False documentation?? I need your help

amzyRN · Feb 19, 2016

If your urine is clean, I don't see what the issue is. Personally, I wouldn't like to work on a unit that would blame a nurse for diverting narcotics for one incident like that. I can sort of see you becoming distracted and forgetting to waste, although I make it a rule for that (getting a witness to waste) to be a priority unless one of my patients is coding at the time.

As long as your urine doesn't have substances in it that shouldn't be there, I don't think you should be freaking out about it.

Karou · Feb 19, 2016

That's why when I do something like that I call another nurse, stay where I am at and leave the mess so they can witness. Then I'll clean it up (for safety) have them waste in the Pyxis (I'll also make a comment in the mar) and I'll get a new dose.

For your protection you have to slow down. Unless it's a code, a rapid response, or a patient fall, then it can wait until you have wasted the drug. I am sorry this happened, but it will be a lesson for you on the future.

I would be most concerned with the dilaudid documented as given and not edited to show that it was in fact not administered. That would be false documentation. Also, did the patient get anything else for pain? Or did you pass off to next shift to give the patient something? Patient was hurting, vial busted, what happened for their pain control? I know it was close to shift change, but it seems like more than one ball was dropped on this situation.

elijahvegas, ASN, RN, EMT-P · Feb 19, 2016

a little confused on the story here.

so you went to give the patient their ordered dose of dilaudid, you dropped the vial, and cleaned it up. then you went to go find another nurse to...waste? i'm assuming you mean you needed another nurse to verify that you broke the vial and document it on your behalf? But somewhere along the way you got distracted with other patients and never got to the nurse? But on report the nurse says the patients blood pressure is low because of the dose of dilaudid that you administered, except you never administered it?

my questions are

1. what exactly happened with your other patients that caused you to completely forget to document something you were right in the middle of doing? i understand things come up and you have to juggle a few balls at once but how did you completely forget not only to administer the drug, but also exited out of whatever EMR you were using and never went back into it until the end of your shift?

2. whats the reason for the low blood pressure if that dilaudid was never given?

3. your title mentions "false documentation". what exactly did you document? if you ended up documenting that you DID give the dose, but on turnover told the receiving nurse that you never gave it, then yeah, that would raise a whole lot of red flags. thats essentially how people divert drugs and its a very serious situation. i'm not implying thats what happened here, but management would have every reason to assume so.

you said this happened a year ago, would you mind sharing what the final resolution was? i'm not entirely sure the point of this post, but i'm very sorry that something so unfortunate happened to you and ended up costing you your job. do you still have a license to practice? have you sought employment elsewhere, or considered a new but similar career?

distressnurse · Feb 19, 2016

AmzyRN thank you for taking the time to read my post, I don't have formal charges for narcotic, the formal charges are for falsely documentation. which was the reason that I went to talk to the manager to help me to correct that mistake. but she presume I was using drugs and after my urine test was negative still I was turn into the TBON.

Karou · Feb 19, 2016

two days later the manager called me and told the drug test was negative, but I was fired and reported to the TBON. almost a year after the TBON send me a letter with a propose agreement to sign it if accept the charges of falsely documentation. the disciplinary action were some classes, monetary fine and one year work under indirect supervision, I denied to signed it because I thought it is too much for an honest mistake. after that my license had formal charges and waiting for a hearing I had paid almost $10.000 in attorney fees, run out my savings, apply 100s of times, and cannot find a job. I feel desperate, and the stress is killing me. can somebody help me please?

I see you edited your post to add some more information (new info is what I quoted). The problem is that you DID falsify documentation, "honest mistake" or not. You documented a medication as administered that was in fact never given. You were rushed, didn't slow down, and made multiple errors in your actions. It shows poor critical thinking and judgement.

You would have been better off just signing the original proposal.

