Anyone encountered this before?

Updated | Posted
by Della4 Della4 Member Student

Specializes in RN Student.

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I'm a LPN, RN student. I am in charge of approx 6 care aids (HCA) per shift. All are very good however not fully educated in dementia which seems to be the case everywhere (a whole other topic). 

With dementia it is common for residents to accuse care staff/nurses of various type things. "Stold my towel, washed my back too hard". Etc

Although we ensure residents are not being abused, it is known that often times these things are just part of dementia and no one should take this personally.  Except... If you are a care aid in this facility.  

I feel it is important to chart these types of incidents to ensure we are doing our due diligence to ensure our residents are safe and keep a documented record. Well, some HCA's take issue with this because they think it makes them "look bad". No matter how many times I tell them it is just fact charting and does not suggest anything bad about the individual HCA. 

Well, they report this to the nursing lead and I get talked to about this! 

I do not understand why these HCA's who have been working for up to 20 plus years do not understand this? 

Not to mention, I was talked to regarding communicating a PRN order. Which the order said that this medication can be given up to 10 x a day. The HCA's pass meds where I work. I guess one of them didn't like how this "sounded" and reported to the nursing lead. Yes. Talked to about this as well. 

Another issue, I was told not to use quotes " " when charting what a resident said because it looks like mocking the person's words. 

So, what I took away from my talk with the lead was, do not chart or make sure you word your charting so that the info does not make the HCA feel bad (eventhough no names are used), when communicating orders to HCA's make sure you say it in a way that the HCA's will feel comfortable with the how the order sounds. Oh and do not use quotations to to chart what the resident said to separate it from my narration because it mocks what the tenant said. 

What?? If a resident says something in regards to care received then I feel its my duty to record this and the HCA's should know this and not take it personally. 

If a Dr order says up to 10 a day (of course within medication administration standards/practices) then they can have 10 a day. How the individual feels about how it "sounds" is irrelevant.  Not to mention if the resident needs this 10 times a day then they should be permitted to have it because its what the Dr orders are. It's not up to the HCA's to pass judgment on a Dr order. 

And I also feel I need to document my observations which are objective, to separate the residents words that are subjective by use of quotations. 

Am I out of it here and has everything I've learned not the right way? 

Sorry for rant. 

Thank you. 

Nurse Pompom

95 Posts

1 hour ago, Della4 said:

If a Dr order says up to 10 a day (of course within medication administration standards/practices) then they can have 10 a day. How the individual feels about how it "sounds" is irrelevant.  Not to mention if the resident needs this 10 times a day then they should be permitted to have it because its what the Dr orders are. It's not up to the HCA's to pass judgment on a Dr order. 

Up to 10 times a day every 30 seconds? Every hour? The order doesn't seem very clear indeed. 

I wouldn't chart something if I didn't believe it happened, if someone tells me their brush was stolen and it's sitting on their night table, I'd probably chart "increased periods of confusion" but I wouldn't be accusatory in my charting, mentioning name or not. It's part of their medical records after all. 

I'd agree that you probably need to work on your communication, but that's not the end of the world. I feel like we all do.

JKL33

6,269 Posts

2 hours ago, Della4 said:

Although we ensure residents are not being abused, it is known that often times these things are just part of dementia and no one should take this personally.  Except.......... If you are a care aid in this facility.  

I think after awhile you might take it personally if residents were making comments thought to be part of their dementia process about your care but someone came around behind you and wrote it all down as if it is fact.  "Resident reports that LPN cut her leg while providing wound care." Etc. Especially if you pride yourself on providing good, humane care.

I feel like there are two instances where you should do something to document these things:

1. If it represents a nursing assessment of their dementia state, e.g. "Following appropriate wound treatment, resident points to her fresh dressing and reports that LPN cut her leg open."

2. If it something that needs further attention/investigation or intervention.

If your CNAs are providing humane care, then no, I do not think every off the wall thing involving them needs to be written down in a patient's chart. The patient is in there because of dementia, no need for a play-by-play.

2 hours ago, Della4 said:

Which the order said that this medication can be given up to 10 x a day. The HCA's pass meds where I work. I guess one of them didn't like how this "sounded" and reported to the nursing lead. Yes. Talked to about this as well. 

I agree with the above, if this order did not include a PRN frequency then that leaves a lot of room for judgment and uncertainty in executing the order. If it did include a time element, say, "every hour as needed for _______, up to 10 times" then they are being silly and I would just make inquiry about why they don't think it sounds right when it makes perfect sense.

