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?
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
I agree with you. Often patients or their families do things and don't admit it. I have heard many times that "so-and-so didn't do such-and-such" only to have proof that the patient was not telling he truth. Just because the wound dressing appeared different than documented, does not mean anything wrong occurred. I would not offer any complaint forms to the family. They know if they have a complaint they can call the office. If they ask me for a form, then I will produce it. I will make sure, as many others have stated, that my care and my documentation is very professional at all times. I would also mention the patient's comments to the nurse invovled (I always do). It gives her a chance to explain herself or at least be more aware of her care.
I'm concerned that the wound deteriorated significantly because this one dressing was not applied. This does not sound possible if wound care is done daily. If it is not done daily, I would seriously question that a wound only detriorated because of one missed dressing. Lots could happen in-between dressing changes. This is not an incident report. What mistake would you say was made? Also incident reports are for internal use only and are not part of any other record, so not useful for outside agencies. This is not reportable to the BON because you cannot prove or even suggest false documentation. It is very serious business when you go after someone's license, so tread carefully in those waters.
Although wound care is a very serious issue, you are prmiarily responsible for what you do and document. If the wound is getting worse, report it, but for medical reasons rather than reporting on the nurse.
I think many people are missing something important here: the licensure of the home care agency. I worked home care for many years and while it is always POSSIBLE that a patient is self injurious or being non-truthful, why would one assume this is true before believing that another nurse could have made a mistake or covered up one? It is a requirement that any incident such as this (especially when a patient complaint is involved) is reported to management asap and an incident form completed. Next the incident must be investigated thoroughly (again, regulations) by the agency. It will be a sorry day when you advise someone not to report and the patient contacts the state with a complaint. Then the entire agency is in jeopardy (especially if there really were past indiscretions). The state can come in on a complaint survey and examine all of your records, not just that patient's -in fact they never investigate just one patient in an effort to protect their identity (patients fear recriminations). At the very least it will be a very uncomfortable several days for the office staff and at the most the agency could be shut down (of course that is the extreme, but believe me I have seen it happen). it is unfortunate, but the state almost always finds citations when they survey, even of they are unrelated to the patient in question the agency will still have a plan of correction to file.You absolutely cannot approach another nurse with any patient complaint as a "courtesy". If the other nurse did nothing wrong, then he/she has nothing to fear from an investigation that will exonerate them if they are indeed in the right. You on the other hand, are guilty by association-if you do not report you can be held liable as well. I am only attempting to answer the original question-falsifying documentation is prohibited by most state nurse practice acts, and can lead to being reported to the board, a fine and even jail time. If Medicaid or Medicare is involved and documents are found to be falsified, the agency can be fined and placed on conditional probation, or shut down if other violations are present. As a former regional director, I can say that once you have reported to the proper people, you are out of it. You have to trust that they will do their jobs appropriately. if you do not trust them, then perhaps this place of employment is not a good match for you.
What mistake was made???????????????? The nurse did not follow physician's orders! The deterioration of the wound has nothing to do with whether a mistake was made. It has everything to do with consequences of the actions and proving injury should there actually be a lawsuit (assuming it wasn't changed, etc.) And this absolutely is reportable to the board if an investigation (which should occur) shows that the dressing wasn't changed and the documentation that is was changed was falsified. Also, Medicare and Medicaid consider falsification of documentation to be a very serious issue.
What mistake was made???????????????? The nurse did not follow physician's orders! The deterioration of the wound has nothing to do with whether a mistake was made. It has everything to do with consequences of the actions and proving injury should there actually be a lawsuit (assuming it wasn't changed, etc.) And this absolutely is reportable to the board if an investigation (which should occur) shows that the dressing wasn't changed and the documentation that is was changed was falsified. Also, Medicare and Medicaid consider falsification of documentation to be a very serious issue.
We do not know that she didn't do the dressing change or she falsified documentation, especially if she changed dressing on two of the wounds. If everyone that made an error was reported to the board, there would be no nurses anywhere. Since we only have hearsay, what sort of investigation could occur? I would be very curious to know how that would proceed. The OPs continued involvement in this situation could put the agency and the nurse at the end of a lawsuit, OP defending a lawsuit, and the OP losing a job and sabotaged in the nursing community (because there are no secrets). The OPs concerns may be best addressed in a legal thread.
I don't think that the OP mentioned what type of facility this happened in, but it has LTC all over it. Before anyone jumps all over me, I have to say that I am a LTC nurse with many years of experience. There are good and bad facilities.
I have seen this situation occur way too many times. Dressing is signed off as being done, heck there even could be a nurses note written. Dressing wasn't done. If the patient is A and O X 3 and made a complaint about it then it should be investigated.
