Paper trail?

Nurses General Nursing

Published

Specializes in CV Surgical, ICU.

I work with an aide who is very lazy, always trying to skip/pawn off her duties on others (showers feeds etc). Lately she has been getting worse, and today really took the cake. Lets call her "Gwen". I work in an LTC facility. Apart from the many ways this aide has attempted to avoid work I'll just get down to the worst offense today. I work 7-3. Near the end of the shift (2:40 PM) another aide approached me saying they saw "Gwen" downstairs chatting away with the activity staff. The aide had already taken their break at 1:00PM, so they weren't on break. We were short staffed today which means she only left 4 of us on the unit when at the very worst there should be 5. Me and the other aide went to make sure that "Gwen's" residents were dry. We found one of them soaking wet and fecally incontinent. When told we would help to clean her she stated "I've been needing that." This implyed (along with the color and smell of the urine) that she had been that way for a while. Definitely more than 2 hours, I would venture to say more than 6. We cleaned her up but made it a point NOT to mention it to "Gwen". He did not return to the patient's room for the remainder of the shift. And I believe "Gwen" had no intention of changing this patient AT ALL! :angryfire

I reported this to my weekend supervisor but intend to mention it to the supervisory staff on monday. There has been trouble with "Gwen" in the past. And I personally feel this aide is not doing an adequate job and being left to work in our facility is not only a nuisance but I feel if he is left to continue down this road he will only get worse, and possibly dangerous! so on to my question..

I've heard a little about a "paper trail" but I'd like to know more about it.

What is a paper trail, exactly? Does it hold up when it's one aide's word v.s. another's?

Would writing my account of this event on a notebook, signing and dating it be sufficient?

Do any of you think that this event is grounds enough for me to go right to the ADON/DON on monday?

Is there anything else I can do to help have action taken against this aide?

Do you think this event would be grounds for discipline? Or do you think she'll just be slapped on the wrist?

Sorry for all the questions! Thanks for reading guys :heartbeat:)

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IMO you should be open with "Gwen" not just suspect. The paper trail would simply say in this instance that you were told he was not on the floor (though I didn't read if you asked so can only assume he was on break for now), that one of his patients needed cleaning up and appeared as if had needed it for awhile (though he can say the patient wasn't like that on his rounds), and since you didn't tell him about it or ask there is not much else to the report. I would suggest first communicating with him. Ask where he was, let him know his patient was cleaned up and ask when he had checked on the patient. I guess what I am saying is there should be no "implying", or no "guessing". The information you write should be as factual as you can make it on what you are told by the patient, and the other CNA's or will look like you have a personal problem with the CNA. Good luck and hopefully just the communication alone will help him straighten up and take care of his patients better!

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Specializes in CV Surgical, ICU.

It was 2:40 PM, the aide had already taken their break at 1:00. But I'll specify that in the OP. I've tried talking to this aide before about things and I only really get blank stares and a lot of sarcasm.

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I've tried talking to this aide before about things and I only really get blank stares and a lot of sarcasm.

That seems like something to add to your report also showing you have tried and it hasn't helped. I would think management would like to know what people have done to work as a team. Possibly even going to talk to them first?

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Specializes in CV Surgical, ICU.
That seems like something to add to your report also showing you have tried and it hasn't helped. I would think management would like to know what people have done to work as a team. Possibly even going to talk to them first?

So should i add it to this report? Or just make it a point to mention it when I give it to the Sup?

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If you talked to him this time and his attitude was like that I would say yes.....a report IMO is one instance. A paper trail is keeping track of all instances separately being as factual as possible. Possibly you will get more advise however from others. I haven't kept a paper trail myself managing to solve the problem with talking to my supervisor and the person in question.

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Specializes in med-surg.

In the following reply I have not read the others so I may be repeating what others have said. In my experience with this matter it depends on your managment. Would your management be willing to let an employee go when you all are already short? To your question about the notebook i would definitely do that. Write the facts of Gwens actions and the date.No opinions just the facts. Also, if there are any other aids that are willing to back you that is even better. The "my word against yours" scenerio is always complicated without evidence.Evidence being your written documents of day to day occurances or another persons testimony to back what you say.I commend you for caring enough to do something about this and i hope your DON will back you as well.:nurse:

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I've heard a little about a "paper trail" but I'd like to know more about it.

What is a paper trail, exactly?

Sorry for all the questions! Thanks for reading guys :heartbeat:)

A paper trail just means properly documenting EVERYTHING. Whatever incident reports your facility has, fill them out and keep copies. Make sure that what you write down is descriptive, not evaluative--for the patient you mentioned, say "2:40 pm, resident found with urine and stool in brief. brief was soaked all the way through. this staff changed resident's brief and provided peri care. resident stated 'I've been needing that'." If the resident told you how long it had been since they were last toileted/changed, include that as well but write 'resident stated' to indicate that you're not just assuming it had been 2 hours or whatever. If you had to change the bed linens, say so. Ask others at the facility to fill out reports about things they have seen, so it's not perceived as you being out to get 'Gwen'. Having a wet brief on for hours at a time puts the resident at risk for pressure sores, which I'm guessing your facility does not want to happen. Good luck, and keep us posted.

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A paper trail just means properly documenting EVERYTHING. Whatever incident reports your facility has, fill them out and keep copies. Make sure that what you write down is descriptive, not evaluative--for the patient you mentioned, say "2:40 pm, resident found with urine and stool in brief. brief was soaked all the way through. this staff changed resident's brief and provided peri care. resident stated 'I've been needing that'." If the resident told you how long it had been since they were last toileted/changed, include that as well but write 'resident stated' to indicate that you're not just assuming it had been 2 hours or whatever. If you had to change the bed linens, say so. Ask others at the facility to fill out reports about things they have seen, so it's not perceived as you being out to get 'Gwen'. Having a wet brief on for hours at a time puts the resident at risk for pressure sores, which I'm guessing your facility does not want to happen. Good luck, and keep us posted.

And don't forget to make copies for yourself. I consider this to be the 11th Commandment. JMHO, and my NY $0.02.

Lindarn, RN, BSN, CCRN.

Spokane, Washington

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