is this legal?

[Ms.RN]

i work in ltc facility and one day my resident had a fall and hit her head and had to be sent to the hospital for sutures. i charted everything in her chart about the fall and notification of physician, family and neuro checks. obviously i filled out an incident report. i worked the next day and i checked nurses note and to my surprise a nurses note i charted on about her fall was gone!! few monthes after another resident had a fall and ended up sending to the hospital and patient ended up dying few days later and we were reported to the department of health. so we are expecting state surveyors to come to our facility any time soon to investigate. i watched all the unit managers and don take charts of patients to the conference room and they were looking at nurses note. one of the person i work with told me that whenever patient falls don doesnt report it to the state and edits the nurses note. is this legal??????

[CapeCodMermaid, RN]

We never write that we've done an incident report. It's supposed to be an internal tool but if you put it in the nurses' notes, if the chart goes to court, the other side's attorney can get a copy of the IR.

Not every fall requires a report to the DPH. Charts are often reviewed after a serious incident. But, certainly, if you can prove your note was taken out of the chart, I'd call someone at the corporate level.

[pennyaline]

At my job, we were specifically told not to write "incident report filed" because incident reports are not part of the chart.

and

--incident reports are for the facility's use only, for tracking and quality improvement.

and

We never write that we've done an incident report. It's supposed to be an internal tool but if you put it in the nurses' notes, if the chart goes to court, the other side's attorney can get a copy of the IR.

Which is exactly why I asked the OP if she had by any chance mentioned the incident report in her chart note.