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 accommodating area for showers and bathing. After being contacted by the nurse on duty upstairs 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 sterile 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 because 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 disappeared and is no longer in the chart. The nurse who told me about this said that i report that she received 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?

[CapeCodMermaid, RN]

Just curious as to why you posted this in the DNS section.

If you know your note has been taken out of the chart, tell your DNS or administrator. Did you do an incident report? Did you get a statement from the CNA? Did you tell the doc what had happened when you called to ask for an order to transfer to the hospital? If you smell a rat, make your own note, and mail it to yourself. Don't open it unless you are called to speak to the DPH or an attorney.

Does your company have a compliance hotline? Call and ask their opinion.

[bluegeegoo2, LPN]

There was a situation on my unit where one nurse (a favorite) had missed the fact that heparin was d/c'd from the hosp upon admission, and the res rec'd it for 5 days/BID. When the med error was discovered, it was merely d/c'd from the MAR as if this res was supposed to have had it, and the transfer papers from the other facility mysteriously disappeared. No PT/INR was ordered or anything to ensure the res wasn't in danger. Some people, (facilities) are so wrapped up in protecting the bottom line that the res' safety/care fall to the wayside. I'm with capecodmermaid: I would absolutely mail myself a written record of the actual events. If a lawsuit does come of it, you and the aide will have to testify, or at least submit a sworn statement about what happened. You have to protect yourself and your license, your facility won't do it for you.

[CapeCodMermaid, RN]

I find this really hard to believe. What DNS would risk her license and her career because one of the nurses was her favorite? None that I know. If you read all the posts on here, you'd think that all managers and DNSs are the embodiment of evil, which I know from being in the business more than 20 years, is patently untrue.

[bluegeegoo2, LPN]

Yes, you're right ccm, I made it all up. (Sarcasm intended). Just because you haven't experienced a situation doesn't mean that they don't happen. I happened to have seen the documents first hand as they were shown to me by the nurse who found the error. The error was also confirmed by a third nurse as well. In case you're confused, this is a forum for nurses to post questions/observations to receive feedback to clarify or help us be better nurses and make better decisions. No good can come of someone posting untruths, as comments on fictional situations serve to help no one. And frankly, I am offended you doubt my integrity. Several of your posts have raised an eyebrow with me, but I gave you the benefit of a doubt. It seems you could extend the same courtesy.

[CapeCodMermaid, RN]

Cripes...I didn't mean to offend you....chill. Maybe I've been exceptionally lucky to have always worked with ethical people. I don't know why people do what they do. I am entitled to the same rights of voicing my opinions as anyone else. Didn't ask you to agree nor do I need you or anyone to give me the benefit of the doubt.

It's a place to post opinions and ask for help...apparently not everyone's opinions are allowed.

[noc4senuf]

To the OP, I would certainly rethink if this is the place you want to work. As far as CCM goes, I have found her to give quite intelligent answers and comments to others in this forum. As a fellow DON, I respect what she has to say.

I actually had a PEG get pulled out by accident by a CNA several years ago. We did send the resident to the hospital to have it replaced, the documentation of the actual incident was intact, and no harm came to the CNA or facility.

Back in the mid-90's, I remember a resident making suicidal comments and a weak attempt at committing it. The DON I worked under had the nurses all come back in from the last two days and rewrite all of their notes. Yes, it does happen but, I am happy to say it never will on my watch.

[bluegeegoo2, LPN]

Cripes...I didn't mean to offend you....chill. Maybe I've been exceptionally lucky to have always worked with ethical people. I don't know why people do what they do. I am entitled to the same rights of voicing my opinions as anyone else. Didn't ask you to agree nor do I need you or anyone to give me the benefit of the doubt.

It's a place to post opinions and ask for help...apparently not everyone's opinions are allowed.

You openly question my integrity then claim you "didn't mean to offend" me? Seriously? That's fine. We'll just disagree here, and leave it at that, shall we? Moving forward, since that particular incident, there hasn't been one like it. I choose to believe that the persons involved had a momentary lapse of good judgement for whatever reason, and have since chosen to "fly right". Unfortunately, there are people out there who wil stop at nothing to make "it" look good for state, or to protect their facility from a lawsuit. I hope they are few and far between. LTC is hard enough without added stress.

[CapeCodMermaid, RN]

I wasn't questioning the other poster's integrity. I am really shocked that there are people who would do something like that...it is so foreign to the way I practice. No wonder people in the public have a bad impression of LTC. And in this state, where arguably we have more regulations than in any other, the surveyors from the DPH most likely wouldn't be fooled. They would find something in the chart somewhere and there would be a commotion.

[bluegeegoo2, LPN]

For the record for anyone reading these posts, capecodmermaid and I have come to understand each other through a PM. I took her posts wrong and jumped to conclusions. I apologize to everyone for causing any ill feelings toward this community. I was absolutely wrong, and for that, I'm sorry.

[NRSKarenRN, BSN, RN]

Had a former DON in home health pull similar stuff re creatively inserting documentation.

They sent LPN to do admission visit for new patient under another homecare company we were subcontractor for then co-signing admission assessment never having eyeballed the patient and well aware that only RN's can do admissions under Medicare/HH regs in PA.... info I submitted in my resignation letter ---later realizing should have been seperate documentation to Administrator.

I'ts one thing when newly licensed staff on orientation write note in chart that should have been written on incident report and you are asked to correct and resubmit....another thing to have entire note MIA and something else submitted in it's place that you didn't write about incident without any explanation.

Difference in writing "CENA wasn't paying attention and stepped on patients PEG tube while undressing her for shower" vs "CENA reported that while undressing patient for shower, stepped on PEG tube and it came out with intact balloon." Always document facts without injecting supposition or personal opinion into situation.

Being proactive, I'd discuss situation with your boss "My note is not on the chart, can you tell me what happened to it?? How would you like similar situations documented in the future". Make your decision to stay/leave after you have conversation.

[CoffeeRTC, BSN, RN]

Yeah...I've worked with a few unethical nurses, adms and dons in my time. It is hard to beleive that they would act this or that way, but they do....hey...they are human too.

I would also take Karen's advice....ask them what happened.