nurse doesn't do her charting

[NayNeyRN]

I work night shift in a specialty surgical hospital. We get lots of admits, even well into my shift, and patients tend to discharge the next day (not all, but most).

There is one day nurse in particular, who never seems to get her work done. She frequently times out the autologous blood re-infusion drains and has to waste the blood, and she barely does her hourly rounding charting. Most concerning though, is she often doesn't enter her admission assessments, saying that she'll come in and do them tomorrow. I had one patient that she did this on, and I went back in and looked at their chart after discharge, and she hadn't entered one at all, and it was now 48 hours post admission. She even told an orientee to not worry about charting, they could do it later and to make sure meds were passed and such, then went home and left the orientee at work hours after her shift trying to catch up on charting.

I have brought these issues up with both the day shift supervisor/charge nurse and my unit manager, and am frequently told that "day shift is so busy" or that "they have 24 hours to get the admission assessment in". I feel as though my concerns are being pushed aside and swept under the rug, and I worry for both patient safety (what if we have an emergency or have to transfer a patient out and I can't present all the necessary data because she wasn't charting properly), as well as for my own license when I follow her. I am at my wits end, and I have no idea what I should do.

[Kooky Korky, BSN, RN]

I've worked second shift at a larger surgical hospital, and occasionally work day shift if they ask, so I know how busy it can get. Any admits that come to the unit after 1800 are the responsibility of the oncoming nurse to assess. There have been many times where I get the patient that came in at 1800, then turn around and get my own fresh admit at 1905 (Sometimes sooner, but some of the PACU nurses try to hold them until after shift change for us). If it was just those not done, it wouldn't be a problem, but she gets admits starting at 1000, with no patients prior to that, and still doesn't get her assessments done. It's frustrating, because if I have a patient who is sedated or has something going on, I'll do a quick look back at the previous assessment to see if it's a new occurrence. I've had to narcan patients just after shift change before.

Can't assess pts who aren't there.

[KelRN215, BSN, RN]

Why would your license be at risk because another nurse didn't chart her assessments on a shift you weren't working? You are responsible for you. The other nurse's poor habits will catch up to her eventually.

[NurseBlaq]

I would never leave without charting. Even if I got an admission at shift change I'm charting a quick note about patient received alert and oriented, no distress, blah blah cause you never know what may happen. I'm not going to be held accountable for anyone's short comings or thrown under the bus cause there's a gap in charting.I don't understand the careless attitude some nurses have.

I used to work with a nurse like that and when she'd tell me adverse information during report my response would be did you chart it? I can't follow up on information not charted. Then I would make her do walking rounds with me. I spent the first hour of my shift making sure I didn't have patients about to code on me. We were on a critical care unit with patients on tele, how the hell do you not chart? I left because there were too many times I rolled back the monitors and patients were pausing, throwing PVCs, and all types of abnormal rhythms but nothing was charted. I was afraid I would have multiple codes working behind her with nothing to go on.

[hppygr8ful, ASN, RN, EMT-I]

Unless I have been specifically tasked with auditing someone else's work I don't make it my business to snoop around to see if other nurses are doing their jobs correctly. I am way too busy for that kind of malarkey. If what is happing is putting a patient in danger it should be reported. You may never know the result of your report so don't stew if you don't see immediate action. It's quite possible that this nurse has been on the radar. With today's litigious environment it is tremendously difficult to fire anyone with out risk of litigation. Often progressive discipline needs to be proven. We had a nurse like this and one day she was just gone.

Hppy

[Have Nurse, ADN, RN]

Have a chat with your Medical Director. Also, not charting on a patient is inexcusable. If the patient's condition takes a dive, and there is no baseline noted, it puts everyone in a difficult position. This is neglect, as there is no safe data with which to make nursing judgment when needed.

Example: Patient's lung sounds not charted. IV is going in at 125cc/hr. Time goes on, the lungs sounds continue to remain uncharted. If they have a history of CHF this is dangerous. If they don't, and the patient is tolerating fluids already, and it's STILL not charted, and the IV continues at that rate for a prolonged period of time, we can send them INTO CHF and there's no documentation warning us that it could have been prevented.

