Written up for false documentation...

Nurses Safety

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i work in ltc and today i was written up for false documentation. i documented in the tar that a treatment was done when it wasn't. when questioned by the supervisor i admitted that i did not do the tx d/t patient being asleep. however, i forgot to chart it was not done on the day it happened therefore it is false documentation. i am petrified that this may be taken to the bon and my license be taken. this is a serious offense and i'm sick over it. i didn't get fired today but i feel that it's coming. this makes my 5th write up and i'm still in my probation period. i'm seriously considering putting in my two weeks before i get fired.

i have seen several nurses and cnas get fired the pass two months i've been there. i've been warned by co-workers to leave this job asap and that nurses that work there often get fired and reported to the bon.

ltcf expects so much to to be done in so little time with so little staff. every nurse should be guilty of falsifying records at this facility. i know for a fact that not every resident is toileted and turned q2h, i know for a fact that every cream is not applied every shift, i know for a fact that every tylenol is not given in the middle of the night when a resident is asleep. how do i know? nurses tell me all the time. however, i'm the one that got reprimanded today. i take full responsibility for my actions, however i know that i can't do it all. i'm one nurse to 30 residents, every day i feel like i'm putting my lic. on the line.

i did write a late entry that the tx was not done on such and such day. i just hope and pray that this mistake did not cost me my career.

Specializes in LTC.
Why blame the facility for your mistake? Falsifying documentation is a serious issue. I had a nurse who did it frequently because she was lazy. We kept an eye on her and found it was shoking how many things she signed off as done when she hadn't done them. Instead of making excuses, do something about your lack of follow through or being unorganized or whatever it is.

When did I ever blame the facility for my mistake? I have stated several times that I take full responsibility and do not make excuses. The DON praised me for my honesty. Ironic, I know!

Specializes in LTC.
5th write-up and still I on orientation? How have you not been fired already?

I'm not on orientation. In LTC you get 2 days of floor orientation if that. I'm still in my probation period Getting fired right now would only be a blessing.

Specializes in nursing education.
With all due respect, should be fired. Since you are ADMITTING that you LIED on your charting (why didn't you just either A. wake the pt up and do your treatment, or B. Wait until the pt woke up, or C. Just pass it along to the next shift.....??? Remember nursing is 24 hour care!!!), how can your supervisor trust you now? Also if this is your FIFTH write up in a short time frame...wow, I think it time try to realize you need to cut your losses and MOVE ON, either new career, or somewhere else more at your speed sister, cause you just aren't cutting there.

OK, pre-nursing student.

Specializes in MCH,NICU,NNsy,Educ,Village Nursing.

OP--while I recognize the awfulness of your situation, you DID contribute to it, so please, consider that. You CHOSE to not document correctly, and no matter how many patients we have/busy we are, that is not truthful nor good nursing practice. Neither is documenting that we DIDN't do something that we did. You said you have been written up 5 times. It's not a matter of them being out to get you, but perhaps a matter of you examining the "why" of being written up those 4 other times and if there are opportunities form learning/relearning from those. Hang in there, keep your nose clean, and press on.

Specializes in wound care.

if i dont do something or a resident refuses a tx or med , initial the box circle it and on the back of the mar or tar put res refused, boom ur good

Specializes in LTC.
OP--while I recognize the awfulness of your situation, you DID contribute to it, so please, consider that. You CHOSE to not document correctly, and no matter how many patients we have/busy we are, that is not truthful nor good nursing practice. Neither is documenting that we DIDN't do something that we did. You said you have been written up 5 times. It's not a matter of them being out to get you, but perhaps a matter of you examining the "why" of being written up those 4 other times and if there are opportunities form learning/relearning from those. Hang in there, keep your nose clean, and press on.

Once again, I take full responsibility and do not make excuses. I don't think they are out to get me at all. I'm moving on and that is all that matters. I'm at peace with my decision.

I have been a Hospital Corpsman in the U.S. Navy for 6 years, and an L.V.N. in California for 6 almost 7 years now. Yes I am a pre-nursing student, I am finishing up some pre-req's for nursing school, so I guess that means in your books "hey_suz", I am not smart enough to know not to falsify my charting?!?!?!?!?!?!? I am sorry NurseLoveJoy88, what you did was WRONG!!! YOU LIED!!!!! Good to see you are brave enough to admit your mistake, but it was stupid in the fisrt place!!! Also since you were written up five times in such a short time frame, you should actually be thanking your supervisor for not just firing you earlier instead. I am glad you gave a PRN notice, because the way the picture is painted, you would have hurt someone soon enough!

Specializes in Paediatrics.
I have been a Hospital Corpsman in the U.S. Navy for 6 years, and an L.V.N. in California for 6 almost 7 years now. Yes I am a pre-nursing student, I am finishing up some pre-req's for nursing school, so I guess that means in your books "hey_suz", I am not smart enough to know not to falsify my charting?!?!?!?!?!?!? I am sorry NurseLoveJoy88, what you did was WRONG!!! YOU LIED!!!!! Good to see you are brave enough to admit your mistake, but it was stupid in the fisrt place!!! Also since you were written up five times in such a short time frame, you should actually be thanking your supervisor for not just firing you earlier instead. I am glad you gave a PRN notice, because the way the picture is painted, you would have hurt someone soon enough!

Now that seems a little overkill. Nothings been mentioned about the intelligence of students or LVN's, that appears to be a misunderstanding on your part. Students lack experience not intelligence. She admits her errors and I don't think this thread is for hauling people over the coals but support and sound advice in my personal opinion anyway.

A nurse in the LTC facility I was trained in as a CNA resigned shortly after an incident that happened on the evening shift I worked one night. Let me mention that this was a very competent caring nurse I'll call K and what happened I don't blame him for at all. I got report that one of my residents was not feeling well and didn't get up for lunch. First thing I did after report was check on her; I was alarmed to find her resps were 44 and she was satting at below 88%. She was semi-conscious and practically panting. Apparently no one was checking her vitals because she wasn't on the vitals list. Quickly I interrupted nurse's report -- a very big no-no unless it's an emergency of course. When I stepped in the room to tell them what was happening, they just stared at me as if I was some kind of bimbo that didn't know how to count resps...(I was still a new employee there) -- I offered...please someone go check on her to make sure. K was just getting off shift at the time but he wanted to see for himself. He confirmed what I noted and the resident was immediately admitted to the hospital with pneumonia. Later he came to me privately saying "Good call" and shook his head sadly as he continued, "I was just in there 20 minutes before you came and told us what was happening and I somehow missed this. When you are one nurse responsible for 32 patients, this is what can happen." Last I heard he was working at the local university in Student Health Services and totally loves his job there. There's a lot of good advice on this forum, and what I keep hearing is don't stick around in a facility that isn't supportive of their employees but rather makes them put their own licenses at risk.

Specializes in Med-Surg, NICU.

You would have gotten kicked out of nursing school for falsifying care. That is a serious offense.

Specializes in LTC.

Thank you for all your support, encouragement and opinions. I guess I'll go somewhere so that I can be stoned to death. I'm such a terrible nurse! Who is willing to throw the first stone?

Specializes in geriatrics.

I don't think anyone here (ok, the exception of a few) was implying you are a terrible nurse. You have been given support and constructive criticism throughout this thread. However, with that also comes some strong opinions. Hopefully, this was the wake up call you needed. I wish you luck in your next career venture.

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