Chart Audits....you have to be kidding me!!!!!

Nurses General Nursing

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Ok......I just got a call from the night charge nurse. She audits the restraint charting somewhere around 2000hrs. She called to tell me that I didn't check the box (in EPIC) that states I notified the family regarding the restraints. Every other bleepin' box was checked except that one..........she called me to tell me that I had missed that one box. FYI.....this lady was maxed on pressors, rapid Afib, intubated and lined today and started in CRRT....wasn't like I was sitting on butt all day.

She apparently will call you up to 2 times and on the 3rd time if your restraint documentation isn't perfect........you have to come back in to fix it. I work 12 and half hr shifts. Some staff members have been called as late as 2200hrs. Can this even be legal???? I feel totally harassed. I was always under the impression that my documentation was mine....done under my license. If I failed to complete everything, than it was my license at risk and that it would also show up on my evaluation.

Can management really call you for such small infractions?

The main issue is that it is not the Nurse's responsibility to comply with regulations such as restraint charting. It's the Nurse's responsibility to follow their obligation to prioritize appropriately, if the facility is not supporting the ability to make it down to restraint charting on a properly prioritized worklist, then that is the facility's failure, not the Nurses.

I'd loooove to be present to observe an RN offering that to a supervisor as an excuse/rationale for why s/he did not complete charting appropriately on a client placed in restraints. Since when are nurses not responsible for following facility policies and state and Federal regs re: clinical documentation??

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It's sort of a moot point, but there are no federal or state agencies that require family be notified of the use of restraints.

That's quite a sweeping statement. You're familiar with the Dep. of Health and Dep. of Mental Health rules/regs in all 50 states? I worked for several years as a hospital surveyor in NC, and the NC states rules about patient rights do specifically require in some circumstances that a designated individual (usually, but not always, a family member) be notified of any use of restraints. That was something we looked for when reviewing restraint charts, and facilities did get cited for lack of compliance. I'm guessing there may well be other states that have similar rules/requirements, but am certainly not in a position to comment definitively on rules/regs in other states.

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Specializes in Emergency & Trauma/Adult ICU.
That's quite a sweeping statement. You're familiar with the Dep. of Health and Dep. of Mental Health rules/regs in all 50 states?

Agree -- it is quite the all-inclusive sweeping statement, and definitively inaccurate in the context of mental health patients.

I can only assume Muno's comments are intended to convey the "systems" issues related to a nurse's failure to document completely ... but to suggest that it is, for lack of a better word, a *defense* is not accurate in regard to most U.S. workplaces.

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Specializes in LTC, Psych, M/S.

Then there are the nurses who make sure they have every box initialed but they often didn't complete the task. Alot of times they get away with it.

For example when I worked LTC at the end of every month the lowly night shift nurse would do " change out" - replacing the bubble packs of medication - which should be empty- with the new ones filled with 30 day supply of meds. Many times there were pills still in the packs.

You see, the NM's would "audit" the MAR for the initials but wouldn't audit the MAR against the bubble packs. So as long as you initialed every box you were ok. Who cares if the med was actually given. WTH??

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Specializes in Critical Care.
That's quite a sweeping statement. You're familiar with the Dep. of Health and Dep. of Mental Health rules/regs in all 50 states? I worked for several years as a hospital surveyor in NC, and the NC states rules about patient rights do specifically require in some circumstances that a designated individual (usually, but not always, a family member) be notified of any use of restraints. That was something we looked for when reviewing restraint charts, and facilities did get cited for lack of compliance. I'm guessing there may well be other states that have similar rules/requirements, but am certainly not in a position to comment definitively on rules/regs in other states.

This is from a regulatory compliance resource we use:

"Joint Commission standards PC.03.03.11 and RC.02.01.05 are the only standards that address the notification of family when restraint or seclusion is used."

QUESTION OF THE WEEK: Family Notification of the Use of Restraint or Seclusion -

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Specializes in Critical Care.
I'd loooove to be present to observe an RN offering that to a supervisor as an excuse/rationale for why s/he did not complete charting appropriately on a client placed in restraints. Since when are nurses not responsible for following facility policies and state and Federal regs re: clinical documentation??

The first time I explained that it was my typical rambling explanation. The above quote was paraphrased from the Dept of Health Compliance Officer that I asked about it, who put it much more succinctly than I did.

Our administration is well aware of our reasoning. I, and none of the many other Nurses who chart "unable to complete restraint charting due to workload" in our notes have any problem at all explaining that our obligation is first and foremost to our patients, our ethical obligations, and the requirements of our license, which is to prioritize appropriately. It is then the facility's responsibility to ensure proper time and support is provided to ensure that we're able to make it far enough down that list priorities so that regulations are complied with. Skipping more important things, not that restraint charting is not at all important, but skipping more important things to help your facility cheat is arguably poor Nursing form.

