Help! New nurse needs advice: Incident at a LTC facility

[changeofpaceRN]

i posted about a week ago over an incident that happened at my work. here is the full story:

one man got aggressive with me during his 12am neb treatment. i documented that he was aggressive and refused his neb but wasn't specific about the incident:uhoh3:- i'm rusty with charting and really don't know what the heck to write (new grad, new nurse- my mistake).. he's one we have to chart on because of insurance- we don't chart on everyone on the 11-7 shift.

anyway, two days later, i get a call from the risk manager asking if i know what happened to his toe. i say no, what happened? apparently, it's fractured and they think someone bent it on purpose.. of course, i'm thinking great- i'm new, no one was with me, i charted he was aggressive and i was the last to see him before the toe was discovered... they turned the incident into the state for investigation and i lost sleep over it.

they were trying to blame his injury on that night he was aggressive with me but one of the cna's on the prior shift said "no i found it earlier and reported it to xxx nurse, it's even on the back of my cna assignment sheet that i found a bruised, reddened area on his toe". so here i am, about to be in the spot light there when some other nurse never reported it to the next shift (which was me) and didn't bother to file an incident report:angryfire. this guy has a history of psych behavior and is aggressive about 20 days out of the month. i felt like a scapegoat. even after the cna's statement and assignment sheet showing she did write it down on the previous shift, they still think it happened that night he was aggressive with me. ***i wish i would have charted details- lesson learned***

would you talk to the risk manager to explain things in detail? would you put it in writing for your file? would you talk to the don about it? it's really bothering me that i know it wasn't me and it's very hard to prove you are innocent these days. the cna's sheet proves the injury existed before my shift and 11-7 does not do skin checks at night. how can they continue to assume it was my fault? what happens in an investigation? does this go under my license? how can i protect myself if this happened to someone who doesn't have to be charted on and the cna never discovered it?

then a few days after that, one lady had a fresh bruise on her elbow that was about 1.5 in x 1 in and the same cna reported it to me (she worked a double that day). what was i suppose to do, ignore it? i didn't so i made an incident report to cover my butt. needless to say, i was basically the joke of the day because i filed an incident report over a bruise and everyone commented on how petty the report was over a simple bruise. i don't know if i was right or wrong to do it but i'm not getting blamed for an injury i didn't do.. was i suppose to dismiss the cna's observation? who am i to ignore a bruise? what if the family comes in and asks where the 70 bruises she has came from?

i feel lost and upset with this whole situation. is there a protocol on what is good enough to report verses what can be brushed under the carpet? yes i'm new and i'm going by the book- too many of these people don't follow the "rules" and it's making me question myself. would you look for another job or is this what i get to look forward to in ltc? i only have 1 month experience under my belt so it's not like i'm able to get any job i want. pease offer any words of wisdom you can share! thanks for making it this far!

[TrudyRN]

You were absolutely correct to do the incident report about the bruise. You should also have taken a picture of it and put it in the chart and kept an extra photo for yourself, with the pt's name, date, name of aide who informed you, time notified, etc.

We always had to notify the supervisor, the doctor, and the family of any and all bruises, scratches, any skin problems at all, any falls, any incidents of any kind. Also, they must be charted, photographed, and an incident report made. That way, no one can blame you for anything you didn't do or say you ignored it or tried to cover it up. It's a time-consuming way to have to do things but it does protect you.

The H with anyone who wants to laugh at you for doing the IR. Follow procedure, follow policy, follow what you have been taught.

I would definitely notify the supervisor, manager, risk management, admin, anyone else I could think of that the aide had reported matters to the nurse before you, who didn't bother to do anything about it that she was supposed to do, didn't notify you, the doc, the family, or even bother to chart. Let her take the heat. Clear your own name and sleep well at night. Let her get mad at you.

Do not sweep anything under the carpet. Be open and honest in your work and you will never get caught for being otherwise.

Get the CNA's report sheet, keep a copy of it, get her written testimony that she notified Nurse ________ and when. Make these things known to your boss, etc. and keep copies of them.

This is war and you must protect yourself. Don't be stupid. You are new but you know what to do.

[steelcityrn, RN]

My advice would be to find another job! The way you were treated in both situations was wrong.

[us4halls]

i am just starting my nursing pre requesites but i have worked as a CNA in LTC for last 8 yrs and we were always told to report any l;ittle bruise/scrape etc to cover our own butt just because it may have happened on the previous shift doesn't necessarily mean it was reported on the previous shift. and about the incident report in all the LTC's i worked on the nurses had to file incident reports for any bump,bruise,scrape ,fall no matter how minor and they also had to get statements from anyone who witnessed the incident as well. i would ignore the ones who are making fun of you cause its obvious they are just mad cause the incident report is making a little more work for them.

about the gentelman in the beginning of the post , is he a total care patient or does he do some thing for himself ? the reason i ask is because if he is a total care or requires assistance getting to the bathroom then the cna on your shift should of noticed it . hard to say though without being there

with patients like that who were like that we would sometimes bring another aide in with us or the nurse just so there was a witness

[ohmeowzer RN, RN]

you did the right thing. i would of done the same thing. who cares what the other nurses say. you should do a incident report for new contusions or any type of injury.

