Got citation on my documentation by department of health surveyor...;(



I'm a new grad nurse who just started with a home health agency about a month ago.

A few days ago, my agency called me really late at night to tell me that I need to come in right now or early in the next morning to complete my paperwork cuz department of health was gonna come next day for a survey.

I completed most of the paperwork as they told me (which they didn't orient me on) but they told me today that they got a citation on one of my patient whom I recently recertified.

They said surveyors pointed out I didn't make a thorough assessment according to OASIS especially about pain...

Apparently when they went to see Pt at home she had some pain...but on my OASIS, I put she doesnt have any pain cuz she didn't when I was there...

My agency didn't tell me much about the citation in detail but told me to be more thorough with my documentation...and also said it's part of my experience.

But I'm so scared right now because they said the surveyors took a copy of my recert OASIS to compare with their assessment and see if there's anymore discrepancies...

I reviewed the chart again to make sure if I did everything else complete and except for the very last page (summary page to send to MD), everything is complete and matching.

My agency told me not to worry as long as I didn't cause any harm or med errors which I checked and seemed fine but I can't stop worrying...because one of the staff told me they might suspend my license if I did make such mistake...;(

I'm just trying to think positive and forget about it but I can't stop worrying...I feel so incompetent as a nurse...

Does anybody else have experience like me? Please share...


1,246 Posts

Has 36 years experience.

No one is going to suspend your license for a discrepency in an Oasis. If I could, I would personally come to wherever you are and slap that nurse for handing you that line of bull$hit. Truly. I simply don't understand why people do those things.

If the pt stated that she has no pain at the time of your collection, well, she had no pain. The question might lie in whether she was taking pain meds and if they were effective. There may be a slight difference in no pain and pain is controlled w/current meds.

Please let your agency handle this, and calm yourself.

And trip that idiot the next time she walks past you.


20 Posts

Thanks merlee!!!

You don't know how much your reply helps my troubled mind...

My ultimate goal is to get a job in hospital like any other new grad nurses and I don't want to add another problem on top of my lack of nursing

And that person who told me that is not a nurse...she's one of office staffs...I asked her what does usually happen if you get a citation and she told me that...I guess she was telling me the worst scenario so I don't make any more documentation errors...? :uhoh21:

But I've learned that I should definitely work on my assessment skills and documentation. Thanks for your reply:redbeathe


38,333 Posts

You are too new to all of this for you to expect perfection from yourself. As for the assessment, it is your assessment. What you observed at the time and how you interpreted your findings. Unless something grossly out of whack, they can not fault you for what you assessed at that point in time. If her temp was ....., it was ...... If she stated she had no pain, then she had no pain. You should have more input about expectations from your boss as time goes on so you will feel more comfortable with what you are supposed to be putting on that document. The surveyor is not there every day, so they won't be able to fault you on your every day job. I would take my cues from your immediate clinical boss if I were you, and don't worry about what the surveyor focused on for this one shot.


849 Posts

Specializes in Home Health.

Don't lose any sleep over it. When you assess a patient for pain, there may be no pain in that moment. There was a real good article on pain at Medscape that taught me quite a bit (wish I could remember the title), but anyway, it discussed problems with pain assessment in that when that question is asked patient response is for that time only. Further the article explained how pain should be globally assessed, i.e., Do you have any pain while in bed, upon awakening, when rising out of bed or standing from a seated position, etc . You'd be surprised how specific we need to be when assessing pain. My patients often respond 'no' when I ask if they have any pain and then when I ask more specifically there is pain with certain activities. There is another good article at Medscape that discusses the increased rate and risk of falls with pain as a causative factor - it make a good point for teaching that I frequently use. Good Luck to you, you'll do great!


20 Posts

Thanks Isabelle49

Like you said, globally assessing pain was what they wanted. I didn't ask those additional questions like 'do you ever experience pain? how often? what makes it worse?' kinda stuff that are right below the pain question on OASIS. The office staff said the surveyors said its like I didn't do assessment at that comment got me pretty frustrated...;(

And she also said I didn't write down one of her that's pretty big deal too...

But I did learn from it so that I ask my patients every single questions on OASIS.

I just hope nothing happens from this experience though...


849 Posts

Specializes in Home Health.

It's a learning experience, enjoy!


18 Posts

Has 23 years experience.

I've been a home health nurse for a long time and the oasis question deals with pain and/or the ability to perform normal activities. A patient may not have pain when you are assessing them at that moment because they are laying in the bed, or laying on the couch in a nice comfy position. But as soon as they set up or move they get pain in their back etc. Now if that pain in the back prevents them from getting around the house and doing their normal activities then it should be documented, even if at the time of assessment they have NO pain. Also I make sure I look at the med profile and see if they are on any pain medications. I ask them when the last time they took a Pain pill or "tylenol" for pain? How did it work for them, how often do they take it, what do they take it for. Often I get, "I don't have any pain but I take a pain pill at night to get comfortable and sleep". I document that. I document patient has no pain today but says they take pain pills at night for comfort/sleep. I also document on the patient that is laughing, smiling, walking around the house safely and pleasant, and says that their pain is 8/10 and they take xyz pain meds q 4-6 hours and appear to be able to function but still report a high pain level. Then there are the patients that go to the pain clinic and get multitudes of pain medications, take them as ordered, but still talk about their specific pains for more than 15 minutes during your visit, and if they show signs of having pain like facial grimicing, holding to the couch in a gripping mode every time they have to move, and how they rate their pain scale.. is the pain throbbing, constant, intermittent, aching, burning, sore etc and what they do to relieve it. I also document interventions around pain and pain medication. Like instructed patient to try heat to arthritic joint, or visual imagry, or journaling about pain, or taking the medication (if they can on schedule) before the pain gets so bad the pain pill doesn't seem to help. Even if the patient says they have NO pain when you ask, you sometimes have to dive in further and assess the bigger picture.


849 Posts

Specializes in Home Health.

I once worked with an RN who refused to globally assess her patients for pain. Every patient she did an OASIS on never, ever had any pain (per her statements). I think she felt like it was her fault or she was doing something wrong if they said they had pain, lol. I can honestly say that I have pain somewhere every single day, it may not last long, but it's there and I'm only 62.