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Specializes in Certified Med/Surg tele, and other stuff.

Can't they build hard stops into certain boxes so you can't SAVE unless they are checked?

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Specializes in Pediatrics, Emergency, Trauma.
Can't they build hard stops into certain boxes so you can't SAVE unless they are checked?

^This...depends on the program...it would make more sense to do this. :yes:

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Our administration is well aware of our reasoning. I, and none of the many other Nurses who chart "unable to complete restraint charting due to workload" in our notes have any problem at all explaining that our obligation is first and foremost to our patients, our ethical obligations, and the requirements of our license, which is to prioritize appropriately. It is then the facility's responsibility to ensure proper time and support is provided to ensure that we're able to make it far enough down that list priorities so that regulations are complied with. Skipping more important things, not that restraint charting is not at all important, but skipping more important things to help your facility cheat is arguably poor Nursing form.

I do legal nurse consulting for attorneys but I am not a lawyer and don't play one on House. However, if I were doing a chart review and found a note like that, I would ask my atty client if s/he wanted me to find out how often this happens, and if there are similar notations for anything else besides restraint documentation. I would want to know what steps staff and mgmt took to address this, referencing the ANA Scope and Standards of Nursing Practice and the ANA Ethical Statements which apply to all RNs. I would want to know if staff or mgmt contacted the facility risk management department to report this problem, referencing the ANA documents. The RM office knows that the facility is required to provide safe staffing, and that includes enough staffing that the RN and other staffers can complete their required care elements, including documentation. The facility is allowed a rare bye for emergencies, but if this happens week in and week out that's a pattern of short staffing, not an emergency, and they have to address it.

If I worked in a facility like that, I would be making sure to do my professional duty by reporting it to RM every single time it happened, referencing the ANA documents; I would be covering my (behind) with so much paper I'd need bigger scrubs. If I were in a union shop, I'd be sure they knew. If not, I'd call my state nursing association's legal office, and notify my own atty division (which might even shake out a letter).

Of course, I'm a troublemaker when I think things are just plain wrong, but most of the time I'm right. :) If you're not making waves, you're not moving forward.

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Specializes in Critical Care.

....

If I worked in a facility like that, I would be making sure to do my professional duty by reporting it to RM every single time it happened, referencing the ANA documents; I would be covering my (behind) with so much paper I'd need bigger scrubs. If I were in a union shop, I'd be sure they knew. If not, I'd call my state nursing association's legal office, and notify my own malpractice insurance atty division (which might even shake out a letter).

Of course, I'm a troublemaker when I think things are just plain wrong, but most of the time I'm right. :) If you're not making waves, you're not moving forward.

We have an unsafe staffing reporting system. There are multiple reports submitted daily, and there would likely be many more if the Nurses actually had time to submit them. Unfortunately there are no direct legal requirements to enforce safe staffing, and most facilities are pretty safe so long as their level of non-compliance with safe staffing is on par with everyone else's unsafe staffing. Our reporting system is implemented by our Union which tracks unsafe staffing complaints throughout the state and we're pretty much on par with everyone else.

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Actually, your state nurse practice act does exactly that. Referencing the ANA Scope and Standards here:

Std 15 (in part): The registered nurse identifies healthcare consumer (patient) needs, potential for harm, complexity of the task, and desired outcome when considering resource allocation... Identifies the evidence when evaluating resources ... Advocates for resources, including technology, that enhance nursing practice ...

See also: Std 10, Quality of Practice; Std 11, Communication; Std 12, Leadership. You may think it's pie in the sky, but it's actually something that can empower you and your colleagues IF YOU DO IT.

Your nursing supervisors and management are RNs and bound to this, too. I'd say it's time to take it to the next level. "The way it always is everywhere" isn't much of an excuse for throwing up one's hands and stopping there.

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Specializes in Critical Care.
Actually, your state nurse practice act does exactly that. Referencing the ANA Scope and Standards here:

Std 15 (in part): The registered nurse identifies healthcare consumer (patient) needs, potential for harm, complexity of the task, and desired outcome when considering resource allocation... Identifies the evidence when evaluating resources ... Advocates for resources, including technology, that enhance nursing practice ...

See also: Std 10, Quality of Practice; Std 11, Communication; Std 12, Leadership. You may think it's pie in the sky, but it's actually something that can empower you and your colleagues IF YOU DO IT.

Your nursing supervisors and management are RNs and bound to this, too. I'd say it's time to take it to the next level. "The way it always is everywhere" isn't much of an excuse for throwing up one's hands and stopping there.

I couldn't agree more, which is why chart what actually got done (and more importantly what didn't actually get done), as opposed to just making the charting "look good", which essentially takes away our ability to claim insufficient staffing and support. We communicate regularly with out BON compliance officer and have had them come down and meet with us and administration on numerous occasions. What "next level" beyond the BON are you referring to?

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