discovered and reported falsification of VS

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by traumaRNdrama traumaRNdrama (New) New

Specializes in Trauma/ICU step-down.

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PediNurse3

PediNurse3

142 Posts

When I worked in the ER I witnessed a nurse making up vital signs. He was sitting at the computer beside me, and was going through hours worth of vital signs to update the patient's chart before sending them upstairs. The funny part was that the patient was on the trauma side- so there was a monitor in the room that you could set to cycle bp, etc...he just never "admitted" the patient so the information wasn't saved and didn't bother to reconnect them when they came back from CT.

He justified what he was doing by saying that the patient was fine and that "vital signs don't really need to be done that often". :/

Ruby Vee, BSN

Specializes in CCU, SICU, CVSICU, Precepting & Teaching. Has 40 years experience. 67 Articles; 14,008 Posts

i had a cna tell me he could do manual b.p.s w/o a stethoscope:eek: i suspected he was part bat with sonar....definitely wasn't human :devil: he didn't last long.

actually you can -- you can either doppler or palpate pulses while deflating the cuff. that will give you a systolic.

RNdiva505

RNdiva505

Specializes in med/surg. 76 Posts

Well at least some of you have success stories. At my hospital I can not find a CNA to save my life because they are either down on their hourly break, watching tv in an empty room, in the kitchen eating , smoke break or something. And when you do ask for help they are rolling their eyes, looking at you like your stupid, or say they are busy taking their 4 o'clock vitals at 530. When I do complain to upper management they say that due to the lack of CNA's here they cannot afford to fire one! Great I'm stuck with lazy a$$ people!:cry:

Don't even ask about write ups... Some of them have been written up so much that they can publish their own bood out of the paper used! :flmngmd:

Ruby Vee, BSN

Specializes in CCU, SICU, CVSICU, Precepting & Teaching. Has 40 years experience. 67 Articles; 14,008 Posts

years ago, i came to work for a day shift on a med-surg floor. i was team leading, and was giving my 8am meds based on the vital signs taken at 6am by the night na. the patient in room 6 had normal vital signs listed on the temp board, but when i tried to wake her, i discovered that she was rigor mortised. the 24 hour holter monitor she was wearing showed vt at midnight, followed by vf and asystole by 0100. interestingly enough, vital signs recorded at 2 am and 6 am were all normal.

the na kept his job, the rn who worked overnight lost hers for "failure to supervise." i'm just lucky it wasn't me -- i'd been on nights the week before.

floridanurse1983

floridanurse1983

169 Posts

years ago, i came to work for a day shift on a med-surg floor. i was team leading, and was giving my 8am meds based on the vital signs taken at 6am by the night na. the patient in room 6 had normal vital signs listed on the temp board, but when i tried to wake her, i discovered that she was rigor mortised. the 24 hour holter monitor she was wearing showed vt at midnight, followed by vf and asystole by 0100. interestingly enough, vital signs recorded at 2 am and 6 am were all normal.

the na kept his job, the rn who worked overnight lost hers for "failure to supervise." i'm just lucky it wasn't me -- i'd been on nights the week before.

cause, yeah, why fire the person that did it?? makes perfect sense:uhoh3:.

wishinguponastarLPN

wishinguponastarLPN

Specializes in Rehab, LTC. 217 Posts

This CNA was wrong for falisfying VS records. However you are the professional and the one administering the med with BP parameters. If something was to happen it would come back on your license. With this in mind I would ALWAYS double check a VS no matter who just did them if I am the one giving the medication. :twocents:

xtxrn

xtxrn, ASN, RN

4,266 Posts

years ago, i came to work for a day shift on a med-surg floor. i was team leading, and was giving my 8am meds based on the vital signs taken at 6am by the night na. the patient in room 6 had normal vital signs listed on the temp board, but when i tried to wake her, i discovered that she was rigor mortised. the 24 hour holter monitor she was wearing showed vt at midnight, followed by vf and asystole by 0100. interestingly enough, vital signs recorded at 2 am and 6 am were all normal.

the na kept his job, the rn who worked overnight lost hers for "failure to supervise." i'm just lucky it wasn't me -- i'd been on nights the week before.

:eek:

xtxrn

xtxrn, ASN, RN

4,266 Posts

Although i don't use this technique; you actually can measure a bp by looking at the dial and usually you can tell what the bp is by seeing where the dial "bumps". If you release the air slowly its usually pretty accurate. I dont actually do this but i have notice this when auscultating BP.

Yeah, but it can 'bump' 10-15 mm/hg before you can hear it...BTDT when mine has been checked at the doc's office. I'll note when I see the 'bumps', and then what the nurse tells me she got... significant enough to matter if I did the same thing and gave meds by that method :)

xtxrn

xtxrn, ASN, RN

4,266 Posts

actually you can -- you can either doppler or palpate pulses while deflating the cuff. that will give you a systolic.

i've just had it be enough of a difference to matter if using it for meds... :) i know about palpable b.ps :D the guy in question was an idiot.... he wasn't doing anything useful, let alone doing it right :D

Edited by xtxrn

dudette10

dudette10, MSN, RN

Specializes in Med/Surg, Academics. Has 11 years experience. 1 Article; 3,530 Posts

I also would not give cardiac medicines based on anyone's assessment findings but my own. Surprised this wasn't previously mentioned.

Me either. Initial shift vitals are taken by the CNAs, and I always see them going in and out of rooms with the Dynamap. I'm often in there intro'ing myself as they are taking vitals, so I know they aren't made up (except for RR...another story...). But I always take a manual BP and apical HR before giving BP or chronotropic meds.

As for RR, I do chart if it is higher than normal, but I also chart other things (shallow breathing, pt reports no SOB, dizziness; O2 sats w/ pulse ox at 97%) and interventions (educated patient on turn/cough/deep breathing, HOB elevated to 35 degrees, O2 via nasal cannula checked at 2L per order) to justify why I didn't report the "sudden" increase in RR. Although I suspect it's the patient's "norm" and the RR was never accurate, I leave that out of charting, of course.

dudette10

dudette10, MSN, RN

Specializes in Med/Surg, Academics. Has 11 years experience. 1 Article; 3,530 Posts

Although i don't use this technique; you actually can measure a bp by looking at the dial and usually you can tell what the bp is by seeing where the dial "bumps". If you release the air slowly its usually pretty accurate. I dont actually do this but i have notice this when auscultating BP.

You know, I've checked this technique while doing a manual BP. More often than not, I've noticed that the "bump" begins before I can hear the beat, and the "bump" ends before I stop hearing the beat. I did a LOT of BPs in one of my clinical rotations, with consistent verification by the sole nurse assigned to me, so I'm pretty confident in my ability to take a manual BP. I wouldn't use this technique in my own practice.

traumaRNdrama

traumaRNdrama

Specializes in Trauma/ICU step-down. 14 Posts

To those of you saying you measure your own VS before giving certain meds because you can't trust others/your co-workers to take and document/report accurate VS, which is clearly a VITAL and routine part of their job description/duties in a acute care setting: I'm curious, do you give patient's their coumadin based on the coags that the phlebotomist drew and the lab tech ran, or must you verify those coags for yourself as well? Do you shoot and read your own XRAYs as well? I'm not asking my CNA to do something outside their scope of practice by taking VS. Where does your mistrust end? The majority of my patients are on BP meds and/or some other med that could affect them in some profound way. You must have a lot more time on your hands then we do on my floor if your re-doing everyone's VS...