Asked NOT to document - What to do?

JustBeachyNurse, LPN · Dec 6, 2015

Not document in official paperwork as you have no duty as an agency employee to the family member. Any care provided documented in your client's chart regarding the family member will be a huge red flag to QA & insurance. It will be questioned why you provided care to someone who is not a patient in your agency.

Calling 911 was kind, but not your responsibility as a agency employee. You were there for your patient. If your patient fell or suffered an adverse event while you were assisting the family member you would be fully responsible for any injury or deficit resulting from you caring for the non-client

As a CNA its not your job to assess or send people to the ER. If a family member falls while you are at work and no one else is there call 911 but stay with your patient.

BethCNA · Dec 6, 2015

Would you ask to fill out an incident report?

Lev, MSN, RN, NP · Dec 6, 2015

No, there is no reason to fill out an incident report since the family member is not connected with the home health agency. If the family member assaulted a staff member, then that would be a reason to fill out an incident report. The family member is not your responsibility. There is no reason to document anything about the fall or the hospital trip.

caliotter3 · Dec 6, 2015

When I called to inform and make sure about an incident in my client's home which involved the police, I was told not to mention anything in the patient's documentation. I just made a personal memorandum for myself, should I need any of the details in the future. PP correct, does not directly involve your patient, you don't chart on it.

JustBeachyNurse, LPN · Dec 6, 2015

Would you ask to fill out an incident report?

No. Unless the family member injured you, your coworker or the patient. You had no legal duty to act for the independent family member. If you left the patient to care for the family you are guilty of abandoning your patient.

KelRN215, BSN, RN · Dec 6, 2015

I agree that there is no need to document it. In pediatrics, we do sometimes document parents' behavior but only in so much that it is relevant to the care of the child. When I was an inpatient nurse, it wasn't rare that we had to send patients' parents to the ER. If it was relevant to what was going on with the child or the parents' ability to care for them, it was documented. If not, no reason to. For example, earlier this year a patient of mine's mother was found with a needle in her arm outside the hospital. She was taken to the adult hospital next door and they notified the floor that she had overdosed on heroin on hospital property. This led to her being restricted from visiting or participating in her son's care. This is relevant. As is the time we sent a mother for an inpatient psych hold because she expressed that she had a gun at home and wasn't sure that she could be safe with her child. A parent who is sent to the ER for vomiting or chest pain or something like that, not so much.

turtlesRcool · Dec 7, 2015

Think of it this way - what you chart goes into the medical record of your patient. Another adult falling in the house does not affect the care your patient received. Therefore, you do not chart someone else's medical information into your patient's record.

JustBeachyNurse, LPN · Dec 7, 2015

The only reason I can see an incident report required is if you and your coworker left your patient (who you have a legal duty to care for) to attend to the injuries of a fallen independent otherwise able bodied family member. Or if one of you attended to the non-patient family member while your coworker or the patient were at risk for or injured as the plan of care is 2person assist. This would be to address the deficiency of abandoning a patient to care for essentially a bystander. Such an incident came up in one of my agencies. In one incident the nurse's shift was over and she was relieved as she was leaving the parent had a new onset grand mal seizure and the nurse cared for her while awaiting EMS. The patient was under the care of a different nurse.

In another incident a "helpful" aide was helping a family member but the patient fell sustaining minor injuries. The patient was a known fall risk and needed 24hr direct supervision and assistance. The fall would not have occurred if the employee was watching/caring for the patient