2 hours ago, Della4 said:

Another issue, I was told not to use quotes " " when charting what a resident said because it looks like mocking the person's words. 

I have heard two perspectives about this and think both are valid. It can sound mocking or derogatory, such as how you put "look bad" in quotes about your CNAs' feelings in your OP. Since there is no need for quotes in that sentence and you could have just written that they feel it makes them look bad, your use of quotes adds a different dimension.

The second perspective is that sometimes a direct quote can make the situation more clear than just a summary or paraphrase; it helps distinguish whether something is a nurse's judgment vs. reality. Example: Nurse could chart Being abusive towards staff and who knows what that means? Maybe the patient isn't being abusive at all but the nurse doesn't like what was said. Or the nurse could write, Patient threatening staff, states, "If you don't get the doctor to give me my percocet I am going to come back and blow some heads off."

I do think using some discretion in the documentation matters your superior discussed with you is probably necessary. You could probably tighten things up a bit. It's always a learning process.

Edited by JKL33

Della4

Della4

Specializes in RN Student. 33 Posts

3 minutes ago, JKL33 said:

I think after awhile you might take it personally if residents were making comments thought to be part of their dementia process about your care but someone came around behind you and wrote it all down as if it is fact.  "Resident reports that LPN cut her leg while providing wound care." Etc. Especially if you pride yourself on providing good, humane care.

I feel like there are two instances where you should do something to document these things:

1. If it represents a nursing assessment of their dementia state, e.g. "Following appropriate wound treatment, resident points to her fresh dressing and reports that LPN cut her leg open."

2. If it something that needs further attention/investigation or intervention.

If your CNAs are providing humane care, then no, I do not think every off the wall thing involving them needs to be written down in a patient's chart. The patient is in there because of dementia, no need for a play-by-play.

I agree with the above, if this order did not include a PRN frequency then that leaves a lot of room for judgment and uncertainty in executing the order. If it did include a time element, say, "every hour as needed for _______, up to 10 times" then they are being silly and I would just make inquiry about why they don't think it sounds right when it makes perfect sense.

I have heard two perspectives about this and think both are valid. It can sound mocking or derogatory, such as how you put "look bad" in quotes about your CNAs' feelings in your OP. Since there is no need for quotes in that sentence and you could have just written that they feel it makes them look bad, your use of quotes adds a different dimension.

The second perspective is that sometimes a direct quote can make the situation more clear than just a summary or paraphrase; it helps distinguish whether something is a nurse's judgment vs. reality. Example: Nurse could chart Being abusive towards staff and who knows what that means? Maybe the patient isn't being abusive at all but the nurse doesn't like what was said. Or the nurse could write, Patient threatening staff, states, "If you don't get the doctor to give me my percocet I am going to come back and blow some heads off."

I do think using some discretion in the documentation matters your superior discussed with you is probably necessary. You could probably tighten things up a bit. It's always a learning process.

Yes! I did use quotes for their "feelings" to be derogatory LOL. However this is not how it is used in medical charting. 

The way I use in charting is, "resident says pain "extremely bad" and "7/10" and "sharp down leg". 

Or important things like, Resident was asked if they had any thoughts of self harm, residents stated "no". 

Or if a Tenant has been warned of self administering medications. 

Writer advised resident that taking over the counter acetaminophen may cause harm if not ordered by Dr,  writer asked resident if they understand risks? Resident replied " yes, I understand". 

(All for residents who retain most cognition) 

Della4

Della4

Specializes in RN Student. 33 Posts

Yes the order did have a frequency, every 2.5 hrs. I was told to say it in a different way. However I read the order as the Dr wrote it. It was a proper PRN order. I also clarified that it did not mean give her 10 a day, only that she could be given 10 a day. So how would I say a Dr order to sound better?  What I resolved to do is tell the HCA's that the resident has a PRN order for every 2.5 hrs, if you not comfortable with this frequency,  call the LPN on duty. Haven't hear anything from that yet. 

My question next is. What if a resident reports something and perhaps it is true? Like if a HCA did harm them. How would you chart that? 

I'm confused. 

 

Della4

Della4

Specializes in RN Student. 33 Posts

1 hour ago, JKL33 said:

I think after awhile you might take it personally if residents were making comments thought to be part of their dementia process about your care but someone came around behind you and wrote it all down as if it is fact.  "Resident reports that LPN cut her leg while providing wound care." Etc. Especially if you pride yourself on providing good, humane care.

I feel like there are two instances where you should do something to document these things:

1. If it represents a nursing assessment of their dementia state, e.g. "Following appropriate wound treatment, resident points to her fresh dressing and reports that LPN cut her leg open."

