Falsifying Documentation

[scorpiaRN]

Has anyone ever been asked to falsify documentation? I had never experienced this until my current job. JC was due to visit and the powers that be were present and concerned for the patients?... My Nurse Manager called me on the phone at home one morning and stated that the PCA had documented 4 side rails were up on a patient's bed two nights before on the 7a-7p shift and the 7p-7a shift. Therefore, we needed a restraint order, which we did not have. I worked the 7p-7a shift. She stated that she had backtracked and created a restraint order along with the other necessary paperwork. She then asked me if she could sign my name to the paperwork. I agreed, as did the RN on the 7a-7p shift. I don't know what I was thinking! And sadly, I was so busy that I did not realize that there were 4 side rails up. I am ashamed. A week later, JC still not there , I had a patient with 4 side rails up (and documented) as per family request with no restraint order when I came on shift. I called my Nurse Manager and told her about the situation. She stated that "Nobody can be in restraints now, do not try to call the doctor this late at night for a restraint order" and asked me to change the documentation from 4 side rails up to 3 side rails up. I refused. She then said she would do it herself. I am running as fast as I can from this job.

[PacesFerryBSN]

"Run as fast as you can" sounds like a good idea.

[squatmunkie_RN]

Next time as you're putting a side rail down say to the family we cannot have all four up as that counts as restraints. Then document what you did and if the family puts it back up document that too.

This NM will burn you when all this is found out. If worse comes to it she'd fire you in a minute. Hate working with NM like that. Shame on her for doing that.

[xoemmylouox, ASN, RN]

Uhhhhh. Get out ASAP.

[psu_213, BSN, RN]

Someone beat me to it, but I was going to say that family request is not enough to justify use of a restraint.

I agree that this is not a NM that you want to be your boss...

[Scorpia1027]

Next time as you're putting a side rail down say to the family we cannot have all four up as that counts as restraints. Then document what you did and if the family puts it back up document that too.

This NM will burn you when all this is found out. If worse comes to it she'd fire you in a minute. Hate working with NM like that. Shame on her for doing that.

I am somewhate confused about this reply. In the end, the Nurse Manager falsified documentation including a physician's order, and I refused to change another health care provider's documentation (conversation over heard by two other RNs). She can try to burn me or fire me, but although not on the floor, she still has a license to uphold. I have actually considered reporting her to the OBN.

[Ntheboat2]

I am somewhate confused about this reply. In the end, the Nurse Manager falsified documentation including a physician's order, and I refused to change another health care provider's documentation (conversation over heard by two other RNs). She can try to burn me or fire me, but although not on the floor, she still has a license to uphold. I have actually considered reporting her to the OBN.

That reply you are confused about was probably referring to this comment by you:

"She stated that she had backtracked and created a restraint order along with the other necessary paperwork. She then asked me if she could sign my name to the paperwork. I agreed"

If you hadn't agreed to let her falsify documentation with your name then you might consider reporting her. However, since you did agree to let her sign your name...you might want to take it as a lesson learned and not report it. If she goes down, she will take you down with her.

[ashleyisawesome, BSN, RN]

related question: if the patient requests all 4 side rails are up, would you still need a restraint order? i usually just oblige, and chart all 4 side rails up per patient request..

[Scorpia1027]

I definitely have taken this as a lesson learned, which is why I refused to personally alter someone else's documentation on another patient afterward (which she did), Also, she signed my name as per a phone conversation (not documented). Unless this was recorded, she has no proof that I obliged. At the time, I did not realize all of the documentation that she was planning to forge, including a physician's order...lesson learned. I would not report her, just angry when I posted, like her as a person, and feel that she is treading on very dangerous ground...because she will do this again in the future, and I will be no part of it. Leaving ASAP. Ironically, she also has a JD degree.

[Scorpia1027]

related question: if the patient requests all 4 side rails are up, would you still need a restraint order? i usually just oblige, and chart all 4 side rails up per patient request..

Good question, sounds simple but not. In all facilities that I have worked, 4 side rails up, even per patient request, requires a restraint order. Is this per facility policy or law? Can never get a straight answer. Would like to know myself.