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DON telling me to omit facts from documentation

tell me if im wrong, please. first I am a new RN and at first job for 6 months. I work on a skilled/rehab floor of a LTC. we use chair alarms as bed alarms. Big problem when a person is alert and oriented and feels they can get up on thier own without falling. so my patient removed his alarm, clamped and disasemlbed his wound vac tubing, went to the bathroom and fell getting back into bed. no injuries luckily but an incident none the less. so my DON and andministator adimantly told me not to document that he removed his alarm. DON actually said "you don't want to kill the facillity". The administator mentioned something about if I should be pulled into court... Well my thinking is if I should be pulled into court I want it documented that I had his alarm on and he was noncompliant. the DON said I could chart that I replaced the alarm. What?? to me that does nothing to show I had it it on to begin with. Incidently next night the same patient removed alarm and ripped his wound vac dressing so he could get up to turn his light down. I should add that interventions were put into place, different alarm ordered and i did 15 min. checks. still he got up many times thoughout that second night. I asked 4 different nurses who all said document that he took off his alarm, which I did. sorry so long, my question is am I right to document what happened? am I missing a way of wording it that won't "kill the facility" Honestly I feel like the truth is that they couldn't care less about me and my liablility they are just worried about themselves.

amarilla, RN

Specializes in MS, ED. Has 2 years experience.

I am also a new nurse, finishing my first year on a post-op floor, but I think we both know that omitting information or altering documentation is not in your best interest. You're right - the facility only cares about protecting themselves, and will handily abandon you (and your spotty charting at their behest) at the first sign of trouble.

I know that doesn't help you to do the right thing when your job is at stake, but it really comes down to the risk you want to take and how much you can live with. Your charting needs to be accurate and reflect the reality of the situation, which it seems you did; if you detailed information about the interventions taken for this patient's non-compliance, I'm doubtful that you could be liable...

unless, of course, you omitted the information about the patient's actions, your interventions, and the results. ;) Do you have the option to start job hunting?

I don't see where what you posted would be a problem but maybe there is something I am missing. Yes you are right to chart what really occurred, in this case I think that charting what they wanted you to say would have put you at risk. Your standing there will probably deteriorate. It would probably be wise to start job hunting.

ckh23, BSN, RN

Specializes in ER/ICU/STICU. Has 6 years experience.

Bottom line is you document what happened. Yes it may cost you your job, but losing a job is better than losing your license. Do you think if you were ever called on it that the DON would admit that he/she told you not to document it? My guess is they would leave you high and dry.

On a side note, if this one instance would "kill the facility" makes me wonder what other events happened in the past to make them say something like this. I'm thinking this is just one incident on a long list.

maybe there is a problem with the wording? if you documented 'Mr. A. disabled his alarm' it won't stand up in court as well as 'nurse observed that alarm had been disabled. Mr. A. stated, "I turned it off when I got up."'

Florence NightinFAIL

Specializes in Medical - Surgical. Has 9 years experience.

You did the write thing. [EDIT: lol, pun? 'right' thing]

ALSO: Keep a personal note about the situation - your own documentation. About the incident, times, people there, witnesses, name of don, what he said in qoutes, your reponse, date and time. keep it somewhere safe and easily accesible. just in case your document disappears or is tampered with and somehow you are involved in an investigation. I wouldn't put anything past this piece of work.

I would also start job hunting -if he actually said you would 'kill' the facility unless you FALSIFIED events - I wouldn't feel safe with him. You worked hard for your license.


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