Incident Documentation

[Baddmedicine]

the client activities in our department are implemented by non-medical staff. they are also in charge of the non-medical workers that do activities of daily living with our residents. they give baths, dress clients, feed the clients who have oral feedings, position them, change their briefs and, in essence, do the heavy lifting. recently, one of my clients began having hypo-thermic events. he was sent to the er twice for temperatures less than 94 degrees. he is very medically fragile and has a trach and peg. his o2 sats have remained high but as he chills, his heart rate drops as well as his respiratory rate. upon his last return from the er, his primary care physician wrote orders that he is to remain in bed with only quick bed baths and only small parts being bathed were to be exposed to the air. i had him bundled up in his bed, including a knit hat on his head and had his temp up to 97 degrees. he hadn't been bathed the day before, so i suggested we bath him. his room where he sleeps gets very chilly during the winter months as it's poorly heated and cold air leaks around the windows. (this has since been repaired) no resident is allowed to be in their room during the day. if they're sick and on bed rest, they still have to go to the day room but their whole bed will go, with them in it. when i wanted to bathe my client, i told the staff that i would help but wanted to bathe him in the day room (the only room in the whole area that was comfortably warm) i was told that no client would be bathed in the day room because it was their living room. (all other clients in beds in the day room had their brief changes done there as well as oral care by the nurses) there are screen available which we would use and no major exposure of any body part since we were limiting exposure to the cooler air. the options i was given was his room (cold) or the shower room. in order to go to the shower room he would have to be taken from his bed on a lift and transferred through the cool halls into the just as cool shower room. then he would be placed on a shower table, undressed and essential areas washed. i told them that the options weren't acceptable and went to my nurse manager to turn it over to her. she basicly didn't care much about the issue and told me that if i disagreed with it, to call the doctor. i called the doctor who tried to remain uninvolved as well but finally did say reluctantly that they could use the bathing area if they kept blankets on him at all times. when i returned to my client's bed, i found that he had already been taken to the bathing room, minus blankets, stripped of his clothing, and washed. when he was returned to his bed, his body temp was 95 degrees. it took 6 hours to get his temp back up to 97. i carefully documented the occurrence and the titles of the individuals involved, in the progress notes of this client's chart. i was given a verbal reprimand by my nurse manager who told me that my documentation was "punitive" and that i was not to document issues like this in the chart. i didn't argue with her but i know for a fact that my documentation was non-judgmental and contained only the facts and the steps i took on behalf of my non-verbal client.

what say you? should i have the reprimand put into writing? if i do this, should i try to take it to someone who might possibly care? (there is no one at this facility who isn't always trying to cover someone else's fanny) i had other nurses read the note, give me feed back and also be witnesses to the fact that the note is there in case it might disappear. they each have agreed that the note presents just the facts and have told me that it didn't matter how it is documented, it is obvious that the non-medical staff overstepped medical, ignored a physician order and that the nurse manager as well as the doctor should have intervened but didn't. they all look negligent with the non-medical staff bordering on abuse.

[lpnflorida]

In reading what you wrote, I believe a short note regarding patient was bathed in shower room without blankets would have been sufficient, I then would have written up an Incident Report which is not part of the chart referring to the doctors orders as written at the time that the patient was in the shower room being bathed contraindicated the Doctors actual orders and in the Incident Report would have put specific names of people involved..

[Baddmedicine]

Thanks lpnflorida

I would have preferred to be able to do that as well but this facility doesn't have incident reports for things that occur that are unusual. I believe that it would be a good thing if incidents could be reviewed by a committee of some sort to give more direction to all involved in how to handle situations as they come up. As it is now, the two disciplines must somehow blend in order to effectively care for our clients. Medical staff often have to give way to non-medical staff during the course of care. Really, what I should have done would have been to just tell them to NOT bathe at all until the conditions were right. I didn't forsee the situation escalating to the degree it did.

[lpnflorida]

I believe that it would be a good thing if incidents could be reviewed by a committee of some sort to give more direction to all involved in how to handle situations as they come up. As it is now, the two disciplines must somehow blend in order to effectively care for our clients. Medical staff often have to give way to non-medical staff during the course of care. Really, what I should have done would have been to just tell them to NOT bathe at all until the conditions were right. I didn't forsee the situation escalating to the degree it did.

Is there someway to bring to the powers that be, the importance of having incident reports? You make very good points. I thought they were mandatory everywhere.

None of us can foresee everything. You did what you could, you advocated for your patient the best that you were able to. Sometimes we all hit brick walls, but never quit being a good /great advocate.