Incident report on residnet who went out door. Advice

[ElderCare Nurse]

The other evening when I was working my evening shift as an LPN a resident went out an alarmed door in the dinning room .No staff where present at the time. The alarm sounded at the nurses station and the unit secretary sent staff to check it out. A confused resident from my unit had gone out looking to go home. . Another nurse working on a unit closer to the dinning room informed me of the incident. Two CAN's where able to redirect resident back into facility from what I was told. The CNA then brought the resident back to my unit .I immediately went to the unit manger on duty and informed her of incident and asked her how to get a wandergaurd for resident. She did not know and stated she will call our rehab nurse as the rehab nurse is the person who has our alarms. I also reported the incident to the nursing supervisor on duty a short time later. We discussed alarms and what doors have alarms along with the wandergaurd system . I was later informed by one of them that the dinning room door does not have a wandergaurd alarm. The only door having a wandergaurd system was the front door. I did not think of doing an incident report and both supervisors did not inform me to do so. So two days later on my day off I get a call from the ADON saying she is doing a VA report and asks me some questions. I informed her I had reported it immediately to my unit manager . She called me back a short time later and asked that I fill out incident report. I offer to come in and do it right away and she informs me I can do it the next day when I come to work. Again she asks me if I reported it to anyone. Again I tell her I informed the unit manger right after it happened. She states " Oh she is new "

So the next day when I get to work I fill out the incident report and then talked to my unit manager. She shares with me the internal investigation that the ADON has done. She informs me it is a learning experience for all of us. Here is what ADON has document in her report on me.

Team Leader- was notified of incident between 4-4:30pm. She did not do an incident report or called in the potential VA. She was educated that there needs to be documentation and VA called in, she was informed to notify the supervisor. She was told she needed to come in and complete the incident report.

So it looks like I did nothing. I am angry and feel I should talk to DON on this matter.

PS - Internal conclusion : This is not a VA as staff responded to door alarm.

[achot chavi]

I agree, reporting is good but doesn't replace a written incident report, and from what you describe I think this warrants a written report even if no harm came of the patient as it establishes an increased risk for future incidences and in turn requires a care plan for prevention.

This is all Risk Management, and as we know- if you didn't write it- it doesn't count. I am unclear who was responsible to write up the incident you or your supervisor but one had to be written up that same shift. In our facility it would have been you and the ADON is correct.

I have learned more from my mistakes than from all the textbooks and lectures so you might want to chalk this one up as a learning experience...

You do sound like a caring and good nurse and I am sure that your patients appreciate you.

[freddiebear]

The bottom line is outcome. The resident was observed and brought back to safety.

If you want to defend yourself please look at the facility policy. If the facility policy states you were supposed to do something and failed to do it then it is appropriate to have a mini inservice that you sign and they place in your file so if it happens again they can prove that you were informed.

If it is not in the facility policy or told to you during orientation then you can file a written grievance in regards to the facility making policy, not documenting it in a policy book and not providing inservice to new employees about how to handle a resident who attempts to wander outside of the facility.

Good nursing judgement might come in handy. If a resident tries to leave a facility it may mean that the facility is not an appropriate place for this resident to be due to the fact if the residents leaves they are at a great risk for harm. If a nurse is aware of this, they do need to review the care plan and make sure all the interventions are being implemented. If not they need to revise the care plan. Sometimes their are prn meds that are ordered. You might also want to call the MD and see what they suggest as well as the family. In any case if you are taking care of someone that you cannot keep inside the facility you might want to consider having them transfered to the ER for an eval and an appropriate placement. Sometimes family members are willing to come in and stay with the resident.

[ktwlpn, LPN]

An incident report is not needed in this case due to the fact that there is no harm to the resident in this case!

This is not true in every facility-check your facilities policy and procedure manual.

If I understand the OP she believes the incident report completed by the ADON contained erroneous info and she felt it implied that she was neglectful and she wanted to know if she should go to her DON to clear it up.I think you should follow your chain of command and educate yourself regarding your facility p and p- and then speak to your immediate supervisor.Ask her advice-she may clear this up for you ...If I were you I would write down my version of the events since they are in opposition to what the ADON states..

[fortune-teller]

This is not true in every facility-check your facilities policy and procedure manual.

If I understand the OP she believes the incident report completed by the ADON contained erroneous info and she felt it implied that she was neglectful and she wanted to know if she should go to her DON to clear it up.I think you should follow your chain of command and educate yourself regarding your facility p and p- and then speak to your immediate supervisor.Ask her advice-she may clear this up for you ...If I were you I would write down my version of the events since they are in opposition to what the ADON states..

You must quote my post entirely!

I said an incident report is not needed and I stand by my decision;however, it seems to me you intentionally left out the big part of it. Anyhow, I rest my case, as there is no needed to go on further.

Have a good day! And good luck to whatever you do in the future.

[ktwlpn, LPN]

You must quote my post entirely!

I said an incident report is not needed and I stand by my decision;however, it seems to me you intentionally left out the big part of it. Anyhow, I rest my case, as there is no needed to go on further.

Have a good day! And good luck to whatever you do in the future.

OK,sure thing.....- QUOTE-There is no need for any incident report unless a harm/injury is being done to the resident.

Anyhow, for your information, you must document the findings in the nurses notes. Plus, you also have to state that nursing supervisor was informed and issue was discussed. Also, what did you do after the "incident." This is an intervention. This will protect yourself from the state investigation should there is a harm/injury to that resident. The state want to see your intervention/action whenever there is a problem. Failure to act is a negligence; and a lawsuit is a possibility.

Good luck! And I don't think you will have to worry QUOTE

If this happened at my facility and you did not do an incident report you would be in violation of our policy and procedure. We do incident reports on any unusual occurence regardless of actual harm-just like the DOH tells us.

It does not matter what some people "think" YOUR policy and procedure are what matters.....Every facility has had situations like this occur and have followed up with the DOH-each interaction with them is different and each facility may have a different culture regarding these occurences.The DOH really looks to make sure that staff are following all p and p -if you are not then you are wrong.It is really important to know it and follow it.Citiations from the DOH are based on this criteria-Minimal Citation - No Harm- Minimal Harm -Actual Harm -Serious Harm ...You can still get a citation when no harm has occurred.

[fortune-teller]

OK,sure thing.....- QUOTE-There is no need for any incident report unless a harm/injury is being done to the resident.

Anyhow, for your information, you must document the findings in the nurses notes. Plus, you also have to state that nursing supervisor was informed and issue was discussed. Also, what did you do after the "incident." This is an intervention. This will protect yourself from the state investigation should there is a harm/injury to that resident. The state want to see your intervention/action whenever there is a problem. Failure to act is a negligence; and a lawsuit is a possibility.

Good luck! And I don't think you will have to worry QUOTE

If this happened at my facility and you did not do an incident report you would be in violation of our policy and procedure. We do incident reports on any unusual occurence regardless of actual harm-just like the DOH tells us.

It does not matter what some people "think" YOUR policy and procedure are what matters.....Every facility has had situations like this occur and have followed up with the DOH-each interaction with them is different and each facility may have a different culture regarding these occurences.The DOH really looks to make sure that staff are following all p and p -if you are not then you are wrong.It is really important to know it and follow it.Citiations from the DOH are based on this criteria-Minimal Citation - No Harm- Minimal Harm -Actual Harm -Serious Harm ...You can still get a citation when no harm has occurred.

You must also read the OP statement--the very first post in this thread.

You will come up with a bigger picture because I was responding to the OP.

In this case, there is no need for an incident report!