Fictional vital sign charting

[Rabid Response]

Today, as part of my rapid response rounding, I spent an hour at the bedside of a patient who was having respiratory issues secondary to TB and exacerbated by CHF. The whole time I was there, the patient's O2 sat never exceeded 89% despite his being on Hi Flo NC at 100% FIO2 and 30L/min. I had a lovely argument via telephone with the brand new intern who claimed that putting patient on NRB would violate the patient's wife's wishes that he be a partial code and basically disallowed everything except for pressors in the event of a code. (The patient and his wife had no idea that they had apparently signed away their rights to an O2 mask!).

In any case, the doc at one point said, "I just checked his chart, and he looks like he's doing okay.". HUH??? I walked to the nearest computer cart and opened the patient's chart. Sure enough someone had charted the patient's vital signs as O2 sat of 94% on 50% FIO2--ten minutes ago! Up and down the halls I roamed searching for the person who had charted these vitals. The hour I spent in that room, not one other person had come in to take vitals or assess the patient. Apparently it was the CNA. CNAs are responsible for getting vitals on the patients on our med-surg floors. Unfortunately this is not the first time I have found the charted vitals to be completely divorced from reality. Every med-surg patient has a respiratory rate of 18 or 20 for some reason, and nobody's O2 sat is ever below 90 unless the patient is busy for some other reason (diarrhea for instance) and the floor nurses want her/him transferred to a higher level of care. I have noticed that assessments and vitals are especially fictional if the patient, like this one, is on isolation precautions.

I could not find the CNA, but the RN for the patient assured me that the charting must have been a mistake. She thought that the CNA must have charted another patient's vital signs in this patient's chart. I decided not to make a stink about it so as to maintain good relations with the staff on that med-surg floor, but the more I think about it the more I feel that the CNA made up those vital signs just so he wouldn't have to enter the room; the values were much too similar to what the vitals had been 4 hours previously.

What do you think? What would you do? Find the CNA and question him (he pretty much disappeared after that!)? Fill out an incident report. Contact the manager for that floor? I did put a note in the chart stating that I had been at bedside during the time the vitals signs were alleged to have been taken and charted the actual O2 sats and FIO2 on top of the erroneous values.

[misswhitney]

Umm I would have gone straight to my manager and wrote an incident report. Not only is this person falsifying a legal document (that ultimately falls back on the nurse), but they are putting lives in their own hands.

[Leelee2]

Wow. That is falsification of records. Do you have a Risk manager in the facility? At the least, I would contact the Nurse Manager and report this.

Unacceptable and dangerous.

[WDM08002]

I can't even count how many times I've witnessed RNs, LPNs, and CNAs all writing in vital signs that they didn't take. Often they just use the previous set of vital signs and maybe change a few numbers.

[Thedreamer]

Ive had this happen to me a few times. Once on a patient who was charted as 120/80 at @0900 when I was in the room at 0910 taking a vital of 190/100. This happened a FEW times with this particular CNA. I went through the chain of command with this particular CNA but due to the units "politics" nothing was ever done and it was always deemed "an accident." Needless to say, I transferred off the unit and took every single vital myself when assigned this particular CNA until that transfer.

[Thedreamer]

I had a whole post I wrote but it ended up being a rant. I thought it best not to post it and instead say that I have seen a lot of unethical nursing so far in my few years of working. All I can really say is that we can do our best on our shifts and pray that others do the same for our patients.

[CVmursenary]

No point in falsifying vitals when it is your most important job as a cna. I myself go with the 16,18, 20, 22, 26 etc respirations, i dont always count them but i am very good at visualizing quickly.

[KayRN910]

I have seen that a LOT, even in the ER (which is even more dangerous because it's the very first set of vitals people get!)

But, even worse than that.... a hospital across town stopped allowing CNA's to do blood sugars a few years ago... because they were charting FICTIONAL BLOOD SUGARS! Eeeekkkk!!!! I can't imagine how many people were over/under dosed of insulin because they were on a sliding scale!!

*shiver* I get fired up every time I think about it!

[Pepper The Cat, BSN, RN]

The only thing that comes to my mind is perhaps a nurse just selected the wrong chart?

I know that if I type "Jones" into the search area, all pts with the names of "jones" will come up. It can be very easy to select "John Jones" instead of "Jane Johns"

I had admissions actually discharge my pt as "dead" once. was a big surprise to me when I typed in their name and it came up with "death stars" as we call it next to the name. I had to argue with them for over 5 minutes that my pt was very much alive and breathing and they had selected the wrong pt and needed to correct it ASAP!

[joanna73, BSN, RN]

What do you mean you don't always count respirations? Are you saying you're guessing? Visualizing is not the same....

[MKS8806]

I would say this needs to written up via an incident report and by letting your manager and risk manager know. Then I would find the CNA and tell them the vital signs were not entered correctly and they need to be corrected immediately.

[anotherone, BSN, RN]

The 18-20 respirations.min phenomenon annoys me. I dont think anyone has fictionalized vitals on patients where I work.I hope not!!!!!! We deal with low bps, high bps, low hr, high hr, low O2 levels ALL THE TIME. and i always page about it if need be or do something, prn meds etc........ Why make it up? I don't get it? to avoid more work? Better to catch a 86% on ra O2 level than waltz in there an hour later and you are calling a code..................Why would the cnas make them up, if they don't have to deal with any of it, aside from informing the nurse? VItals are a MAJOR source behind the direction of care the drs chose. How scary!!!!!!!!!!!!!!!!!!!!