I am a RN in LTC. It has been well over a year now that nurses are not following important protocols. The new nurses in the last year are not taught to follow protocol or to document correctly, then they orientate new nurses without teaching them protocols, then no one knows what they are doing. Recently I have reviewed approx 30 charts for the MDS, and found many problems with documentation. Here is just a couple of protocols they do not follow:
1. Skin Protocol & Protocol for Pressure Ulcers - many nurses document like this: open area on buttocks, duoderm applied, check daily for placement or open area 1cm x 1cm, duoderm applied, check daily. Thats all thats done. My main gripe is Protocol for pressure ulcers, no prog note, skin sheet not started, order for labs, orders for zinc and vit.C not obtained by MD, referral to dietician not made, care plans not updated, no skin assessments to follow, pressure relieving devices not initiated. This is a constant problem, no inservices to correct this problem.
2. Fall Incident Reports - the nurses do not fill out the incident reports correctly, and the prog notes are extremely vague. Reading the prog notes, I have no idea when the fall occured, how they fell, no vitals, no intervention to prevent fall and care plan not initiated or updated.
I am not in the position to make corrections with the nurses. The DNS is and is not doing so. Any thoughts on this?
