Is this legal??

Specialties Geriatric

Published

Because there have been so many "holes" (missing initials on MARs), our DON has established a new policy that if a nurse forgets to initial a med or treatment given,

that nurse AND the nurse who worked right after her

would both be written up! The outgoing and oncoming nurses are supposed to stand there together and look through the whole MAR while the outgoing nurse checks for holes, then both nurses have to sign this daily. The main trouble I'm having with it is ----how can I be responsible (& written up) if another nurse won't initial her work ?? This just doesn't seem legal. Are they just trying to scare us and don't actually intend for the oncoming nurse to be written up along with the outgoing nurse? Crazy!!!!

Ruby

I was always taught that if it is not documented, then it did not occur. At patient is c/o pain and you check to see when he/she can have a PRN or scheduled pain med. You notice that the previous nurse did not sign out the scheduled med. Do you assume the patient was given the med and not give the patient any thing for pain or do you give the med? Its med error because there was documentation that the med was given. Sounds like what the DON is trying to do is to cut down the med errors that are occuring. If you see a med error, its your job to report it and that includes the lack of documention that a med was given. You will be written up if you notice the error but dont do anything about it. That is how I am taking it.

You are correct, missing documentation is 100% a patient safety issue. Other posters are correct too in that mistakes do happen but we always strive to perfect our practice and should never become complacent to make mistakes.

Poor MAR documentation is a very serious and very real risk to patient safety.

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The DON is hoping to add peer pressure to her orificenal when dealing with this problem. I don't think I would like this policy. Each person should be responsible for their own work. You aren't getting paid extra to supervise your coworkers and neither are they getting paid to supervise you.

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The DON is hoping to add peer pressure to her orificenal when dealing with this problem. I don't think I would like this policy. Each person should be responsible for their own work. You aren't getting paid extra to supervise your coworkers and neither are they getting paid to supervise you.

You are responsible for ensuring that you have all the documentation you need to provide safe and competent care however. Accepting a MAR that is incomplete is the fault of the nurse who accepts the assignment.

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I can tell you that holes in the MAR is a big deal. For example is a patient has a seizure, falls, and sustains a hip fracture. If the family seeks legal action, you can bet the MAR is going to be called in to court as evidence. The lawyer is going to try and prove that the seizure was a result of medication not being given as ordered. At one facility I worked at. The nurses at the end of the shift was suppose to go back and check their MAR's with the on-coming shift to make sure that no holes are present. We used a ruler and lined it up with the date and it went pretty fast. It is reasonable to think that one could remember in 24 hours whether or not they gave a medication but after that it is hardly unlikely. One facility asked the staff to put a dot in the box when they placed a pill in the cup and if they forgot to initial it, then at least a dot in the box would tell them that they had given the medicines. People have been trying to come up with a way to ensure that there are no holes in the MAR, but short of a EMR, there is nothing to ensure no holes. By the way we had one DON that told the staff that the very next person that had a hole in the MAR would be terminated. She was true to her word and fired the nurse that committed the offense. Her rationale for this was that she had been preaching,check your MARS for holes for months and it was not getting any better. Did she get everyone's attention? You betcha.

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Yes, failing to document that you gave a PRN narcotic could result in an overdose if the next nurse gives it 20 minutes after you did without realizing the pt just got one. But going over the entire MAR to check for holes before you start your med pass is NOT a pt safety issue. That's what the OP is talking about. What's more of a safety issue is to sit and go over both MARs at each shift change. To tie two nurses up three times a day for this results in much needed "face time" with the pts not being done. It's just not feasible in LTC.

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If my boss fired the nurses who turn over MARs with holes (like not charting at all for days and weeks at a time), perhaps the employer could hire people who check their work before passing it on to the next shift.

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I can tell you that holes in the MAR is a big deal. For example is a patient has a seizure, falls, and sustains a hip fracture. If the family seeks legal action, you can bet the MAR is going to be called in to court as evidence. The lawyer is going to try and prove that the seizure was a result of medication not being given as ordered. At one facility I worked at. The nurses at the end of the shift was suppose to go back and check their MAR's with the on-coming shift to make sure that no holes are present. We used a ruler and lined it up with the date and it went pretty fast. It is reasonable to think that one could remember in 24 hours whether or not they gave a medication but after that it is hardly unlikely. One facility asked the staff to put a dot in the box when they placed a pill in the cup and if they forgot to initial it, then at least a dot in the box would tell them that they had given the medicines. People have been trying to come up with a way to ensure that there are no holes in the MAR, but short of a EMR, there is nothing to ensure no holes. By the way we had one DON that told the staff that the very next person that had a hole in the MAR would be terminated. She was true to her word and fired the nurse that committed the offense. Her rationale for this was that she had been preaching,check your MARS for holes for months and it was not getting any better. Did she get everyone's attention? You betcha.
As you said as long as the MAR in LTC comprises of thousands of little boxes, 100% error free charting is almost impossible. I'm good about it, but I probably miss a box on a rare occasion. It's prudent to go over your MAR at the end of your shift, but sometimes that isn't feasible. For a boss to fire a nurse over a single empty box is pathetic. This is why I'm glad I don't work in one of those kinds of nursing homes. We don't go to those extremes and pt safety has never been an issue nor has lawsuits. Of course we try hard to document timely and accurately, but pt care comes first. All that manager is doing is creating a paranoid atmosphere where everyone hates their jobs. Our residents are safe and happy and so are our nurses.
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Specializes in LTC.

