Falsifying documentation

[jigi888]

Hi,

A patient of mine whom has multiple foot wounds whom I see for wound dressings made a complaint to me that one of the previous nurses had attended 2 out of the 3 wounds on his foot only. The nurse was bandaging up his foot and when the patient realised that she had missed the other wound, pointed it out to her. She continued to bandage up the foot and did not attempt to dress the remaining wound. The nurse then documented that she had attended all of the dressings and left.

When I went in for the next visit, the patient advised me of this, I took the bandaging off and there was indeed no dressing on the wound in question.

Is this considered falsification of documentation and what would the consequences be?

Thanks

[roser13, ASN, RN]

Of course it's falsification of documentation and I wouldn't worry about the consequences. Report it before you somehow become involved due to inaction on your part.

If Medicare is involved, then the charges get way more serious for your facility.

[taivin]

You need to talk to the nurse first...before talking to management...

It's called simple courtesy and it's protocol in many places. Are you going to go run to management every time you see something or hear something amiss? Sounds like you're going to be in the manager's office a lot.

[jigi888]

The reason which I didnt directly approach the nurse first about this issue is because there is a history of her being dishonest and trying to cover things up in the past.

If you were in this situation, what would you do?

You need to talk to the nurse first...before talking to management...

It's called simple courtesy and it's protocol in many places. Are you going to go run to management every time you see something or hear something amiss? Sounds like you're going to be in the manager's office a lot.

[Sour Lemon]

The reason which I didnt directly approach the nurse first about this issue is because there is a history of her being dishonest and trying to cover things up in the past.

If you were in this situation, what would you do?

For me, it would depend on the exact history and whether or not I had personal involvement. If I'd "heard" things, but not experienced them, I'd still talk to her. If I'd experienced things and talked to her about similar issues multiple times in the past, then I might consider handling it another way.

[AliNajaCat]

Make sure your documentation is good.

"Left foot Kerlix wrap removed, medial malleolus Telfa dry and intact; lateral malleolus Telfa saturated with serous drainage; no dressing on hallux, serous drainage about 3cm in diameter on Kerlix. All three wounds cleansed c NS, redressed with Telfa reinforced c sterile 2x2s, wrapped with Kerlix, labeled with (date and time)."

[jigi888]

I have reported it and the nurse denied it, and it appears that management has done nothing except to tell the nurse no longer sees that specific patient.

This particular nurse also has a history of trying to cover up a serious incident in the past.

Of course it's falsification of documentation and I wouldn't worry about the consequences. Report it before you somehow become involved due to inaction on your part.

If Medicare is involved, then the charges get way more serious for your facility.

[llg, PhD, RN]

That's actually not a terrible outcome. The management is not letting her see that patient: that specific patient will get better care. If there are repeated problems, the management will eventually have to take more serious action. You might want them to take more serious action now, but it usually takes a few things like this to get someone fired -- unless there is some big bad patient outcome or charge they have to deal with.

[jigi888]

Hi llg, just wanting to pick your brain as you have had loads of experience in the field.

Have you had previous management experience as that is not my forte.

If you have, what would your action be in regards to the above nurse, also knowing that there was a prior incident in which she attended to a procedure which she was not accredited to do, and she knew she was not meant to do, resulting in harm to the patient and also tried to get another nurse who picked up the incident to try and cover up for her?

[jigi888]

Hi Sour Lemon,

Yes I was involved and the incident was in regards to the nurse attending a procedure she knew she should not do, and had not been signed off to do resulting in harm to the patient. She also then tried to cover up the incident by asking the nurse who picked it up initially to not tell management.

What would you have done in this situation?

For me, it would depend on the exact history and whether or not I had personal involvement. If I'd "heard" things, but not experienced them, I'd still talk to her. If I'd experienced things and talked to her about similar issues multiple times in the past, then I might consider handling it another way.

[roser13, ASN, RN]

You need to talk to the nurse first...before talking to management...

It's called simple courtesy and it's protocol in many places. Are you going to go run to management every time you see something or hear something amiss? Sounds like you're going to be in the manager's office a lot.

Any facility I've ever worked for had protocol requiring simultaneous reports to facility/risk management and notification to the involved nurse. Particularly in this situation, where the patient is presumably A&O and OP's findings correlate with the patient's complaint, documentation must happen. When this A&O patient and his family make a report to the state about inadequate wound care and lack of follow-up, the fact that Mary told Suzy that she skipped a wound will mean absolutely nothing.

[jigi888]

Patient is A&O - wife was also present and witnessed it all.

Also, when people mention that I need to talk to the nurse first, can they give me an example of what they would say?

In my head, due to the seriousness of the issue, I believe that this is not in my scope to deal with. The only thing I could think of saying the nurse is 'Why did you falsify the documentation' which is not appropriate for me to say.

If others suggest that I try to ask questions to investigate the issue, once again, that is not in my scope of practice to do, but rather managements.

I could say to her that 'Patient x made complaint that you did not do x dressing' but due to the past history this would give her an excuse to make up prior to management approaching her.

Your suggestions are all welcome and helpful to give me other perspectives/points of views on the matter.

Also roser13 - I absolutely agree with you. Also of note, the wound deteriorated significantly after the event.

Any facility I've ever worked for had protocol requiring simultaneous report to facility/risk management and notification to the involved nurse. Particularly in this situation, where the patient is presumably A&O and OP's findings correlate with the patient's complaint, documentation must happen. When this A&O patient and his family make a report to the state about inadequate wound care and lack of follow-up, the fact that Mary told Suzy that she skipped a wound will mean absolutely nothing.