Need advice, please!

netglow, ASN, RN · Jan 17, 2011

You don't know if the patient fell or not. Did you ask just simply, "patient, how did you get this bruise?" I think documenting in great detail of what you found is most important. Time, place, what you found (exactly how it looked), patient's vitals, Patients pain level, Patient's mobility status, Patients report (quote exactly what was said), what you did, how patient responded to tx... who you notified (NM, Surgeon).

You see, this IS you reporting.

INLPN93 · Jan 17, 2011

A bruise that size would in most instances be reportable.

If someone is point blank asking you to not document by the right channels, I'd seriously ask to not work with them. Give the reason why too.

Somebody somewhere in this facility has got to disagree with this approach.

Any time a res/pt voices being abused do not hesitate to move up the chain of command because it was YOU the res/pt reported it to and YOU are responsible for its reporting.

Review your P & P on abuse and c/o abuse. There should be a detailed what to do and who to report to in it. I can't imagine not verbally reporting this to your Administrator. If they don't have any type of abuse policy, look for employment elsewhere.

And like the above poster stated, Document it. All of it. Don't forget to add the notification of the supervisor in your notes. That person should always be noted when you notified them, they took the job and the resposibilities that it includes.

MomRN0913 · Jan 17, 2011

I would report it. Save yourself. We just had a patient claim she was molested. She had just arrived at our facility. It was reported right away. Turned out she was confused has major anxiety and because there was a male RN, CNA and RT, she probably felt attacked, because they were cleaning her (The RT wasn't, obviously) They got everyone in on the case, then she changes her story...... have to report it anyways!

UFmomof2 · Jan 17, 2011

Oneclearday: I asked the patient if she fell, stumbled during transfering from bed to chair, tripped and bumped into something, and anything else I could think of. It's also notworthy that there are no lower side rails on her bed, just upper side rails and over head trapeze. I was instructed to NOT chart what the patient stated, per my supervisor!

INLPN93: I went home after my shift riddled with anxiety! Never before have I been instructed by a supervisor to omit information in my documentation. I feel that I was put in a very awkward position, and that's unethical. I have followed the chain of command up one level, and I was told that I did everything correct. However, what I'm being told conflicts with the facilities written P&P. Needless to say, I'll be consulting with others up the chain tomorrow. My apologies for being so vague in some aspects, but I'm doing my best to not disclose where I work, as I'm sure you all can understand.

MomRN0913: Thanks for your insight. I know reporting it is the right thing to do, which is why I feel so conflicted when following direct orders of my supervisor. Guess I just needed the emotional support of fellow RNs.

Thank you, all, for your input!

canesdukegirl, BSN, RN · Jan 18, 2011

UF,

Did this pt have a total knee replacement? If so, I can tell you that some surgeons use an additional safety strap over the lower (non-op, of course) extremity to secure the pt to the OR bed. Additionally, some surgeons order 81 mg ASA the night before surgery. This would account for the bruising that you witnessed.

The lower back pain can be explained by the way she was positioned on the OR bed. Depending on the surgeon, a total knee can take between 1.5-4 hours to complete. She would have been in a supine position for this procedure. OR beds are terribly uncomfortable, and despite the gel pads and positioning equipment we use, we still have pts that develop bruising, especially if they are elderly. I would also question if this pt had a pre-op epidural or a spinal for this procedure. That could also explain the back pain.

If this pt attempted to get OOB unassisted, she very well could have smacked her thigh on the siderail.

I think that your NM is wanting you to chart objectively because they know that all of the above scenarios could have happened. I understand that you are concerned about the "rough handling" by the staff member, but thinking purely from a legal stance, your NM is trying to gather as much info as possible before making the assumption that a staff member caused this bruise. I commend you for being thorough in your assessments and trying to find the cause of this bruise. Please do not beat yourself up about it...so many things could have contributed to this bruise.

Keep us updated and rest your head easy tonight, honey. You are doing everything right.

neuroms · Jan 18, 2011

Dido to canes. If it's still bothering you, tell the pt's social worker of your objective findings and she/he is in a better place to investigate across the continuum.

UFmomof2 · Jan 18, 2011

canesdukegirl,

thank you so much, your kind words made me cry! Your perspective made me aware of possibilities that I hadn't considered. I'm going to read through the operative notes tomorrow and see what I can find out. Yes, she had a right TKA. I'm trying to be open minded about this, and certainly not quick to pass judgement on the staff member in question. I'm at a bit of a disadvantage because I'm at a new facility, and I'd never before been instructed to provide only select information in my documentation. Just the mere thought of compromising my integrity, or ultimately, my license, has had my stomach tied in knots all day. Thank you, again! Your input is so appreciated!