As I was reporting off the the next nurse at 10 pm the cna's told me they needed me in a room asap. An air mattress had somehow become unplugged and had deflated and the resident had fallen down under the mattress and it was over her head. When they found her she was cyanotic and I had my doubts if she would pull through. We put her on O2 and she pulled through ok. when I left she was back to baseline.
Here is my problem.
I was called into the DON's office a couple of days later and counseled and they really came down on me for making a nurses note about the situation. The DON said that I should've called her at home and asked her if she wanted that documented or not. The counseling is for not calling her. She said that it looks really bad and that a "seasoned nurse would've known not to write something like that".
I don't understand how you can not document something so serious. Since then they are on my case really bad for a lot of stupid things and the company just offered a raise for all nurses and they upped the shift differential for afternoon shift. She called my into her office on monday and said that she is with-holding both raises from me because of this counseling.
You should take action immediately. Call the state and report the incident. Then call the BON and report her. I would also call the Dept of Labor to state you were denied a raise due to writing up an incident report. All are illegal. Chances are if something goes down they will blame you. Take the appropriate action to protect yourself. Then leave.
[nQUOTE=missykalo]As I was reporting off the the next nurse at 10 pm the cna's told me they needed me in a room asap. An air mattress had somehow become unplugged and had deflated and the resident had fallen down under the mattress and it was over her head. When they found her she was cyanotic and I had my doubts if she would pull through. We put her on O2 and she pulled through ok. when I left she was back to baseline.
Here is my problem.
I was called into the DON's office a couple of days later and counseled and they really came down on me for making a nurses note about the situation. The DON said that I should've called her at home and asked her if she wanted that documented or not. The counseling is for not calling her. She said that it looks really bad and that a "seasoned nurse would've known not to write something like that".
I don't understand how you can not document something so serious. Since then they are on my case really bad for a lot of stupid things and the company just offered a raise for all nurses and they upped the shift differential for afternoon shift. She called my into her office on monday and said that she is with-holding both raises from me because of this counseling.
what would you have done in the situation?
NEVER EVER FALSIFY RECORDS! You are the patients advocate. You are there to protect the patient. It is your nursing license that is on the line. Educate yourself about nursing law. I would report this DON to the State Board. If she told you to falsify records-she has done it before. I agree, but be aware of the HUGE ramifications of reporting your employer, I speak from personal experience.
Scary stuff here! I guess I feel fortunate. I work in a LTC/rehab facility and we are told to document every incident including interventions taken...and I do. We are also told not to mention the incident report in our nurses note, which I find very peculiar.
we never document in the nurses note the incident report. It is an inside document usually used for safety meetings and ways to prevent things from happening again. If you mention it in your nursing notes then outside people can request to see it.
We were taught in nursing school that you never document about that an incident report was filled out. You document about the situtation, interventions, outcome, md notified and family notifed.
Specializes in Med/Surg, Geri, Ortho, Telemetry, Psych.
You totally did the right thing. Always chart; not just to cover your butt, but also for the patient's sake. You are here to take care of the patient, not the facility. Bravo for standing up and doing the right thing. And she was wrong about a "seasoned" nurse. Because a "seasoned" nurse would know better than to omit details or hide the truth. I would quit. Then I would report the facility, then I would report this supervisor also. You did good.:icon_hug:
I worked at a facility that did this. Forever asking me to change the wording of my documentation or to omit documentation all together. My standard reply became "Excuse me while I check with state to make sure that is legal" Usually shut them down fairly quickly. Of course you have to be willing to back that statement up.
I worked at a facility that did this. Forever asking me to change the wording of my documentation or to omit documentation all together. My standard reply became "Excuse me while I check with state to make sure that is legal" Usually shut them down fairly quickly. Of course you have to be willing to back that statement up.
Old post, but still a major problem.In nursing school we are taught to not write the word "incident report", and other "flag words", but just how ethical is it to try to HIDE information from family or the state? Who are we trying to do a favor for by this practice of "hiding " info, being sneaky about the words we use in charting, etc.I understand that there are frivolous lawsuits out there, but why are we allowing ourselves to be cooerced into hiding info from the state? IS this LEGAL??
you are not hiding information if you chart in nurses notes what happen in an incident, the information should be identical in both cases but one is an internal memo
lawyers are not so naive as to not know that an incident report is not in existance
SuesquatchRN, BSN, RN
10,263 Posts
Heh. I constantly got into trouble about charting things - decubiti got them particularly incensed.