Nurse charting stuff she did not do.

Nurses General Nursing

Published

I work in LTC/RH and we are having to deal with family of a resident over a wound. There is talk of lawyers, suits and what not. I found out that the documentation for this "wound" was poor if at all. There was a signature that another nurse has preformed a skin audit the same day and it was negative, yet did not fill out the paperwork for skin audits ( she never does, even after repeated complaints to the DON.) There are several resident she charts that she does treatments on and I know they are not getting done. I feel this is another treatment that she signed off on and did not actually do.

Has anyone had this happen and what was the outcome. This RN has been there many years and feels she is un-fire-able. I would really like to see this person reprimanded for her actions, simply so things change for the sake of the patients. I believe in education first and discipline second, but she has been told multiple times about skin audit forms and just refused to take part in any change.

Specializes in LDRP, Wound Care, SANE, CLNC.
You don't have to be "nosey" to realize someone is falsifing documents. We had a nurse fired because when she had to leave early(1200), the nurse taking over for her discovered she had filled out her assessments for the whole 12 hours, including hourly vital signs.

Also, where I work, we change Broviac dressings once a week. When I am checking my chart and making a list of the things I need to do that day, I look in the box to see when the last time the dressing was changed. If it states it was changed yesterday, but when I go to do my assessment, I see that the dressing still has my intials on it, from when I changed it last week, I know it was falsified.

There is a treatment for one patient that I know is not being done because I asked the patient. She is A&O x4 so I trust what she says. The treatment is not a life sustaining treatment but still being signed for and NOT being done, and this particular "treatment" is not one a person would forget happened daily either. lol

Up Vote Up Vote ×
Specializes in LDRP, Wound Care, SANE, CLNC.
One of the nurses on my home health case only charts once every month or six weeks. She will chart ahead. Patient was recently hospitalized and there are her initials on the MAR that she gave meds two or three times while the patient was in the hospital. I don't know how it is that the supervisors see this month in and month out, and feel it is not necessary to do anything about it.

We had a med aide who charted they gave meds to a person after they died. I called her on it and she admitted to charting ahead.

Up Vote Up Vote ×
This is about proper pt care. I am a strong advocate for education before discipline and feel a strong dose of re-education is what this rn needs most.

The facility is barely making it, a law suit could bury this small facility. We are a good facility, I would hate to see that happen.

I have no desire to retaliate, she has never done anything to me personally to warrant payback. Honestly I feel that payback is childish and a waste of energy. I did not get into nursing to stand by and watch lazy people do a half baked job of patient care.

I respectfully disagree that someone committing fraud needs more education. Charting that something was done, when it was not is SO basic, it would be laughable if it weren't criminal.

"Payback" is for personal gain; reporting a nurse who is negligent focuses on the well-being of the residents. By watching it, you are participating. You would be deposed also- and with nothing to save yourself. This situation bites- and I'd hate to turn someone in- but how are you going to feel when someone loses a leg, or dies from sepsis d/t improper wound care? I realize it's hard- but you may want to check your state's mandatory reporting info in your nurse practice act. :twocents:

I feel badly that you're aware of this- and have to make the decision to ignore it (as it seems the 'brass' is), or do whatever your nurse practice act demands for YOUR license in this situation. :hug:

Up Vote Up Vote ×
i am the other day shift charge nurse. it was the family that was using the words like lawyer, suit and neglect repeatedly during their visit. i am only on shift a few days a week due to my schedule at school , i am half way through my bsn. i understand that staffing is small, the nurses are asked to do more than we have time for, but if something does not get done it can be picked up by the next shift.

the don is aware of this issues and it was going on for a while before i came on shift. my issue is when they asked to see the would care documentation, there wasn't any to find which really looked bad for the company.

each week i do would documentation on all current wounds that are not due to surgery. i get a list of who has wounds and measure ,describe and document them. this person was not on my list, i only had two, which seemed small so i asked the don if that was truly all we had. ( which is a really good thing) she assured me it was.

