False Documentation?

[RPN_2006]

I need advice.

I have a home health client who is 100+ years old, end stage renal failure, anuric, +++sediment in foley causing obstructions.

This man was getting cath irrigation c NS q week for months and I increased him to q2days when obstructions were becoming a problem. Even then he obstructed and so I increased him to daily irrigations..so far so good.

I am responsible to order all supplies for clients and when i saw this man on friday I took a count of supplies and put in an order for more NS and irrigation trays. There were three of each left...one for Sat, Sun, and Mon. I had Saturday off.

I saw this man today and began my visit by reading his chart entry for Saturday...all is good, VS stable, NS irrigation given...no prob.

Except when I began to gather supplies there were neatly stacked as I had left them, 3 trays and 3 bottles of NS.

We do carry minimal dressing supplies with us, but not irrigations trays, not as a rule, and who would drag them out of their car for no reason.

To further complicate matters, the nurse who made the visit is well respected in our practice. She precepts new students and new hires. Unfortunaley, she is always giving me the a** about something, always questioning the frequency of my visits, or the dressings I choose. She is snide when talking to me. I have considered why this may be but have come short of a satisfactory answer. Feedback from other members of the team and from patients themselves towards me has been good, but I digress...

What would you do? What should I do? I can never prove that the tx wasn't given, and the pt cannot say. Fortunately there was no harm to the pt and I did not have to replace his catheter once again.

I'm just fuming! :angryfire

[MQ Edna]

We had a nurses where I work that had been there for YEARS and I highly respected her. Turns out she was allowed to resign for not actually giving individuals their medications! I don't care how respected you are, if you're not giving a pt. the care they deserve then you don't deserve to care for that pt... or any other IMHO.

[steelcityrn, RN]

Probably better to let this one blow over. If you had the gumption, I would just flat out ask her what irrigation did she use that day since none of the trays there were used, and see what she says. What if she thought maybe there would not be one there, so she brought one in with her?? To make sure he gets his catheter irrigated when you are not there, maybe you can number them, setting one out for use. If anyone asks what your doing, just say your keeping track of ordering supplies.

[MQ Edna]

Probably better to let this one blow over. If you had the gumption, I would just flat out ask her what irrigation did she use that day since none of the trays there were used, and see what she says. What if she thought maybe there would not be one there, so she brought one in with her?? To make sure he gets his catheter irrigated when you are not there, maybe you can number them, setting one out for use. If anyone asks what your doing, just say your keeping track of ordering supplies.

Yeah, let her explain herself first and give her a good talking to if she can't come up with a good reason. After thinking about it a while, I guess what I said was kind of harsh. I'm just a creature of habit. We have a 0 tolerance policy where I work, which is been ingrained in my mind. I know if I accidentally neglected to do something, I know I would want to be given a second chance.

[RPN_2006]

I think this is a good idea, I'll try it.

[jojotoo, RN]

Probably better to let this one blow over. If you had the gumption, I would just flat out ask her what irrigation did she use that day since none of the trays there were used, and see what she says. What if she thought maybe there would not be one there, so she brought one in with her?? To make sure he gets his catheter irrigated when you are not there, maybe you can number them, setting one out for use. If anyone asks what your doing, just say your keeping track of ordering supplies.

If she is bold enough to lie via false documentation, what's going to keep her from just throwing away an irrigation kit without using it - if she just doesn't want to do the task?

[RPN_2006]

Jojotoo,

A very good point.

So many things in home health frustrate me.

The day following her visit I was able to irrigate, but the next day he was yet again obstructed and I ended up changing cath again ( very painful for him )

He is very old, very fragile and deserves good care. (as do all our patients)

It just makes me sad some of the things I see...I'm no Florence, but I care.

[caliotter3]

Please don't let this situation bring you down. Maintain your high standards. This type of situation is a lot more common than one would imagine, even in home health. You would think that even the lazy could do some level of quality care for one patient. Try to minimize the bad effects on your own morale by compartmentalizing your energy to what you do on your shift and good documentation. If you see that something is not in order, then correct it, and document in a factual manner. When you see a pattern of important matters not attended to or circumstances jeopardizing the client, you might consider documenting your findings in a memorandum to the nursing supervisor/Director of Clinical Services. Good supervisors want to be informed about problems/potential problems; particularly if you can make suggestions to correct the problem.

Unfortunately, you must also be prepared to be labeled a "troublemaker" or non team player if you bring up matters that seem to point out poor performance of your peers, especially, as you say, someone who is respected (or a favorite). Your management team might be lazy, preferring smooth sailing and the status quo.

You need to think about what might happen if negative outcomes come about for the client if you just let something slide by, going with the flow, and keeping your mouth shut. Doesn't your agency have case conferences where patient care issues can be discussed without necessarily pointing fingers? Case conferences can be instrumental in improving patient care and solving problems. Unfortunately, most agencies don't seem to use them at all.

Sometimes you face a difficult decision. Acting in the best interests of the client may benefit you in more ways than one. Or you may find yourself becoming known as the workplace pariah. I always ask myself: "Can my nursing license hold up if I don't report this? What might happen as a result?"

I am not there to make friends with my co-workers by hiding their shortcomings (usually nobody hides mine!), yet on the other hand, I can't change everyone else's behavior and I can only take so much berating for being perfectionistic. I just do my job the way I think it should be done. Somewhere there's got to be an answer in the middle. Likewise, you are not there to see that this other nurse does a good job but you are there to see that the client gets the best care possible. Sorry this was so long, but your post struck a nerve with me and I felt I had to respond. Hang in there.

[jnette, ASN, EMT-I]

Nice post, Caliotter. :)

Well said. Thanx.

[RPN_2006]

Caloitter, thank-you so much for the post. You have really said everything I've been considering on the matter.

I let the first incident slide.

Since the original post I have had another weekend off. Different nurse did coverage. Exact same results as the first time...no supplies used..worked documented as done. I found the patient Monday in pain with a completely obstructed catheter, which I had to replace.

We do have group conferences in our office one weekly. This week I was sure to discuss with all (including the two) that pt X was obstructed again on Monday. I re-iterated how traumatic a cath change is for him (no-one else has replaced his except me) and asked my group for advice on how they thought I might manage to keep his catheter clear of mucous plugs if the daily flushes weren't working. I knew the response from ethical nurses would be to consider twice daily flushes, which I don't believe are necessary at this time, but that I knew the nurses who weren't willing to touch him once would certainly be less happy about seeing him twice on my days off. I hope that this will be enough to change behaviours.

I have been keeping factual documetation on the client in case involving the sup. is required, although I truly hope not to need to.

[NRSKarenRN, BSN, RN]

Others have given you great advice re documentation issues.

What type of foley catheter are you using? If standard latex, I've seen that change to silicone catheter in some patients with renal failure helps decrease sediment....along with taking cranberry capules which help decrease ph crystal and sludge formation.

Anything to help prevent suffering should be done for this patient.

Would CBI irrigation be an option rather than BID visit too....tossing out ideas.

Please address your concerns with supervisior too re weekend staff re same # kits in home + finding patient in pain to CYA.

[vigilants]

hi,caliotter,i really agree on your post.i hve quite similar experience. in the morning, i hve to check blood sugar level to a resident who is for insulin.i found in the tray an insulin syringe with medication on it,we had only one patient on insulin on that time and the dose in the syringe was the same amount of resident's 6pm dose.i checked the MAR sheet, and found out,it was my line manager who was on duty and the last person who gave and signed the last dose.thanks God nothing happened to the resident whole shift.It was difficult for me to asked her for not making her feel being demoralized and the consequences .But i did.