN had torn my charting out completely and re-created the top of tyhe chart, with two entries by other staff, forging their writing and signatures. Trouble is...I had made copies of my charting and when you compare them, it is obvious what she has done.

Sooo, what would you all do??

Thanks!

Greg

[jemb]

Originally posted by AndyLyn

At our hospital, we've been instructed not to chart about med errors or falls, etc. on the patient's chart, but instead to fill out an incident report and not to refer to the incident report anywhere in our charting. I agree that the charting you did should not have been altered by anyone else, but I can understand why you couldn't find it in the previous charting.

It is true that putting anything about writing an incident report in the patient's chart is a red flag for anyone who decides to file a lawsuit.

However, how can you chart your follow up to the problem if you do not mention that it occurred (without calling it an incident, of course) in your charting. You need to chart what you did to resolve the problem, i.e., "Dr. X informed that Mr. Y found by RN on the floor in bathroom. No visible injuries noted. X-ray of RUE ordered due to pt c/o pain at elbow.." etc.

In the case of a patient saying the wrong med was received. charting could be something like, "Informed Dr. X that Mrs. Y believes she received an unfamiliar medication this morning. States she received a red pill in addition to several that she recognized". Then document whatever you did in response to any orders you may have received.

Be objective, avoid any finger-pointing, and take care of business.

[Xtreme1]

Well, I found another chart in which the nurse removed another med incident that happened on July 8th. The same RN took/ tore the charting out and re-wrote others charting, but omitted a lot of other information that had been charted. I knew this because copies of the chart were in another location that she wasn't aware of. Then, when she re-wrote the incident, which happened on 7/8/2003, she mistakenly wrote 9/8/2003! It sticks out like a sore thumb!

I showed this to the Admin and admin made copies. This RN told one of my co-workers that she had "shredded" some of the charting because it wasn't written right and that she was doing the organization a favor by shredding the charting as what was written, by another employee, was not proper, so she was actually doing the organization a favor!!! She said that the reason that she did not call the employees in, but instead, forged their names was because she didn't want to "bother them"

The admin called her and she refused to come in, but told them that she was doing them a favor by removing the charting and by forging the sigs as she didn't want to bother the employees.

The kicker....tonight, while at work, the RN calls me and threatens me! She tells me that I committed a federal offense because I had photocopies of the charts, which I made and took directly to Admin and that I could go to jail!!! I told her that I took the info/copies to admin after I discovered what she had done, nothing more, and that that's where the copies are today and that they didn't seem to have problems with it...in fact they also made copies. She was VERY threatening and was trying to intimidate me. I am an ex-police officer of 18 years who worked undercover drug investigations and professional patient cases, so I do not intimidate easily. I told her that we would see what the BON would say about her actions.

Her answer: She did nothing wrong by removing the charting and the forged signatures were done to avoid bothering the employees. She says that ANY NURSE would have removed the charting in question if they didn't think it was written right.....SO, what does everyone think? Bottom line: Irregardless of whether or not the charting was done correctly, can it be romoved, destroyed, altered & forged by the charge nurse??? I think not! Let me know what you think.

Greg

[Burnt Out, ASN, RN]

Oh my........

[Gardengal]

Xtreme1,

Your screen name says it all...this sure is an extreme one. You are absolutely right. She is obviously wrong.Obviously administration is viewing the severity of the situation to call her in. I do question their confidentiality however by you knowing that she refused to come in. For her confidentiality as an employee-they should not have revealed that and should instead have said that they are "arranging for her to come in and discuss it" The other real issue here though is the hostile and threatening environment that is resulting. There are whistleblower laws which should protect you, and if there is any witness to the call that in itself should be grounds for dismissal. Obviously what she did was also wrong and also grounds for dismissal and a board reportable offense.

You did the correct thing, and I'm sure it is an enormously painful process. I recall the initial fallout I received from an accused individual and coworkers when I brought to light false narcotic documentation several years back. It led to an investigation and the nurse, choosing not to admit a problem , lost her job. I felt guilty for a while until I remembered that although the discharged nurse was gone because of my observations and complaint, she was the one who did wrong....to patients and the organization.

Try to feel good about what you did, correctly in the protection of your patients. We are patient advocates and need to act in this way. Stick to your guns and try to ride it out. If it gets increasingly messy, insist on time off with pay while th eorganiztion deals with the issue. I would also recommend an unlisted phone number so you don't have to deal with harassing phone calls if you get any calls at home.