she gets her information from weekly skin audit sheets, no sheet turned in on this patient and the mark in the treatment book was negative for skin audit. ( meaning no issues) that was day shift on the 29th. that evening family came in ( angry over another issue) and observed her being put to bed, the wound that was observed at that time was a large excoriation wound on the buttock. there is no way that would have been missed with a skin audit that morning.

huge red flag that this is already going on in their heads. protect yourself. and the residents still at risk w/this nurse :twocents:

Up Vote Up Vote ×

believe me, i understand your frustration in dealing with substandard nsg.

what i don't understand, and correct me if i'm wrong...

is why are you taking it as your burden?

you stated the DON is aware...it's really her responsibility to deal with this employee.

if your DON knows of your frustration, what else can you do?

it sounds like it's out of your hands.

of course you can anonymously report this nurse to the bon, but other than that, it doesn't sound like she's inclined to change.

leslie

eta: i do believe you should write an incident report, ea time you see a dsg that hasn't been changed, even though it was documented as done.

this way, you're covering your own hide, should this ever come to litigation.

Up Vote Up Vote ×
Specializes in LTC, Nursing Management, WCC.
Yes, I am referring to a baby.

OK... :)

Up Vote Up Vote ×
Specializes in LTC, Nursing Management, WCC.

If you are a charge nurse, do you have the authority to coach her? And if no improvement then start the disciplinary process? I have a feeling your and anyone's incident reports is just getting put in the shredder. After all it would be dumb for the DON to keep all this information without out doing anything, it would be considered failure to act. Plus it's ultimately the DON's license as she is in charge of the nursing services provided and if she decides not to intervene than she is actively participating in the problem.

It also comes down to this... you have a duty to act. If you you know a nurse who is habitually omitting or falsifying documentation, you could be pulled into the lawsuit. Simply reporting the incident to the DON does not absolve you of anything. Sure you reported it, but if it continues, you are on a slippery slope. Your DON's failure to act can potentially be hazardous to your license. Is there a corporate compliance hotline for your company? Not doing treatment is not following the patients PPOC and is neglect and now you know. What are you going to do?

Some of the burden is now on you. You have to protect the patient. It is your duty.

Up Vote Up Vote ×
believe me, i understand your frustration in dealing with substandard nsg.

what i don't understand, and correct me if i'm wrong...

is why are you taking it as your burden?

you stated the DON is aware...it's really her responsibility to deal with this employee.

if your DON knows of your frustration, what else can you do?

it sounds like it's out of your hands.

of course you can anonymously report this nurse to the bon, but other than that, it doesn't sound like she's inclined to change.

leslie

eta: i do believe you should write an incident report, ea time you see a dsg that hasn't been changed, even though it was documented as done.

this way, you're covering your own hide, should this ever come to litigation.

Keep copies of EVERYTHING you do re: trying to get something done about this.

You've identified the problem...and causative or not- someone was hospitalized.

Please check your state's requirements about mandatory reporting- and protect the residents, and YOU :)

Up Vote Up Vote ×
Specializes in ER, TRAUMA, MED-SURG.
worked with a nurse who was caught charting ahead (same idea) and was fired on the spot. It is against the NPA in my state to falsely document. It is also required that if an RN has knowledge of this, it will be reported to the BON. The idea is to protect the patient, not the nurse. In this case, she is actually harming or has the potential to harm someone. I would check the meds too. Is she diverting or just lazy?

I've worked with two nurses that I became aware of doing this. Both from same facility. Both were terminated, and the PCP of one of the patients filed a formal complaint with state boards and they found out this wasn't her first time. She got her license suspended, and eventually revoked.