I was talking about both ways of documenting. The last LTC place I worked at did in fact have a computerized charting system. However, I believe the OP was refering to the old school paper charting like you mentioned. I was just trying to say that yes, we as nurses, are human and there will be holes, however, its not good practice because like I said that if its not documented then the next nurse must assume the med was not given. Maybe making the nurses check the MAR book after each shift is the only way the DON can hopefully solve the problem. And I dont think reporting the holes as med errors to the manager is being mean and spiteful. If the same nurse is constantly leaving holes maybe he/she needs extra training. And if a nurse accepts report, the count in the NARC book, and a MAR; then its that nurses responsibilty if something is wrong.

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Yes, failing to document that you gave a PRN narcotic could result in an overdose if the next nurse gives it 20 minutes after you did without realizing the pt just got one. But going over the entire MAR to check for holes before you start your med pass is NOT a pt safety issue. That's what the OP is talking about. What's more of a safety issue is to sit and go over both MARs at each shift change. To tie two nurses up three times a day for this results in much needed "face time" with the pts not being done. It's just not feasible in LTC.

Although your scenario is a realistic concern for LTC, staffing is a risk/benefit that the DON has to analyze and determine where the greatest benefit is.

Should we do away with nursing reports because it takes away "face-time?"

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And to clarify I'm not saying that it's okay to leave blanks or become complacent. As I said, best practice is to go over our MAR once more before the end of your shift. But this doesn't always happen. If 3rd shift comes on and I haven't had a chance to double check, they still want the books and want to get started. If a facility is having such a big problem with it, why not just have the 3rd shift nurse go through the MAR during downtime and tag any holes for others to fill next time they work. No need to fire a nurse for a missing hole just to make a point. That's insane. And having two nurses go over each MAR with a ruler looking for holes at EACH shift change is neurotic. The nurses will revolt quickly. Or just say they're doing it and lie. No one in LTC has time for this. I have 49 pts on 3-11. Two huge MARs. Not gonna happen. I'm not saying the issue shouldn't be addressed, but let's try to be realistic here.

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As you said as long as the MAR in LTC comprises of thousands of little boxes, 100% error free charting is almost impossible. I'm good about it, but I probably miss a box on a rare occasion. It's prudent to go over your MAR at the end of your shift, but sometimes that isn't feasible. For a boss to fire a nurse over a single empty box is pathetic. This is why I'm glad I don't work in one of those kinds of nursing homes. We don't go to those extremes and pt safety has never been an issue nor has lawsuits. Of course we try hard to document timely and accurately, but pt care comes first. All that manager is doing is creating a paranoid atmosphere where everyone hates their jobs. Our residents are safe and happy and so are our nurses.

If you know that you miss documentation periodically and that it is prudent to check your documentation then how can it not be feasible to double-check your work? I am under the presumption that you do give a nursing report during shift change and that you count your scheduled medications so why can you not check the MAR? How long does it take to look at the little boxes, two maybe 3 minutes?

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And to clarify I'm not saying that it's okay to leave blanks or become complacent. As I said, best practice is to go over our MAR once more before the end of your shift. But this doesn't always happen. If 3rd shift comes on and I haven't had a chance to double check, they still want the books and want to get started. If a facility is having such a big problem with it, why not just have the 3rd shift nurse go through the MAR during downtime and tag any holes for others to fill next time they work. No need to fire a nurse for a missing hole just to make a point. That's insane. And having two nurses go over each MAR with a ruler looking for holes at EACH shift change is neurotic. The nurses will revolt quickly. Or just say they're doing it and lie. No one in LTC has time for this. I have 49 pts on 3-11. Two huge MARs. Not gonna happen. I'm not saying the issue shouldn't be addressed, but let's try to be realistic here.

I worked in two facilities that had a policy in place that the oncoming nurse was to examine the MAR with the outgoing nurse, this was considered a part of the nursing report. I never saw anyone explicitly fired for leaving holes but I have seen nursing written up for it.

P.S.

You cite pressure from the oncoming nurse to hand over the MAR, including the oncoming nurse in the disciplinary action will motivate them to give you the time.

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