-or-

IV infiltrates, not charted. Re-started, still not charted. Phlebitis develops from previous infiltrate....do you see where I'm going with this?

[NayNeyRN]

Can't assess pts who aren't there.

But the patients ARE there? An admit arrives at 10:00 am, and no assessment until the next shift does their daily assessment that has to done every 12 hours.

Shift change is at 0700 and 1900, anyone admitted after 1800, the night nurses perform the admit assessments

[NayNeyRN]

Unless I have been specifically tasked with auditing someone else's work I don't make it my business to snoop around to see if other nurses are doing their jobs correctly. I am way too busy for that kind of malarkey. If what is happing is putting a patient in danger it should be reported. You may never know the result of your report so don't stew if you don't see immediate action. It's quite possible that this nurse has been on the radar. With today's litigious environment it is tremendously difficult to fire anyone with out risk of litigation. Often progressive discipline needs to be proven. We had a nurse like this and one day she was just gone.

Hppy

Our ER nurses typically do chart auditing. But it's not uncommon for a nurse to do a couple as well. Small facility means we wear many hats

[hppygr8ful, ASN, RN, EMT-I]

Our ER nurses typically do chart auditing. But it's not uncommon for a nurse to do a couple as well. Small facility means we wear many hats

I get that - I work at a small free standing psych hospital and our noc shift nurses usually do the audits. Still in your original post you did not say you had been asked to audit this particular nurse's work. I agree that inaccurate or missing charting is inexcusable but you have done what you can. now focus on your own charting and work and let the wheels of discipline turn.

Hppy

[Irish_Mist, BSN, RN]

Maybe I'm in the minority here but I do not care at all how someone charts or doesn't chart. I am not in management so I am not paid to care. Now, when it comes to patient safety issues, I definitely care. Your license has nothing to do with her charting. As long as you document everything, you have nothing to worry about. My advice to you is to continue doing what you're doing and provide the best care possible for your patients. I work with a nurse that does similar things that you've described and it amazes me she hasn't been let go. She doesn't chart anything except hourly rounding. There's also been numerous safety concerns I could write a novel on. She frequently leaves figurative messes for day shift (she's a night nurse) but I just keep on going. No sense losing sleep over it as I do not have the authority to address things like this.

[TriciaJ, RN]

The scenario I'm thinking of is when a doctor is informed of an adverse situation. He/she wants to know the baseline and about when things started going bad, right? And there is no info? They generally create a ruckus and that's when management starts to care about poor charting practices.

I take it this hasn't happened, yet? Not even when you've had to narcan patients?

[LibraSunCNM, BSN, MSN, CNM]

The scenario I'm thinking of is when a doctor is informed of an adverse situation. He/she wants to know the baseline and about when things started going bad, right? And there is no info? They generally create a ruckus and that's when management starts to care about poor charting practices.

I take it this hasn't happened, yet? Not even when you've had to narcan patients?

Seriously! The mind boggles at how so many incompetent nurses manage to hold onto their jobs. The best hypothesis I've come up with is that some managers just don't have it in them to confront people, and so it's more trouble than it's worth for them to fire someone, in their minds. This obviously makes no sense, as others have aptly pointed out, because when the ish hits the fan the lack of charting becomes glaringly obvious and lawsuits can occur. I will never truly understand it.

[vampiregirl, BSN, RN]

I'm another one that missing assessments/ info drives me nuts and see the potential to affect patient care/ safety.

Having been in management in the past (I finally decided I'm much happier in a bedside role), I also know that sometimes management is assessing and dealing with the issue but it may not be obvious to others. For example, the nurse may be receiving education and/or progressive action but this remains confidential between the manager and the nurse involved (as it should IMO).

Another approach might be to ask your manager for unit education/ memo/ parameters of what charting must be completed prior to leaving, timelines, and procedure for addressing "missing" charting that directly impacts your patient care if such a formal document/ policy doesn't already exist. Sometimes people are given an inch and proceed to take a mile if there's nothing formally in place. Sometimes this process can in turn cause reevaluation of the workflow processes and initiate changes to make things work smoother and positively influence patient care.