Anne, RNC

Up Vote Up Vote ×
If you are a charge nurse, do you have the authority to coach her? And if no improvement then start the disciplinary process? I have a feeling your and anyone's incident reports is just getting put in the shredder. After all it would be dumb for the DON to keep all this information without out doing anything, it would be considered failure to act. Plus it's ultimately the DON's license as she is in charge of the nursing services provided and if she decides not to intervene than she is actively participating in the problem.

It also comes down to this... you have a duty to act. If you you know a nurse who is habitually omitting or falsifying documentation, you could be pulled into the lawsuit. Simply reporting the incident to the DON does not absolve you of anything. Sure you reported it, but if it continues, you are on a slippery slope. Your DON's failure to act can potentially be hazardous to your license. Is there a corporate compliance hotline for your company? Not doing treatment is not following the patients PPOC and is neglect and now you know. What are you going to do?

Some of the burden is now on you. You have to protect the patient. It is your duty.

Yup, we have all heard about the nurse whom reported to MD with no response, but found culpable because (s)he let it drop at that point instead of going above that doc to the next step....In this case, either the administrator or corporate. After a few weeks with no result, on to the board.....I am not sure if there is anything else you can do. I am also wondering if the nurse is not in early dementia herself?

Up Vote Up Vote ×
Specializes in ER, TRAUMA, MED-SURG.
It's falsification of documents - hope that resident comes back, and there's no legal backlash, because that just added a few decimal points to the asking damages. :down:

I've been deposed (HORRIBLE experience- and the case was nuts)....they blow up the pages of the mistakes into poster size- with highlighted areas, and demands for explanations. They ask "gray" questions, and want yes/no answers. It's hell.... hope this nurse enjoys court if something happens and the family decides to sue- she can't un-chart stuff for when the resident was gone.

The supervisors get sued too.....in my situation, it was the admin, DON, myself, and weekend day nurse. Screwy charting will KILL any chance of a decent outcome (by that I mean NO damages awarded). There were some I&O 'holes' that were a big problem. (on some of the CNA charting. This was a patient who would NOT take in fluids.... the doc didn't answer faxes or phone calls. She'd had a GI bleed to the point of renal failure- and the family refused dialysis- she was 97 years old. The fluid was so far beyond edema that sh had pools under the wheelchair.

Chart what is done- no more, no less. :)

And when it's NH or something, it gets a lot stickier with the Medicaid fraud, doesn't it? Been so long since I've tried to remember any of that.

Anne

Up Vote Up Vote ×
Specializes in LDRP, Wound Care, SANE, CLNC.
I respectfully disagree that someone committing fraud needs more education. Charting that something was done, when it was not is SO basic, it would be laughable if it weren't criminal.

"Payback" is for personal gain; reporting a nurse who is negligent focuses on the well-being of the residents. By watching it, you are participating. You would be deposed also- and with nothing to save yourself. This situation bites- and I'd hate to turn someone in- but how are you going to feel when someone loses a leg, or dies from sepsis d/t improper wound care? I realize it's hard- but you may want to check your state's mandatory reporting info in your nurse practice act. :twocents:

I feel badly that you're aware of this- and have to make the decision to ignore it (as it seems the 'brass' is), or do whatever your nurse practice act demands for YOUR license in this situation. :hug:

A large part of me knows that but the new nurse in me is very naive regarding the outcomes of these things and have yet to come to terms with the fact that she simply is a lousy nurse and should not be taking care of people. I feel bad, but then I don't. I am really unsure of what will happen with this case but the more I see the more I question any of the things she does. I don't like working like this. I changed a bandage today that still had the one I put on on the 28th!! It was nasty and was never checked. I feel so lost as to what to do, I have never been in this situation and really want some advice on what to do next.

I guess my question is, now that the DON is aware of the issue will she take it from there or is it my duty to report this nurse to the board? I will defend my license at all costs, if reporting her is what I am to to then I will, I just don't know how to go about it yet.

Thanks for the advice, I appreciate it.

Up Vote Up Vote ×
+ Add a Comment