There are many reasons it might not have been done. We aren't all super nurses and maybe it was a rough shift and there just wasn't time to get it done. Things happen. It is what happens next that is important. In our place, we would initial and circle it and then make a note on the back of the page. Pass it on to the next shift and ask for help getting it done.
I've seen people out right lie about things like this. I followed on nurse that never did BID dressings. It wasn't as if she didn't have the time or wasn't trained on how to do them. I reported it and it was denied. She even went as far as changing the piece of tape with a new date but not the actual dressing. I solved this by signing the inner dressing then applying the guaze and then signing and dating the outer dressing. Point is...it happens.
All you can do is follow your facility's policy for this event. Report it and hope it gets taken care of by the management.
The patient reports a wound that was not addressed, despite their request. You confirmed that the wound was not treated in YOUR documentation.
It is now up to your powers that be to deal with it.
You cannot confirm that the wound was not treated in your documentation because you were not there. Serious legal rammifications for such documentation.
I would say that yes this is falsification of documentation and more than likely failure to follow policy/procedure. As for consequences will depend on the organization. I am one that believes in mentoring and coaching. Has this person received any of this? What is their work ethic like?
It does need to be moved up to leadership though. It is the right thing to do.
We can't tell you what we would do as a manager, no matter how badly you seem to want to hear, "Your manager needs to fire her!"
We aren't there, we don't know the nurse, we don't know you, we don't know the patient.
If you're not the manager, it's really not even your business at this point.
Take care of the patient, and go on with your day.
I have to see this a little differently. While it does sound kind of like the OP wants the offending nurse out of her life, I do think it's a serious matter to not do a dressing if we are supposed to do it and if the pt says the nurse didn't do it. Also, it is her business if the pt c/o to her. OP does not have a right to know what personnel action was taken with the other nurse, which I think is what you were probably saying is not her business.
Too bad the pt didn't refuse to let her wrap him up without doing the third wound. Also too bad the pt didn't call the Agency himself.
this is the reason the whole story from the patient sound Hindu. Sounds like a tattle tale to me. I would never turn any of that in. I would ask the patient to call the manager and explain it to her.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
I have to see this a little differently. While it does sound kind of like the OP wants the offending nurse out of her life, I do think it's a serious matter to not do a dressing if we are supposed to do it and if the pt says the nurse didn't do it. Also, it is her business if the pt c/o to her. OP does not have a right to know what personnel action was taken with the other nurse, which I think is what you were probably saying is not her business.
Too bad the pt didn't refuse to let her wrap him up without doing the third wound. Also too bad the pt didn't call the Agency himself.
Patients lie. They lie to get someone in trouble because they don't like them, they lie because they think it will get them more attention, they lie because they're liars. I'm not saying that all patients lie, but we all know that some do. If the patient says the nurse didn't do it, it could mean that the nurse didn't do it. It could also mean that the patient is lying to derive some perceived benefit or that the nurse did do it but they removed the dressing because they didn't like the way it was done, by accident or because it wasn't done well and was "flapping in the breeze." It could mean that the patient missed the part where the nurse did it because they didn't want to look, because they were shooting the breeze or because they weren't paying attention for some other reason.
When a patient tells you that "the other nurse didn't change the dressing," you assess the wounds and document what you see. You might also document what the patient said. What you do not do is assume that the nurse didn't change the dressing. You document facts, not assumptions or accusations.
The original poster passed the matter to her manager, and it is now between the manager and the other nurse. The OP has absolutely no right to know about potential disciplinary measures between the manager and the other nurse. Those matters are confidential. It is not the OP's business.
Skippingtowork
342 Posts
I agree with you. Often patients or their families do things and don't admit it. I have heard many times that "so-and-so didn't do such-and-such" only to have proof that the patient was not telling he truth. Just because the wound dressing appeared different than documented, does not mean anything wrong occurred. I would not offer any complaint forms to the family. They know if they have a complaint they can call the office. If they ask me for a form, then I will produce it. I will make sure, as many others have stated, that my care and my documentation is very professional at all times. I would also mention the patient's comments to the nurse invovled (I always do). It gives her a chance to explain herself or at least be more aware of her care.
I'm concerned that the wound deteriorated significantly because this one dressing was not applied. This does not sound possible if wound care is done daily. If it is not done daily, I would seriously question that a wound only detriorated because of one missed dressing. Lots could happen in-between dressing changes. This is not an incident report. What mistake would you say was made? Also incident reports are for internal use only and are not part of any other record, so not useful for outside agencies. This is not reportable to the BON because you cannot prove or even suggest false documentation. It is very serious business when you go after someone's license, so tread carefully in those waters.
Although wound care is a very serious issue, you are prmiarily responsible for what you do and document. If the wound is getting worse, report it, but for medical reasons rather than reporting on the nurse.