Lvn...documentation error

Nurses Safety

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I would like to fist say that I work NOC shift at a rehab center. On most nights I have 48 residents (a wing and a half) and 2 CNAs. I have a midnight med pass where between 1/4 and 1/2 get medication and or accuchecks. Then there is the AC AM (0630) med pass where all but roughly 5 get medication and or accuchecks most with coverage. All of which is suppose to be done by 0630 shift change. On 5 days a week (most of the time), with a space of 2-3 days, another nurse comes in to take over my half wing, I have made the DON aware of the impossibility of the request but it seems to fall on deaf ears. Those 2-3 days are nightmares. I have yet to make a med error but the enormity of the task has allowed other things to fall to the wayside. We document I&Os in a computer, however, administration also has it set up so that our CNAs document on a paper (which never occurs), so that we can then document on other papers their I&Os. As a new nurse (only 3months experiance, I have relied on the experience of my coworkers. I was told that when the CNAs don't write down their I&Os to do my best and make and educated guess, because everything is documented in the computer system. There have been days where I did not document due to not having them because I never wanted to write something down I didn't know as fact. About 2 weeks ago I was told by my DON that I would have a mark in my record due to not documenting the I&Os on the papers (and no I'm not the only ones to not get it done). Yesterday State showed up and my DON asked that I stay and go back and make sure I filled in all my blank areas and not leave them blank while state was there especially. Then today I reminded my CNAs that I needed their I&Os done. Neither did it. We are not allowed overtime so my DON came in and asked why I was still there and I stated I hadn't done my I&Os. She said fine she would do them but she wanted the paper the CNAs filled out, I showed her they had not done so. She said shed talk to the CNAs. I got a phone call a couple hours later stating I was suspended pending an investigation. My question is what can I expect the outcome to be, what could I have done differently? Do they have to investigate everyone because I'm not the only person to estimate? I'm sure Rhodes papers are not accurate 100% in the least.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

:hug: I am so sorry you are going through this........what are they investigating you for? All I can say is WOW........Sounds like they got slapped by the state and you are the corrective action. It sounds unreasonable to me but I am hearing this kind of behavior in LTC by administration more and more......sad, really. If estimating an output is your only crime....the punishment is excessive. If you have malpractice I would notify them that you are being investigated for what I am sure will turn out to be falsification of documentation.

Chin up.....:hug:

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I don't have malpractice :( I was waiting to get enough to pay for it...

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I'm so sorry you're going through this. It sounds like a nightmare. Even if you have to not drink coffee (or whatever) for a month, do not go without . Ever.

mc3:nurse:

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I just signed up for some, not sure it will do anything here. It starts today but I don't know that it would cover anything if anything comes of this. I called and found it is just an in house investigation.

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Specializes in Hospital Education Coordinator.

I wonder if the CNA's were also disciplined?

I would be looking elsewhere for a job, if possible. This is nothing short of horrible.

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I was thinking this too however, ultimately the responsibility of the I+Os is the nurses. Just like vitals etc. that's why a lot of nurses in the acute setting do everything themselves as its a lot less hassle to chase a CNA reminding them to do their vitals and I+Os. The situation sucks btw, hope it all works out.

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I don't have malpractice :( I was waiting to get enough to pay for it...

Please do get a (from NSO)... It's $99 something/year and it's all worth it -- for your peace of mind :-)

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