Blatant false documentation

  1. Hi all!

    A situation arose at work where documentation was changed two weeks after the fact to indicate a doc had assessed a pt in an emergent situation. The pt was never assessed by the doc. I then find out it was changed at the direction of the dept manager. I have gone to the dept managers boss and compliance. It's been 3 months and nothing has happened!? I feel like I need to resign and/or go further up the chain of command. Does it typically take that long for an investigation?

    Thanks,

    Elpeon
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  2. Visit Elpeon75 profile page

    About Elpeon75

    Joined: May '18; Posts: 5; Likes: 6
    from AL , US

    16 Comments

  3. by   caliotter3
    Tread lightly. None of us know the situation at your place of employment, but it might not be a bad idea for you to brush off your resume and let your references know that you will be looking and they might expect to be contacted.
  4. by   Elpeon75
    I am, but I also want to be assured I've done my due diligence. I think I've notified the proper people.
  5. by   Davey Do
    Yeah, Elpeon, three months is way outside of the timeline. In my experience, it should be one week with internal entities and two weeks to a month with outside entities.

    For example, administration replied to my concern within the week. Public Health, OSHA, and Joint Commission all replied in about two weeks to a month.

    Nothing was ever done about my concerns and all I got was just a bunch of rama lama ding dong, but I acted on what I felt and believed were true patient safety concerns. Eventually, the problem resolved in and of itself, within the two week time period, so my complaint was unfounded at the time of the outside entities' investigation.

    Now, regarding the resigning issue, that's totally up to you. If you feel as though you cannot work with this institution as a result of this situation, so be it. However, in my experience, every place I've been employed has manipulated its media to achieve a desired effect and has skeletons in its closets.

    I possess and maintain a wealth of documentation over numerous situations that have and have never been resolved in the institution where I am employed. This documentation proves I've acted prudently. None of the situations have ever resulted in a sentinel event, so I do my job and move on.

    I'm not about to throw the baby out with the bath water.

    Good luck, the best to you, and welcome to AN.com, Elpeon!
  6. by   Meriwhen
    Quote from Elpeon75
    I am, but I also want to be assured I've done my due diligence. I think I've notified the proper people.
    Keep in mind that though you notified the proper people, they may not keep you posted on the progress and outcome. That's how it usually works: they do it in the interest of privacy for all concerned.
  7. by   Have Nurse
    If it were me, I'd report the doc to the states' Board of Medicine. I agree though with our colleagues. You might want to consider moving on. Just make sure you've documented well.

    The Dept Manager isn't the only one culpable if what you state is true. The doc should know better. Good for you though!
  8. by   LovingLife123
    How on earth did you discover this? I would never be allowed to access a patients chart 2 weeks later.
  9. by   Elpeon75
    The charts are audited routinely.
  10. by   Davey Do
    Quote from Elpeon75
    The pt was never assessed by the doc.
    I dealt with a similar situation over a year ago. In their notes, a doctor dictated that they had assessed the patient and had not even seen or talked with the patient. I proved it in an objective narrative, informed administration and Medicare and nothing ever came of it
    Quote from Davey Do
    I possess and maintain a wealth of documentation over numerous situations that have and have never been resolved in the institution where I am employed. This documentation proves I've acted prudently. None of the situations have ever resulted in a sentinel event, so I do my job and move on.
    No harm ever came to the patient as the patient's area of medical concerns were addressed by an NP.

    Sure, it's fraud to bill for services that are never rendered. But once we have informed those who possess the power to do something about it and don't, well then, it's out of our hands.

    Had harm come to the patient, I would have acted as that patient's advocate and pursued the matter to the Nth degree in order to get set right what's right.

    It's like one Medicare investigator informed me: "The government doesn't care about a few hundred dollars of fraud- they want to go after the big fish- the ones who are billing for hundreds of thousands or millions of dollars and not providing services. So if you learn about any of those big fish, let me know."

