disappearing nurses notes!

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Is it legal for the DON to make pages of nurses notes ( paper charting) disappear ? I documented 2 pages of notes on tuesday on a resident about the resident complaining of pain and not recieving prompt calls back from the md and pharmacy. It took 4 hours to get the pain medicine. And when I came in to work today all my charting was gone. The other nurse I work with said the DON has the tendency to make certain charting "disappear " if she does nt like its contents. Is this legal ?

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Is it legal for the DON to make pages of nurses notes ( paper charting) disappear ? I documented 2 pages of notes on tuesday on a resident about the resident complaining of pain and not recieving prompt calls back from the md and pharmacy. It took 4 hours to get the pain medicine. And when I came in to work today all my charting was gone. The other nurse I work with said the DON has the tendency to make certain charting "disappear " if she does nt like its contents. Is this legal ?

No, it is not legal to remove anything from a resident's chart. She is violating your NPA, Medicare/Medicaid regulations, state regulations, to name a few. In plain English she is setting herself, her facility and staff, for a law suit. What was put into the chart to cover your absent note?

GrannyRN65

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Specializes in Hospice / Psych / RNAC.

Absolutely NO! That is considered illegal as she is destroying legal documents. Once it's in the chart it should not be taken out to be destroyed. This is why we have policy of drawing one line through documentation that you don't want. Drawing a line from your sig at the end of documentation so no one else may input anything, no white out and no erasing with a pen eraser.

Of course I have learned on this forum that all the states are different in some aspects of practice but I'm Pretty sure that all states would consider this destruction of the legal record. Sorry can't think of the right term; but there is one.

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We chart almost daily, nothing was put in my missing notes place. The nurses notes go from 10-15-10 and then skip to 10-27-10. So a few pages are missing.

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Specializes in Hospice / Psych / RNAC.

I'm afraid to say this but now that you know..............if you cover as well.

If I was feeling gutsy I would do an incident report but that could result in a bad reaction. I would talk to her and tell her that you and others are seeing that she is doing this.

I don't know I guess it depends on how vengeful she is but can you really sit by and watch her destroy legal documents? Hmm tough one. I guess she may be that naive and believes what she is doing is somehow benefiting the company when in fact it is really putting your facility in sooooo much hot water but sooner or later it's going to come out. I mean she's got to know what she's doing is wrong; doesn't she. Well actually have you ever seen her do it? Hmmm - Good luck

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Not the first time I have heard of this. If I could talk to her I would say, "who or what do you think you are protecting?" Certainly not yourself. You are protecting an institution. Is it really worth sacrificing your integrity and you career for an institution?

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Specializes in LTC, Psych, Hospice.

It's wrong, wrong, wrong! Many moons ago, as a brand new nurse, I worked with a DON like that. One day she asked me to rewrite several days of notes (which she had written out on scratch paper). I refused and was let go the next week.

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Specializes in NICU, Post-partum.

I would find the highest level of management...which would be the President/CEO...however your organization is set up, and arrange a meeting and directly report this....and get anyone else that this has happened to, to follow you.

She is putting the license of every single nurse there at risk because she is taking away documentation you have made to protect yourself and the patient.

I would also find another job...b/c she is DANGEROUS.

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Specializes in Tele, ICU, ED, Nurse Instructor,.

I would even go to the CEO/President because it may be a possibilty they know and in on the illegal scam. I would make copies of every note you write with patient names, date, and time and put them in a safe place. You would have your proof. I would call state board of nursing and/or Joint Commission. The physicians should be reading these notes and should have questions about things being missed. They maybe in on also. It appears to me this place is a set up for failure no matter which way you move or go. Good luck.

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AHHHHHHGGGGG. (that was me screaming)

Why must this DON get away with doing this and perpetuating the stereotyping of LTCs???

You already know the answer. Never is it legal. So, what do you do now?

You have a few options. Stay, do nothing and put yourself at risk.

Ask her if she did it? And why and what she thinks can happen?

Figure out who you need to go to abover her and who will actually do something about this?

When writing a note that might seem controversial to the DON, can you document in other places too? Like on the report sheet make a note "see nurses note" or if it was about pain..make sure you document on the flow sheets or back of the MAR too. Then I'd make a copy of the NN that you made.

Is she also removing other nurses documentation with your note? Make sure they know you might be missing notes.

If you have a 1800 anon compliance line this would be a good place to go.

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what does the RNAC know about this practice? If that many days are missing, the RNAC might be having a hard time getting documentation too.

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Specializes in Home Health.

Your in a tough spot. If you file a complaint, the DON can make life really difficult for you. If you don't follow up, your job could be at risk if (years down the road) if it is discovered that you "failed to chart" on something, even though you did not fail to chart on it.

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