[nurse15dc]

Bravo! Yes you handled both situations extremely well!

For the fx toe situation it is very imp that you write a little note to the DON stating all of the facts just like you did here. But try not to sound defensive.

The times I was in similar situations in LTC noc shift I'd cover myself by writing a little dated note to the DON...I'd make it sound like I was just "keeping them informed."

However I'm sure the ADON, DON & risk management knew I was keeping a copy of my "friendly note" in my locker just in case. I also never used the pts name in my notes, just bed number. (Didn't want to be accused of a HIPPA violation if they found my copy of the note.)

To be perfectly honest, I even held on to a couple of these notes (with resident's identity deleted) after I left certain nursing homes. Sounds paranoid, but I've seen hospitals and LTC's scapegoat naive nurses.

BTW that CNA is ABSOLUTELY worth her weight in gold! Thank her profusely whenever she tells you about ANY skin integrity issues. One bruise or tiny tear can turn into a big decub in your elderly residents.

The way I used to handle situations like the bruise depends on how bad it was. But no matter what it was always put in writing and reported to the next shift. If it didn't seem like a big enough bruise to do an IR, I'd put it IN WRITING on the end of shift report, copy that for my records & tell the next nurse in oral report.

Things may have changed since I've worked LTC BUT...Another way to handle a bruise on a non medicare/non skilled res (the type you aren't required to regularly chart on)...Is to put a brief note of your observations in the chart.

Such as...Size of bruise, when it was observed and your nursing intervention. In charting new nurses sometimes forget to mention intervention & if it gets resolved, the outcome. Just state the facts & what you did to help the resident in the situation. ie "Called to bed 43a by CNA at 0100. 5 cm bruise noted to left elbow. Resident denies pain. L elbow offloaded with 1 pillow to decrease edema. Will continue to monitor and report to oncoming nurse."

Some of your co-workers may say you're overdoing it...But you're there for the residents. And skin care is a huge issue it this pt population.

Good luck, hun. You've made a great start!

[PoppaD]

they turned the incident into the state for investigation and I lost sleep over it.

They were trying to blame his injury on that night

Who exactly did the LTC report this to? You Ombudsman or to your state's Licensing or Certification agency...or to your Board of Nursing? I certainly do not mean to suggest that an injury is a minor detail, but if a pt is aggressive (i.e., kicking at the footboard) then he might harm himself.

By the way, I do hope that you are carrying your own Nursing malpractice insurance...do not count own your facility to cover you in the event of civil action.

[PoppaD]

You should also have taken a picture of it and put it in the chart and kept an extra photo for yourself, with the pt's name, date, name of aide who informed you, time notified, etc.

Be very careful keeping pictures and copies of the MR...you could find yourself on the wrong end of a privacy violation investigation not only by your facility, but also by your BON. This type of information might be of value to your attorney, but I doubt that it would be admissible if the case went to court because it was obtained illegally. I would definitely seek the advice of an attorney regarding this strategy.

[biker nurse]

DOn't beat yourslf up about the charting. Just be a little more clear next time.(what would write'Toe intact??) I agree get a written statement from the aid(I 'd get it to a notary too) 2 copies give one to DON and another for yourself to CYA. GOOD LUCK!!!

[catlynLPN]

I read your post but don't have time to read everyone else's, so you may have already received this advice.

If I were you, I would get copies of all the papers, ESP that paper the CNA documented where she found a bruise on his toe.

Make copies and keep them. Papers have a way of disappearing.

I would consult an attorney, also, for professional advice. Something similar happened on my job to another nurse. She made copies of some things, but not some others, and some papers disappeared, right out of the patient's record. I am a witness to that fact, because I looked for it. It's not there.

[Ms Kylee]

Anything out of the ordinary that I notice when I'm bathing or giving care (bruises, skin integrity, cuts, etc.) I report to the patient's nurse right away. One patient had a history of being combative and aggressive, but when I was bathing him, I found very inflamed and broken skin under his foreskin. Fortunately, while I was cleaning that area, his nurse came in and I pointed it out to her. She looked at it, and said "no wonder he's combative", then left to inform the doctor. I can't chart this since it's not in the nursing assistant's area of charting on the computer, but I'm sure the RN did chart it. I'll continue to notify the nurses until I'm told not to.

[Jo Dirt]

I think those jokers are looking for someone to blame, whether you've done anything or not. If they pursued this ridiculous accusation about the bent toe of a psychiatric patient I would pursue the advice of a lawyer.

It makes me sick that there seems to be no shortage of people who would love to throw a person under the bus rather than try to find a way to help them adjust to a new situation.