I admire your integrity.Hang in there!

[jemb]

Originally posted by Gardengal

Xtreme1,

I do question their confidentiality however by you knowing that she refused to come in. For her confidentiality as an employee-they should not have revealed that and should instead have said that they are "arranging for her to come in and discuss it"

Nor should anyone have been discussing this with anyone else at the facility! You made references to "she told another RN", who apparently told you (or you wouldn't have known). And how did the nurse you reported know that you were the one who reported her? Why is everyone there talking about it with each other?

She sounds like a nut. Your facility sounds like a gossip factory.

Volatile combination...

[angelbear]

If the pt is the one that told you of the med error he was obviously disturbed by it. You had no choice but to chart something on it. ie Joe shmoe reports concern over med error stating and then quote him using quotation marks. Then chart something like reassurance given and protocol followed. Something like that should cover you. It is absolutely 100% illegal to change or destroy the nursing notes as they are legal documents. JMHO

[VickyRN, MSN, DNP, RN]

You did the right thing, Xtreme. Now YOU be very, very careful, because some corrupt organizations turn on the whistleblower and try to cover up for the troublemaker. Hopefully, your facility has more integrity than that. Still, be very careful. Definitely do not talk about this to anyone and be absolutely sterling in what you say, what you do, and in your patient care. You may want to make a typed record of the incident, put it in a sealed envelope (with dated seal) and mail it to yourself. Then put this away in a safety deposit box; this could be very valuable evidence in case you ever have to testify in court.

[debRNo1]

Originally posted by Xtreme1

Trouble is...I had made copies of my charting and when you compare them, it is obvious what she has done.

Be careful and look for another job NOW. You have to leave there because most times its the people like YOU that get canned or worse, especially now that you are a whistleblower. They will protect themselves as a facility and let YOU (not the alterer) take the heat.

They could claim that you illegally copied the chart. Obviously there were charting "games" prior to this incident or you wouldnt have felt like you NEEDED those copies. IF this nurse takes it upon herself to willy nilly change the medical record then what else could she be up to ? She has no morals and no sense of what is right and wrong. God help those patients.

If they condone the alterers actions then they are up to no good PERIOD- get out of there. When they let people like this get away with these types of things they create a monster and she has gotten so bold that she feels she can just change what is written and re-write other peoples notes ????

"She sounds like a nut. Your facility sounds like a gossip factory.

Volatile combination..."

My former facility was a gossip factory and the kind of place where I could very well see this happening -where the "good" nurse would have her head chopped off and the "bad" nurse would get a slap on the wrist-if at all. I saw a few good people taken down by false accusations and it was pretty scary to see all your coworkers writing false "statements" to condem you.

As far as what was reported to you I think that " how the aide tried to talk him into letting her stick her finger down his mouth to induce vomiting! " Im curious did they "make" him vomit or what ?

That is ABUSE and should have been be reported.

I would leave ASAP and in the meantime be very careful while you are there because they could turn anything you say or do around and get everyone to write something bad about you............

good luck

[Katnip, RN]

Regradless of other issues, is someone forged my signature anywhere, I'd be pressing charges. She had no right to alter something anyone else wrote.

And it's true. If the facility is going to do nothing about it, they aren't just covering the nurse's butt, they're covering their own. People sue companies these days for retaining negligent and unethical employees in all industries.

[ceecel.dee, MSN, RN]

This is a legal nightmare! Any sign of alteration, in the court's mind, makes the whole record suspect.

I'm with the above poster who suggested that you secure a new position, then blow the whistle! Your administrators are suspect for allowing this unethical practice to go unreprimanded, and you want no part in it!

[Huq]

A patient's chart is a legal document.

Don't mess with it!

[NicuGal, MSN, RN]

That is totally wrong. I would call Jchaco and report this. They will come in and take a total look at everything. It is confidential.

One of our practitioners, who is very seasoned and also into legal, has told us that after we report something (esp. something that you feel is unsafe, wrong, or a liability), and put it in writing, you put the copy in an envelope, address it to yourself and then when you receive it back, don't open it. The postmark is the proof that you didn't just copy it or write it just to be spiteful and hand it over to whoever wants proof. Just a little tidbit.