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.
