Manager charting and my documentation missing!?

[ladylikeRN]

I had an incident the other day when a CENA was with a resident in LTC and stepped on the peg tubing, ultimately dislodging it from her body while getting her undressed to take a shower. To make a long story short, I was not on the same floor when this happened as the resident is obese and had to go upstairs in the nursing home to a more accomodating area for showers and bathing. After being contacted by the nurse on duty upsatirs about the situation, she asked whether or not I wanted a foley catheter to be inserted for patency or for her to be transferred to the hospital. I opted with the transfer to the hospital and contacted the doc and he agreed. When the resident returned to the floor minutes later, I secured the site which had minimal bleeding with a stereile 4X4 gauze, and fully assessed and documented the actions that I took after the event, including vitals,the circumstances leading up to the event, etc. Well, the next day I did not work, but was told the following day by the midnight nurse to watch my back becuase our boss documented as is she was present the night when the PEG tube became dislodged. Problem is, the boss was not there and my progress notes of the events have disapeared and is no longer in the chart. The burse who told me about this said that i report that she recieved about the resident after her return from the hospital was that the resident took the PEG tube out herself which was blatantly untrue. So that nurse then looked in the Chart as she knows that I document very concise and she found nothing but our manager's writing. The nurse then told me that the organization that I work for (only 3 months) are very big on telling nurses what to chart and when to chart in circumstances like these. However, my boss never even approached me about her taking my progress notes out of the chart and replacing them with her own as if she was there. My boss only received report over the phone from me as a standard rule for all transfers. I don't smell a lawsuit in this particular situation but who knows?

Should I run from this job or just start keeping a log and copies of all of my nursing documentation?

[catlynLPN]

I would run like a scalded dog.

If they change documentation in situations such as this, they will do it on ANYthing.

Eventually, if you stay there, you will find yourself in some very hot water and could have your license put at risk.

[AlabamaBelle]

run run run. you can't run from that place fast enough. protect yourself and your license.

[kurlykay]

After leaving this job, please report this manager. It is illegal to change documentation and she should not be allowed to continue to do this.

Hope your new job is fantastic!

[Patti SW]

Run for sure, especially from LTC. I worked for one whole year in a 500 bed NH. They had no policies/procedures for anything. After working in acute care it was weird but, I was advised it was by design.

I complained daily about the care the pts were ( were not receiving) as every morning when I arrived I would walk into pts rooms and find their nurse call buttons hung up over their heads so they couldn't reach them. The DON would always fight with me and defend them. I went to the Administrator who told me to just let it go. The DON was such an asset because he could convince state surveyors not to tag them. The administrator saw him as the best, in my opinion, cover up artist money could buy. It had nothing to do with those precious elderly pts. The DON always griped and complained about the good nurses because they actually cared about the pt.

I watched as the DON would try to delete information from charts and document that meds were given when they were not. When he would do exactly what happened to you. Why, because it makes it appear there was no wrong doing. When actually the truth would be better. Families were incredibly unhappy because they were not idiots.

Why? Why erase from the truth from the record? Because if it is not documented then it didn't happen. I could not stand it and I had to return to acute care. I loved the pts and it hurt me to leave them knowing in my heart they were not receiving the care they deserved.

My heart goes out to all of the nurses and CNA who work so hard and do care because they are the bravest soles on earth. They put their licenses on the line everyday. LTC forces nurses to turn their heads. They will not protect you, they will throw you to the wolves. Run! Go to a doctors office, an assisted living facility, LTAC, acute care hospital, county health dept. and when you go remember to call the state ombudsmen to report what happened.

[CapeCodMermaid, RN]

Not every LTC is bad and not every DNS is evil. I spend more time on the floors than I do in my office. If the care isn't excellent, I'm the first one to stir the pot and make sure the residents get what they need. Most DNSs I know want to do the best they can for the residents and the staff.

[Patti SW]

Thank you for your response. I am glad to hear you care as my job requires me to tell families why it will be O.K. to place your mom or dad in a LTC. They will be cared for and there are people who care and will do everything they can to protect and care for them. God bless you for what you do. I wish it were true for all LTC facilities. It sure would make my job easier and make family members more secure in their difficult decision to place their family member.

[ladylikeRN]

I really care about my job and in fact the resident who is anox3 knows exactly what happened that day and the family know as well because I told them. I know that I was not at fault with this incident and was told by other staff not to complete an incident report anyhow. The incident report is not apart of the medical record anyway and has no bearing on legal matters. on the other hand, it looks as though I never charted anything at all in the chart, although the transfer sheet is in the chart. I have never witnessed anything like this before and I fear what could come in the future, I hate to have to leave my residents but I feel that my license could be potentially in danger here.

[hippylady7211]

Sorry Lady, BUT RUN RUN RUN, then call the state and report. I know you want to help your residents, but I wouldn't work in a place that would mess with my license. You will need to watch your back forever or will get set up. Bottom line, if you don't work for a good NH, the bad ones will do ANYTHING they can to stay in business and make the $$$.

Get out!!!

[Hopeslayer]

I wish I could link the audio clip from one of Arnold Swartzenegger's movie:

GET OUT!!! GET OUT OF DERE!!!!!

[CapeCodMermaid, RN]

I really care about my job and in fact the resident who is anox3 knows exactly what happened that day and the family know as well because I told them. I know that I was not at fault with this incident and was told by other staff not to complete an incident report anyhow. The incident report is not apart of the medical record anyway and has no bearing on legal matters. on the other hand, it looks as though I never charted anything at all in the chart, although the transfer sheet is in the chart. I have never witnessed anything like this before and I fear what could come in the future, I hate to have to leave my residents but I feel that my license could be potentially in danger here.

OKAY-a technicality....an attorney can request a copy of the incident report and worse, the DPH can have a copy. It doesn't matter that you were at fault or not. If you had knowledge of the event, you should have made sure it was documented.

[lindarn]

Get ahold of and make copies of everything that pertains to this incident from the chart before that dissapers as well. This is why I have always maintained that you make copies of your incident reports and the nurses notes that you wrote. If there are other notes that support you, make copies of these as well. Worry about HIPPA another time. You won't lose your license over HIPPA. JMHO and my NY $0.02.

Lindarn, RN, BSN, CCRN

Spokane, Washington