What happened here may be too harsh, but it's a good lesson for any new nurse to always CYA and ensure your documentation is accurate.

elijahvegas, ASN, RN, EMT-P · Feb 19, 2016

ah i see more info was added. it must've been edited while i was typing in my response, because there are also 2 more replies that showed up before mine haha.

i'm sorry that they took such drastic measures against you, hindsight is 20/20. Even though you made a mistake you knowingly did something wrong and was reported for it. As such its always in your best intention--especially when dealing with the BON--to take whatever punishment they give you when you are in the wrong. in this case it was black and white, you false-doc'd, you got caught. And since you didn't take their generous initial offer, they decided to slaughter you instead.

hope things turn around for you and you've learned your lesson.

i just cant understand why you would document giving it when you didn't. In my opinion, it would've been much more prudent to document that you never gave it, and deal with the lashing of a missed dose, than the other way around. Especially when it comes to narcs. Worst case scenario a missed dose would've given you a write up or some in-house disciplinary action. False documentation is just...yikes:nailbiting:

distressnurse · Feb 19, 2016

thank you for your interest, It was 05:30 in the morning everybody was busy drawing blood, passing pain medicines etc. I don't know exactly why the BP drop, I did document that dilaudid was given but when I was given report to the day nurse I told her that I was going to talk to the manager to help me to fix the documentation and the waste. the propose agreement from the TBON was some classes, monetary fine, and one year under indirect supervision for falsely documentation. I did not sign the propose agreement because I feel the disciplinary action was to much. I don't use drugs and there was no diversion, I forgot to found the nurse to go and waste with me and fix the documentation. an honest mistake. Now I'm waiting for a hearing and had formal charges in my license which the attorney said it can take another 12 months who knows. sometimes we edit nursing documentation 12 hours after, that's why I feel the initial disposition were to much.

Altra, BSN, RN · Feb 19, 2016

If you scanned the patient and the med, that equals administration in most EMRs. You are not the first or last person to drop a vial - it happens - but you MUST then edit your documentation. EMRs have functions for this.

Please also understand that those who do divert narcotics are not always the user of narcotics themselves. So urine drug screens are not the end all determining factor in accusations of diversion.

distressnurse · Feb 19, 2016

I don't have formal charges for diversion. that is the problem everybody seem to condemned me for diversion and focus on that issue while I been charge for falsely documentation, and I feel I shouldn't because I went to look for help to fix the documentation as soon as about an hour later. but the day nurse focus on diversion, the manager focus on diversion, and then the board of nursing did not found proof for diversion and wants to punish me for falsely documentation, while in a first place I told the day nurse and manager my mistake trying to get some help.

Boog'sCRRN246, RN · Feb 19, 2016

I don't have formal charges for diversion. that is the problem everybody seem to condemned me for diversion and focus on that issue while I been charge for falsely documentation, and I feel I shouldn't because I went to look for help to fix the documentation as soon as about an hour later. but the day nurse focus on diversion, the manager focus on diversion, and then the board of nursing did not found proof for diversion and wants to punish me for falsely documentation, while in a first place I told the day nurse and manager my mistake trying to get some help.

But did you ever go back and correct the documentation after the vial was broken? You say you scanned the med, scanned the patient, and documented the med as given...then dropped the vial. So, that stayed in EMR as the pt having received a dose of Dilaudid. If you didn't go back and notate what happened, then it is false documentation, maybe not intentional, but still false. Just telling the day nurse and manager isn't enough if nothing was changed in the medical record.

Horseshoe, BSN, RN · Feb 19, 2016

This is a great lesson to all the new kids on the block:

Don't EVER document a med given until it actually IS given! Sure as you document it and go into the room, the patient will change his mind or something like this happens. Now your documentation is FALSE. If your documentation is set up with bar codes that have to be scanned pre-administration, then you don't walk away until the documentation which shows the med was given is CORRECTED.

Don't ever let "distractions" get in the way of properly dealing with narcotic administration and waste.

There are certain things you can put off or let slide while you deal with the multiple things that come up while you are trying to get things done, but anything to do with narcotics is NOT something you can put on the back burner. Do it now.