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.
