Incorrect documentation co-worker, home care. HELP!!!

[Kirbycrew7]

First off, let me say that I am a fairly new nurse (just over a year). I have been doing homecare and have had the same client, fulltime, for this entire length of time, so am a little protective. I am also his primary nurse. He has gone through a lot of other nurses, due to different things (primarily scheduling). Great client, easy to work with, etc.

So, I am frustrated. We just got another nurse on the case, that has 12 years experience. Last week, I came back from being gone two days, to find that three doses of meds were missed. When I went to check the MAR, it was gone. She had taken it, as well as the communication book, home. I tried to reach her but she wouldn't respond, so I contacted my supervisor, who reached her, telling her to bring me the MAR. When she got here, she was nasty to me and said it could have waited, I didn't need to call the Supervisor, she was new on the case and needed time to adjust (he is ONE client). That being said, I can see missing one set of meds. But not three. I looked at the MAR and all had been documented as given. I spoke to her the next day and told her it needed corrected, and our supervisor told her the same. Last night I was off, I came back tonight and found that another dose of meds, missed. I then checked the communication log and it stated that the client refused. He said he didn't and I KNOW he didn't. Ive been with him a full year. Then she had written in the communication log, "notes" from the prior several days she had worked (dated for those days), which were not in the book when I left Friday morning. She wrote them all last night. My client was not put to bed AT ALL last week one night (he is a college student), and she wrote in the communication book that he was "put to bed at such and such a time". I am so upset. Beyond upset. With any of his prior nurses, I have never had an issue. EVER. As a fairly new nurse, and a home nurse at that I am not quite sure how to properly handle this. In addition, when I went to sign off on the MAR tonight for meds given, she had already signed off on his pain meds for tonight, and they are gone. I know he didn't get them (she left at 11 this morning). I don't want to put my license on the line, playing a guessing game on what has/hasn't been given. Any advice would be appreciated.

[0.adamantite]

If she is stealing medications, particularly narcotics, you need to report this immediately to your supervisor, or go above her head.

[dudette10, MSN, RN]

She sounds like a hot mess. The biggest red flag is pain meds documented as given hours prior to when they are due, and they are now not available at the right time. You need to report all of this up the chain of command and possibly have the appropriate person interview the client about this nurse's activity/behavior while on the case. And she needs to be removed from the case immediately pending an investigation.

[monkeybug]

Go to your supervisor, as soon as is humanly possible. Go with an attitude of "I'm concerned" and "what should I do?" rather than "OMG, she's awful!" and "can you believe that she did that?" No accusations, just lay out what you know, what you've read, and what the patient says.

[HouTx, BSN, MSN, EdD]

Fraud is fraud, no matter what the setting. Falsification of documentation is grounds for loss of license in pretty much every state in the US. Nurses are mandatory reporters..... so, if you fail to take appropriate actions when you "know" there have been violations, then your license is at risk also.

[sissiesmama, ASN, RN]

She sounds like a hot mess. The biggest red flag is pain meds documented as given hours prior to when they are due and they are now not available at the right time. You need to report all of this up the chain of command and possibly have the appropriate person interview the client about this nurse's activity/behavior while on the case. And she needs to be removed from the case immediately pending an investigation.[/quote']

That's what I'm thinking too - hot mess for SURE! Used to work with one like that. I wouldn't wish that kind of nurse on anyone.

Anne, RNC

[mluvsgnc]

I think you should document everything that's gone wrong, including times and dates, an take it to your supervisor. If that doesn't get action, go above that person. It's lame to have to spend so much time and energy on someone else's mistakes, but patient safety must come first. The nurse should be removed from the case until everything is sorted out. If you end up talking with the client, go at it from a perspective of, "how do you feel about so-and-so's care?" And even then I would be hesitant to get the pt. involved (at least not by you- let administration do that). It's important to relate objective information to your supervisor (and patient, if you go that route), not subjective. Please keep us posted on what happens.