Documentation Mistake?

[Jo Dirt]

We had an aide who refused to follow the careplan for a patient transfer and tried to put a patient to bed by herself (this patient is a 2 person assist.) The patient ended up in the floor and I had to fill out an incident report and call the doctor. The doctor became angry and said "He doesn't need to be standing on that leg!" I assured the doctor this aide would be reprimanded and we would continue to trasnsfer this patient using two person assist to minimize weight bearing to the affected leg.

I was pretty wound up after all the drama and I documented what the doctor said ("he doesn't need to be standing on that leg!" and that I assured the doctor precautions would be taken to minimize weight bearing during transfers by using a 2 person assist at all times.

I'm always second guessing myself and wondered if I should not have written that. Another nurse laughed at me and said maybe I could error it out because I should not have said that.

Now, I'm worried. How bad did I mess up? It seemed like the right thing to do at the time.

[NursKris82]

It kinda sounds like admitting that something was done wrong. I probably wouldn't have said it, but I don't think it's that big a deal. He did say it. I wouldn't worry too much about it. (Easier said than done, right?)

[Jo Dirt]

Yes, it sounds like admitting error. But the careplan says "frequently" needs 2 person assist. However, this aide was told not to put the patient to bed by herself but did it anyway. I crossed out the word "frequently" BTW (with one line, of course.)

I was careful to chart that I assured the doctor we would "continue" to utilize 2 person assist, fall precautions, blah blah blah.

I hate nursing.

[diane227, LPN, RN]

You have an obligation to document events such as falls and you must assess the patient for injury and notify the physician. The physician gave you an order that the patient should not be up on that leg and you should write it as an order. If the CNA failed to properly contact someone to help her, then two things need to happen. First, you need to take her aside and tell her that she should have obtained some assistance before she attempted to lift this patient. You must document the situation fully in your occurrence report and forward it to your manager. He/she should then follow up with the CNA in question. Under the new CMS rules, Medicare will not pay the hospital for any injury, such as a fall, that occurs while the patient is in the hospital. Patient falls are a major liability for any hospital.

[diane227, LPN, RN]

By the way, something WAS DONE WRONG and you should never try to cover it up. It only makes the situation worse. Your failure to document properly will give an attorney a smile.

[CathyLew]

I think at this point, drawing a line thrugh and erroring it out would only draw more attention to it.

Im sure the Dr put in his own progress note more than you did.

dont' sweat it. We all chart in the heat of the moment, and then second guess it all the next day.

[Jo Dirt]

By the way, something WAS DONE WRONG and you should never try to cover it up. It only makes the situation worse. Your failure to document properly will give an attorney a smile.

So...did I mess up? Yes, I'm a little thick, too. Last night, I told the nurse who told me I shouldn't have written that I was sure the doctor would have a lot more to say about this incident than what I wrote in the chart and if all I wrote was that I called the doctor then that might not look good, either.

Yes, something was done wrong. I don't know why on earth this aide was scheduled off her regular hall. This aide is a hard worker but is mentally slow and not capable of dealing with the change. I'm writing a letter to the DON to ask that she is not removed from her regular hall again. I became rather angry with her because she had been told repeatedly not to put anyone to bed by herself yet she did and her reasoning when I asked her why she did it anyway was that "I wanted to prove I'm capable of doing it." She couldn't understand why it was a big deal. She kept saying, "it's not like he was hurt!"

At the same time I don't lay the blame totally with her. The other aides do not want to work with her because she is clingy. I hate to see her fired because she really does try hard and can do a good job, she is just needy. AT any rate I believe she will have to be reprimanded just because of the liability issue for the nursing home.

At nearly every inservice we have been reminded how important it is to follow the plan of care and prevent falls in patients. The new DON has even recently implemented a new system where the nurse must monitor the aides transfer a patient two times weekly and see they are following the plan of care. If they are not they get one warning and the second time they are to be relieved of their duties.

Stress, stress, stress.