My Documentation Disappeared...?

[Fyles]

I've been a nurse for 15 years, and was always instructed...from day one...chart what you KNOW. So, here's my sitution:

I work in long term care, nursing home, and was working the other night from 7p -7a. Got called to a residents room when the CNAS were undressing a lady for bed and discovered swelling and dark purple bruising to her right ankle/side and top of her foot. The lady is wc bound, does not walk. She had been sitting in her wc, by her bed, since I came on the hall at the start of my shift. I did the routine actions for the situation...assessed for injury, called doc, family, etc. and started my documentation, including the Incident and accident report. I filled out all areas of the report the best I could, but the one thing that bothered me was that I could not identify exactly how the injury occured, as I did not witness what happened...much less, when it happened. Obvious swelling and bruising to that extent made me to think that whatever happened must have happened a day, possibly two, before. My best guess would be perhaps she turned her ankle. But she doesn't walk. I was always taught you NEVER "guess or assume" what happened. So I documented that the resident was found with the injury. I did not state a cause or what happened, because it was unknown to me.

So, the next day I get a text from my DON, stating that there's not enough information in the I&A, and that she needed GOOD witness statements saying what "possibly" happened. I informed her that the resident was found with the injury, and that I did not witness the injury, so I couldn't state what happened. It was unknown to me. So I went in to work last night, and after my routine charting was completed, I decided to re-read the information I had put in the I&A from the previous day. To my surprise, my charting/documentation had completely disappeared...and in its place was someone else's documentation of what happened. And it told a completely different story. They claimed the "slight bruising" was possibly caused by hitting her ankle on her wc. And that after investigating, she was no longer able to transfer properly, so they changed her to a full body lift. Granted, it all sounded much better than what I had documented, but it was not MY documentation. Another nurse completely deleted everything I had charted and put in her own words, and she wasn't working the night the injury was found. The only thing remaining from my documentation about the event is the I&A note that I had to do while filling out the report. The original report was electronically signed by me, that night. The new one had no signatures. Yet. Where did my documentation go?

My question is, how do I handle this situation? I'm waiting for them to tell me that I have to sign off on the I&A report...but I will refuse to do that, because it isn't MY documentation any more. And no one asked me or told me that they were going to add/delete my charting from the report. To me, this is highly unethical. I've only been working here a couple of months, but I'm seriously reconsidering my place of employment at this point. I'd gladly welcome and appreciate your thoughts on this situation...

[NicuGal, MSN, RN]

If it is done electronically, there is a footprint. On our EPIC we can hit deleted notes or audit and it pops up. I would go and ask about it. And that is pretty shady.

[Here.I.Stand, BSN, RN]

Another nurse completely deleted everything I had charted

WOW. This is falsifying a medical record! I'm assuming this is an electronic chart, if the other nurse "deleted" your note? If so, whoever manages IT for your facility can recover it. I was told specifically in Epic training that we can go back and edit our charting, but they will always be able to recover the original. I would contact them AND risk management.

[quiltynurse56, LPN, LVN]

If we know what happened, we document it. If we don't know what happened and no witness, we document that information. We also have a place where we can write what the patient says happened. If they can't do that, we document that they were unable to state what happened. Then we figure out ways to try to prevent said issues again. We have put lambskin on bed rails for those we can use bedrails on. We also will make sure that staff knows how to ao ssist safely so injuries do not occur. These are also care planned. The inner facility investigation will also talk with any staff who worked during the time period it is suspected to have happened and are to write a statement. It sounds to me like they did not want to do the self investigation and were hoping that state would not do one with how they changed it.

[Fyles]

Yes, or is electronic charting. And yes, I think it's pretty shady, toor. They didn't even inform me that it was done...just did it workout telling me. I intend on along my DON about it Monday morning.