    I don't like it, it's wrong, but once I've done all I can do...
    Quote from Davey Do
    I do my job and move on.

    I'm not about to throw the baby out with the bath water.
  11. by   Davey Do
    Elpeon, here's found a post which I had made some time ago that mentions the subject at hand:
    Quote from Davey Do
    A little over a year ago, I experienced several different situations where a doctor, security guards, an agency nurse, and a tech were involved in inappropriate actions involving patients. These included, respectively, possible Medicare fraud, not following policy and procedure, patient neglect/abuse, and insubordination.

    I objectively documented each specific situation, informing both the unit supervisor and department head. These areas of concern were documented with the appropriate administrative staff informed, but were never acknowledged nor addressed.

    I was called to HR sometime later, after working three 12 hour MN shifts, to meet with the HR head and the department head to be written up for my inadvertent failure to complete a redundant, superfluous form.

    I exploded internally but overtly acted appropriately bringing up the incidents where I believed a doctor was guilty of Medicare fraud, security guards failed to follow policy and procedure during a chemical restraint, an agency nurse was guilty of neglect/abuse, and a tech had been insubordinate. I noted that these hideous acts were never addressed, but I was being written up for failure to complete a redundantly superfluous piece of paperwork!

    I said that I felt harassed and the HR head interrupted and challenged my statement. I replied with, "Show me the same respect that I have shown you- do not interrupt me or challenge my feelings! If I 'feel' I'm being harassed, then I feel I'm being harassed!"

    I informed the HR head that I wanted to file a grievance against the department head for harassment and the HR head apologized for her statement and immediately left to locate the necessary grievance forms.

    While I sat there with the department head, I said to her, "I am sorry it had to come to this. I've known you for over 20 years and worked under you for 14 of those years". I brought up past acts of transgression and ended the one sided conversation with, "I am so disappointed in you!" The department head sat there, red faced and teary eyed.

    Suffice it to say that the grievance was never followed through. I've informed appropriate outside entities of these areas of concern and have received in reply what I term as "Rama lama ding dong".

    I have done my duty, objectively informing appropriate individuals and agencies of perceived areas of concern to little or no avail. I have not spoken to, or communicated with, the department head or head of HR in over a year.

    Now I just have to let it go. But I won't forget it.
  12. by   LovingLife123
    Quote from Elpeon75
    The charts are audited routinely.
    So you audit your own charts? I'm sure there is so much more to this but that is only privy to you. We audit nursing charts, not physicians.

    You must decide how far you want to take it and be ready to either be the odd person out or potentially lose your job.
  13. by   Elpeon75
    The physician component is included in the nurses notes. It can't be missed. If they want to fire me over an internal audit that uncovered a false documentation issue that involved the doc, the director and a nurse to cover up a potential pt safety issue, so be it. I will sleep better at night knowing I did everything possible so that I am not culpable. I have heard of nurses turning a blind eye and then being punished with jail time because they knew and did nothing. I have gone as far as I'm going to go with it. I was just asking if an internal investigation takes so long. IMO that nurse should have been let go.
  14. by   Jory
    Quote from Elpeon75
    Hi all!

    A situation arose at work where documentation was changed two weeks after the fact to indicate a doc had assessed a pt in an emergent situation. The pt was never assessed by the doc. I then find out it was changed at the direction of the dept manager. I have gone to the dept managers boss and compliance. It's been 3 months and nothing has happened!? I feel like I need to resign and/or go further up the chain of command. Does it typically take that long for an investigation?

    Thanks,

    Elpeon
    I'm confused was it YOUR documentation that was changed? If that is the case you need to go up the ladder NOW and no, do not resign. You are legally responsible for what is documented under your name by you and if this was changed, you need to go to the highest level of management including your risk management officer.

    Very, very illegal and if you resigned and something happened to that patient? The false documentation is the leg you'll be standing on.

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