Falsifying documentation

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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

Since the patient brought it to your attention I would write an incident report and give it to management as well as providing the appropriate care and documenting truthfully.

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Thanks caliotter3, thats exactly what I did.

Since the patient brought it to your attention I would write an incident report and give it to management as well as providing the appropriate care and documenting truthfully.
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Management can't deny an incident report exists like they can an oral report.

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Hi, that's true but for the duration of time I have been there, it seems that dealings with incidents is inadequate and appear to just be brushed under the carpet.

Caught in an ethical and moral dilemna, feels like I dont have any more left in me to advocate for the patients anymore. :scrying:

Management can't deny an incident report exists like they can an oral report.
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Specializes in UR/PA, Hematology/Oncology, Med Surg, Psych.

I might get flamed here, but on the surface, I would not have immediately considered this a serious-type/sentinal mistake. It's certainly not good and could have important ramifications, but it's not like a full Heparin bag run in over 30 minutes or 50 units of Lispro given to a non-diabetic. Not dressing a wound is not the mountain top of horrific nursing actions. Now I would have spoken with the nurse; Why? Because I would want the same courtesy. Does her documentation clearly state that she dressed three wounds or does it just state that she dressed THE foot wounds? Perhaps she was distracted and not focused, which I agree is not a good or proper thing, but we all have made mistakes. Is it possible that it was accidental? You are not privy to all of her employment information that your supervisors are. So yes I would have spoken to the nurse AND I would have informed my supervisors of the patient complaint and my later assessment of the dressings/wounds (which I would document with a fine toothed comb) but that is where I would have dropped it.

And did you hear her yourself state that she didn't want her previous issue hidden from the boss? Or is it just gossip you heard from the other nurse involved?

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Specializes in Cardiac (adult), CC, Peds, MH/Substance.

I make a point of not deciding the seriousness of events, because that's something that will become more apparent over time based on information I do not have at the time of a complaint by a patient. Most agencies have a form for a patient complaint. If a patient complained to me about another nurse, I would offer the patient the form and submit it as appropriate. Because I am hearing from one person about another person's actions, I can't verify what did or did not occur. I can only verify what I see. I would chart what I see, and what my actions were. IE, "Patient found with dressing on wound x and wound y; no dressing present on wound z. Wound x is 3cm x ... etc." I would inform the nurse as a courtesy that the patient has complained and filled out a complaint form. Then I would ask the appropriate manager if they wanted an incident report, or just the patient complaint form. I make a point of distancing myself from being the person to "make the complaint" unless it is appropriate for me to do so (IE, I witnessed something personally and find it ethically/professionally very bad), and become part of the process for facilitating a patient complaint. I find this helps with my relationships with co-workers, and decreases my stress level in dealing with complex situations that I may not fully understand.

I might get flamed here but on the surface, I would not have immediately considered this a [u']serious-type/sentinal[/u] mistake. It's certainly not good and could have important ramifications, but it's not like a full Heparin bag run in over 30 minutes or 50 units of Lispro given to a non-diabetic. Not dressing a wound is not the mountain top of horrific nursing actions. Now I would have spoken with the nurse; Why? Because I would want the same courtesy. Does her documentation clearly state that she dressed three wounds or does it just state that she dressed THE foot wounds? Perhaps she was distracted and not focused, which I agree is not a good or proper thing, but we all have made mistakes. Is it possible that it was accidental? You are not privy to all of her employment information that your supervisors are. So yes I would have spoken to the nurse AND I would have informed my supervisors of the patient complaint and my later assessment of the dressings/wounds (which I would document with a fine toothed comb) but that is where I would have dropped it.

And did you hear her yourself state that she didn't want her previous issue hidden from the boss? Or is it just gossip you heard from the other nurse involved?

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Several things to consider:

1. This is a customer complaint of service and should be reported as such. It is important to report this to your supervisor so it can be handled. It appears this might be a Home Health situation. If so, the nurse-in-question (Nurse #1) would more than likely be taken off the case. Nurse #1 would not be put at risk for further complaints.

2. The supervisor should do the investigation. The follow-up nurse(Nurse #2) is better served to report and let management see where things go from there. To approach Nurse #1 opens Nurse #2 up for possible verbal issues if management chooses to terminate the Nurse #1. The professional way to handle the incident is to report per agency policy.