2. If it something that needs further attention/investigation or intervention.

If your CNAs are providing humane care, then no, I do not think every off the wall thing involving them needs to be written down in a patient's chart. The patient is in there because of dementia, no need for a play-by-play.

I agree with the above, if this order did not include a PRN frequency then that leaves a lot of room for judgment and uncertainty in executing the order. If it did include a time element, say, "every hour as needed for _______, up to 10 times" then they are being silly and I would just make inquiry about why they don't think it sounds right when it makes perfect sense.

I have heard two perspectives about this and think both are valid. It can sound mocking or derogatory, such as how you put "look bad" in quotes about your CNAs' feelings in your OP. Since there is no need for quotes in that sentence and you could have just written that they feel it makes them look bad, your use of quotes adds a different dimension.

The second perspective is that sometimes a direct quote can make the situation more clear than just a summary or paraphrase; it helps distinguish whether something is a nurse's judgment vs. reality. Example: Nurse could chart Being abusive towards staff and who knows what that means? Maybe the patient isn't being abusive at all but the nurse doesn't like what was said. Or the nurse could write, Patient threatening staff, states, "If you don't get the doctor to give me my percocet I am going to come back and blow some heads off."

I do think using some discretion in the documentation matters your superior discussed with you is probably necessary. You could probably tighten things up a bit. It's always a learning process.

Yes. I see your point. I always say care staff. Now I say staff so it could be anyone. 

 

Thank you everyone for your thoughtful replies. I plan to take some time to self reflect! 

Now who wants to talk about respecting residents autonomy? LOL. A whole other thread! I may post one though because this was really helpful to see things in a different way! 

sleepwalker

sleepwalker, MSN, NP

Specializes in Occupational Health. Has 18 years experience. 313 Posts

On 7/29/2022 at 9:22 PM, Della4 said:

The way I use in charting is, "resident says pain "extremely bad" and "7/10" and "sharp down leg". 

Or important things like, Resident was asked if they had any thoughts of self harm, residents stated "no". 

Or if a Tenant has been warned of self administering medications. 

Writer advised resident that taking over the counter acetaminophen may cause harm if not ordered by Dr,  writer asked resident if they understand risks? Resident replied " yes, I understand". 

-Pt pain 7/10 via verbal pain scale with c/o intermittent sharp pain radiating to RLE

-Pt denies any thoughts of harm to self and/or others

-Pt advised and acknowledged on dangers of improperly self-medicating with OTC meds

Something along those line...you don't need quotes unless absolutely necessary  

Straight No Chaser, LPN

Specializes in Post Acute; Rehab; Hospice; LTC. Has 6 years experience. 1 Article; 2,155 Posts

I think that you may be over documenting. You have to be really careful what you’re saying in a note - often times you don’t really need to say anything, or you just need to keep it very, very simple.

MunoRN, RN

Specializes in Critical Care. Has 10 years experience. 8,054 Posts

6 hours ago, Straight No Chaser said:

I think that you may be over documenting. You have to be really careful what you’re saying in a note - often times you don’t really need to say anything, or you just need to keep it very, very simple.

When a provider enters an order that is clearly inappropriate, where following the order as written has the potential to cause harm to the patient, it is the legal obligation of the licensed nurse, whether RN or LPN to insist that the order be corrected, and this should be documented in the patient's chart to ensure that this concern has been effectively communicated as their license requires that they do.  

PoodleBreath

PoodleBreath

Specializes in Hospice, LPN. Has 16 years experience. 66 Posts

If residents are consistently making accusatory statements they should be care planned so there is documentation that it is a known behavior and how the facility is working to manage it. The social worker should definitely be brought into the loop because they would be doing the investigation - does this missing object actually exist? Did it go into the laundry? Into the trash? Did another resident take it? Does the resident commonly accuse staff of harm?

Once you've got a formal structure in place there is no need to document anything other than the bare bones and who has been notified for follow up.

The PRN order doesn't make sense and the provider should be contacted to clarify. Not a big deal really.

About 99% of the things you mention needn't really be charted.

Often, the less said, the better.

 

 

 

 

 

 

 

 

 

 

 

 

payitforward

payitforward

Specializes in Med/surg,orthopedics,emergency room,. 97 Posts

Just an FYI on a few things 

1. When you write something in quotes, it means you are repeating something someone said. It’s not used to “mock” someone at all! 
2. WHENEVER you see a doctor’s order that seems unclear to you, get clarification and remove all doubt.