Documentation of report of gradual change

[OttoRN]

I’m an RN in an SNF setting.

A nurse aide had reported to me that a patient’s toe was gradually becoming purple over the past three days. On assessment I noticed the patient obviously had some degree of arterial disease and got MD orders for arterial US. On the next shift the LVNs ended up getting a transfer to hospital order by speaking to the MD again and saying the the patient was getting worse. Based on the pictures they took, the patient remained unchanged and they likely confused long standing hemosiderin staining with the new arterial discoloration based on my conversation with them. The MD likely ordered the transfer because they told him that the peripheral pulse was getting weaker, which I doubt. Like I said, it seemed to me that they actually didn’t know what hemosiderin staining was and thought the díscoloration was spreading when their pictures were no different than the ones I took and shared with the MD.

Now, I disagreed with their judgment and they blamed me for documenting that the aide had said the change was gradual in onset because that might be a liability issue. However I see no issue with writing that because the aide is unlicensed and has no nursing/medical judgment and this provides some info about the onset of the current problem. Am I wrong about this? Also, the arterial US did come back indicating moderate arterial disease without an acute issue. I’m guessing the LVNs are worried about their own liability for the past several days since they do direct patient care. However the aide hadn’t reported anything until they thought the issue was abnormal because the onset was gradual. My main question is, is my documentation in this case really a problem? Or my view that CNAs have a lower standard of judgment because they’re unlicensed and therefore don’t have special professional judgment other than common sense?

 

 

[JBMmom, MSN, NP]

This seems a bit nit-picky. If you take out the word gradual are they okay with that? I haven't seen too many toes with hemosiderin staining, generally the lower calf and ankle area, and that's more of a brown than purple. And even that doesn't seem to develop over three days. It doesn't sound like any harm came out of the situation, the patient was assessed and there was no acute change in condition. I don't see any problem with what was done.

[JKL33]

7 hours ago, OttoRN said:

Now, I disagreed with their judgment and they blamed me for documenting that the aide had said the change was gradual in onset because that might be a liability issue.

Did you go back and document that after their actions, or at the time you reported to the MD? If the above was part of your original documentation and not something you just went back and wrote because you disagreed with their judgment then there's really no problem.

I'm not sure what the CNA's level of nursing judgment has to do with anything. At the end of the day it's your responsibility to assess the situation and you did so, and your assessment incorporated what had been reported to you.

[OttoRN]

18 hours ago, JKL33 said:

Did you go back and document that after their actions, or at the time you reported to the MD? If the above was part of your original documentation and not something you just went back and wrote because you disagreed with their judgment then there's really no problem.

I'm not sure what the CNA's level of nursing judgment has to do with anything. At the end of the day it's your responsibility to assess the situation and you did so, and your assessment incorporated what had been reported to you.

Documented at the time of reporting.

21 hours ago, JBMmom said:

This seems a bit nit-picky. If you take out the word gradual are they okay with that? I haven't seen too many toes with hemosiderin staining, generally the lower calf and ankle area, and that's more of a brown than purple. And even that doesn't seem to develop over three days. It doesn't sound like any harm came out of the situation, the patient was assessed and there was no acute change in condition. I don't see any problem with what was done.

The hemosiderin staining was mostly at and above the ankle and blotchy on the dorsal foot. I'm just saying that based on their pictures, the actual purple area was not different than what I had seen, so I didn't know what they meant when one LVN said it affected the whole leg unless she's just talking about all the discoloration present and was confused about what it was. Plus, the pictures they had taken didn't even show/frame the purple area properly.

 

Anyway, I'm just getting tired of the nursing home for several reasons. Thanks for the replies.