3. Falsifying charting is a violation of most Nurse Practice Acts. If Nurse #1 felt, in her judgement, that the exterior covering was sufficient and charting reflects minimal care need, than the charting may not be false. It may be the patient wasn't instructed by the nurse of the reason for the minimal dressing change.

On the other hand, if the charting is limited or the wound is worsened by the lack of a dressing, then perhaps the employer has reason to report the nurse to the State Nursing Board and maybe others for patient neglect. There are nurses who don't do their job and often are repeat offenders of poor care.

Bottom Line: Follow your agency/facility policy for reporting patient complaints. Keeps patients and keeps nurses safe.

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Specializes in Nursing Professional Development.
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?

As I have only heard 1 side of the story -- and few details at that -- I can't say for sure what I would do. But I would always listen to all sides of the story before making a decision.

If her earlier incident were truly as bad as you make it sound, I would have fired her if I had sufficient evidence to survive a court challenge. If I didn't have sufficient evidence, I would have put her on whatever level of "corrective action" I could justify. But as I have not heard her side of the story or seen any evidence, I can't say what I would do. What was her side of the story? What hard evidence did the management have?

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Hi,

The wound deteriorated significantly after the incident, each wound has its own form to complete and she had marked and signed them all as being complete. She also documented on the computer as having done all 3. She even came up to me later and said she put all 3 dressings on, 'maybe the other one fell off'. There was no chance that was possible as his foot was wrapped in pads, webril, crepe then tubifast. All of those were firmly intact when I arrived the next visit.

Several things to consider:

1. This is a customer complaint of service and should be reported as such. It is important to report this to your supervisor so it can be handled. It appears this might be a Home Health situation. If so, the nurse-in-question (Nurse #1) would more than likely be taken off the case. Nurse #1 would not be put at risk for further complaints.

2. The supervisor should do the investigation. The follow-up nurse(Nurse #2) is better served to report and let management see where things go from there. To approach Nurse #1 opens Nurse #2 up for possible verbal issues if management chooses to terminate the Nurse #1. The professional way to handle the incident is to report per agency policy.

3. Falsifying charting is a violation of most Nurse Practice Acts. If Nurse #1 felt, in her judgement, that the exterior covering was sufficient and charting reflects minimal care need, than the charting may not be false. It may be the patient wasn't instructed by the nurse of the reason for the minimal dressing change.

On the other hand, if the charting is limited or the wound is worsened by the lack of a dressing, then perhaps the employer has reason to report the nurse to the State Nursing Board and maybe others for patient neglect. There are nurses who don't do their job and often are repeat offenders of poor care.

Bottom Line: Follow your agency/facility policy for reporting patient complaints. Keeps patients and keeps nurses safe.

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She said that she did do all 3 dressings. Management did not even bother to contact the patient as the regule manager was away at the time. I was told to tell the patient next time I saw them that the nurse would not visit again, and the nurse was told not to visit them again and that was how my workplace dealt with the incident.

As I have only heard 1 side of the story -- and few details at that -- I can't say for sure what I would do. But I would always listen to all sides of the story before making a decision.

If her earlier incident were truly as bad as you make it sound, I would have fired her if I had sufficient evidence to survive a court challenge. If I didn't have sufficient evidence, I would have put her on whatever level of "corrective action" I could justify. But as I have not heard her side of the story or seen any evidence, I can't say what I would do. What was her side of the story? What hard evidence did the management have?

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Hey, OP.

Ever thought that maybe, just maybe, the patient or the wife removed the dressing?

Yuck. One of the dangers of bedside nursing - patient does something stu..."questionable" and then tries to pass the buck to the nurse :sniff:

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Specializes in Nursing Professional Development.
She said that she did do all 3 dressings. Management did not even bother to contact the patient as the regule manager was away at the time. I was told to tell the patient next time I saw them that the nurse would not visit again, and the nurse was told not to visit them again and that was how my workplace dealt with the incident.

As I said in my earlier post ... that's not a bad outcome. The management had no hard evidence to go on. It was just your word against the other person's word in this case.

In her previous incident, I have no idea how much evidence the management had.

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