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Discussion

Documentation of delegated tasks

I work as a 2nd shift nurse in a LTC facility. 24 residents with 3 scheduled CNAs but half the time actually having only 2 CNAs. We use electronic charting and recently management added that a skin assessment be done for every resident every shift. I objected because an assessment is a nurse specific task and would take 3 hours or more every shift. Management responded by changing it to skin check every shift and said I could delegate it to CNAs. It is listed on my treatment record as a skin check. There is no space or button I can click that would show this as a designated task. I have the choice of putting my initials on the form as completed, hold( I must explain why it was held), or refuse(again I have to explain the refusal). I asked management to move this to the CNA documentation sheet and they refused. They said I must sign or be subjected to disciplinary action and termination of employment. There are items on my treatment record that are delegated to CNAs that I already sign for, such as bed in low position, foley leg bag changed to overnight bag and draining properly, and TED stockings removed at bedtime. I thought that since I can verify those tasks were performed that it was okay to sign for them My objection to signing for skin checks is that I can't verify that they were done. Has anyone else had similar problems? How did you resolve this? I understand my electronic signing of the MAR and TAR as legal documents. I am not comfortable saying a skin check was done when I can not verify it.

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    This is the long term acute care hospital forum...you might want to ask on the LTC forum so you can get more answers.

    But this is a serious issue you raise. A skin check is an assessment and can't be delegated to a CNA...and you certainly shouldn't be signing for a CNA-performed assessment. You chart what you did, or like you said chart things like that the leg bag was changed to the drainage bag, since you can look in the resident's room and clearly see a drainage bag.

    Since your job is on the line here, I think you need to get some higher advice, yesterday. Call your liability insurance carrier if you have one, call your state BON. But do NOT delegate assessments to a CNA and then sign for them. If something happened to a resident...say a stage 1 pressure ulcer wasn't assessed by an RN (CNA thought it was dermatitis maybe, and didn't report it?) and then it quickly progresses to a reportable stage 3?? You will be under that bus with tire marks across your back faster than you can say "Management threatened me!"

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    Oh, and when I worked SNF we resolved it by upon-admit and weekly skin assessments by the nurse. The reasonable thing to do. Otherwise if they insist on a daily complete skin check, they should hire a couple full-time skin nurses. :banghead:

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    • Author

    Sorry about using the wrong forum. I was searching the website trying to find similar situations and came back and entered the wrong forum. Thank you for your thoughts on my question. I did contact my state BON yesterday but have not had a definitive answer yet. Supposed to get back to me this week.

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    I totally agree with your reasoning, but I would try to meet management halfway unless you don't need a paycheck. If CNAs are doing skin assessments, they need to be coached to NOT interpret what they see or filter what info they report, but to objectively report to the RN any findings that could suggest skin breakdown. The RN can then follow up w/her own assessment. I'm new to my job, & I have some issues with how we document. For now, I choose not to challenge the status quo b/c I know it wouldn't be well-received & these charting issues do not place the patients in imminent danger.

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    • Experts

    There were only one or two CNAs that I could trust to give me valid skin check data if I were to delegate the skin check. When our facility instituted separately documented weekly skin checks, I did them myself with the assistance of the CNA, at a time when they would be working with the resident. Otherwise, the trusted CNAs would always keep me informed when there was a problem. Shift to shift skin checks is a noble aspiration, but I highly doubt that they would be done simply to do a skin check. "Papered" yes, actually completed, not likely.

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