Quote from 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??????
are you very sure that what you think happened is what actually happened? after a serious fall, administration will often review charts and take and copy documentation related to the incident. did you check the chart at any time after you noticed your note was missing? it might have been put back.
by the way, did you happen to mention in your note that you'd done an incident report?
if you saw the don and managers taking charts for review after a fall resulting in fatality, don't be surprised. that was a reportable incident and the facility was required to self-report the event. further, every facility i've worked in has responded to the possibility of ensuing investigation the same way: chart audits.
finally, i've learned over the years that if one coworker tells you something uncomplimentary about your employer, take it with a grain of salt. your don is not required to report every fall to the state, and it would be unfeasible to edit each and every chart note regarding falls. it would also be terribly obvious if the notes were edited.