[Fyles]

And that's exactly how I charted...resident was unable to state what happened. What upset me was that "they" charted there was slight bruising, but actually her ankle and foot had dark purple bruising all around the ankle, down the outer side of her foot, and even across the top of her foot. The nurse who signed off on this new and improved I&A want even working the night the incident report (mine) was made. They changed it to how THEY wanted it the next day, and dogs not even tell me about it. I only discovered the changes because I went back to the report to check over what I had charted. Even my electronic signature is GONE. I was telling another nurse about this, that I worked with tonight, and she said they were able to change it because it wasn't "locked". But we're always told NOT too lock them, because others, such as care planning, etc, have to be able to go in and fill out their section. I'm relatively new to E charting, and this is only the 2nd I&A I've done at this facility. But this had definitely left a bad taste in my mouth.

[doodlebuttRN]

Fyles, stick to your guns. You are correct, and this is a big ol' red flag. I would seriously be considering different employment after something like this. What will happen when the resident ends up having an ankle fx, the family calls the state and there is an investigation? You were the nurse on duty assigned to that patient that night, and believe me, they will want to talk to you. Whoever the nurse is who deleted your note and put in a new one will have to answer for that. Do you think that your DON or administrator will hesitate for a fraction of a second before throwing you under that bus?

A long time ago I had a sort of similar situation; except that the nurse on duty didn't write any note. I relieved her, and the patient who had fallen on her shift was sent out with a hip fracture. Family called the state and sued. I have never forgotten being questioned by the state, and I was so glad to have documented appropriately.

Even if you do leave this facility, make sure you have some kind of record of the fact that your documentation was erased and changed. Of course even if they recover it, you don't get a copy. At the very least, write down word for word the details of your conversations with the DON or whoever, when and where they took place, and keep this for yourself. As many have said, there is an electronic trail for the changes they made, and any additional evidence you have to support your version of what happened will help you if it comes down to it.

Hopefully, nothing will ever happen. Take this as a lesson learned about your employer, at least. Best of luck

[cleback]

Correct me if I misunderstood, but incident reports are for internal use of the facility, not part of the medical record. So a nurse deleting your statement and adding hers would not be falsifying a medical record.

That said, still shadey in my book. Did she sign it with her name at least? I'm assuming she did, if you known who wrote it. If the report is generated in your name and they ask you to sign off on it, I would refuse as well. As for CYA, I would just make sure you documented what you found in the medical chart.

[Double-Helix, BSN, RN]

Correct me if I misunderstood, but incident reports are for internal use of the facility, not part of the medical record. So a nurse deleting your statement and adding hers would not be falsifying a medical record.

While incident reports may be intended for internal use, they are still legal documents, and are 100% discoverable in the event of an investigation or lawsuit.

So, the next day I get a text from my DON, stating that there's not enough information in the I&A, and that she needed GOOD witness statements saying what "possibly" happened.

Save those text messages from the DON.

Also, it sounds like the DON needs some education about what an incident report should include. You never want to speculate about what caused an injury if it wasn't actually known. You state what was seen, heard or said and that's it. It does not look better” if the facility comes up with an explanation for the injury- in fact, it can be damaging. In an recent inservice about this very topic, I heard about a case about a patient who experienced a medication error and later developed a complication. Notes by a resident on the case stated that the complication was a result of the medication error. The case later went to court. Even though expert medical witnesses testified that the complication was entirely unrelated to the med error, those notes in the chart were so damning that the case was settled.

As long as your original I&A was saved, there's an electronic trail. Don't put your name on any other reports or notes except the ones you wrote the day this occurred. Your feelings about this are absolutely right. I don't blame you for considering finding another place to work, either.

[caliotter3]

Now that you know what kind of a facility that you are working in your next decision should be how fast you are going to obtain employment elsewhere.

[Fyles]

My documentation is still in her chart, including my I&A note and follow up hot rack charting I dI'd. Her xray was clear, I worked last night and confirmed that. Still, no one has contacted me to alert me to these changes. The new report was signed off by a different nurse, and will not be signed by me. But I have printed off a copy of the new report, and have saved my text messages in case they should be needed for any reason in the future.

[DeeAngel]

I don't care how badly they twist your arm never sign anything you didn't write yourself. If they hassle you on this notify all authorities and consider filing a hostile work environment lawsuit. This will force scrutiny of everything they do.