Problems with CNAs and Jeopardizing Nursing License

EmmaG, RN · Mar 26, 2008

Way back when in my grad year, my head nurse called me to task for not doing anything about a 102 fever in a patient ( the residents jumped on her when they found it). I whined the aide hadn't told me about it, she very bluntly said it was my job to review my patients' bedside charts and know what was going on. She was right, I knew when they did vitals, and could easily have looked for the VS when I was assessing my patient.
It wasn't life threatening the way jerzytech's patient was, though. But it wasn't addressed for several hours either (we had standing orders for blood cultures for fever).

I've never really had many problems with our techs informing us of abnormal VS. They're pretty good about that. What I have had an issue with is the times they chart them under. They'll take VS at say, 2130, yet chart it as '2000'. Even though they do come and report it to me, it then looks as if I waited 1 1/2 hours to address it. That's a big deal when dealing with our patient population...

Our tech sometimes is the only one working at night, and God bless her... she can be a bit slow. I've known her to take upwards of two hours to complete the VS for the floor, and when she charts all of them as being done at the same time, that really presents a problem. I'll do my own when I work 11-7, but when I'm in charge and have other stuff to attend to I really need her to just chart accurately.

medsurgrnco, BSN, RN · Mar 26, 2008

So if the CNA charts the VS as being done at 2000 but you didn't address abnormal VS until told about them at 2130, how do you cover yourself with the apparent delay in caring for the patient? Do you document in a nursing note the time the abnormal VS were reported to you and your actions taken at that time? Would this work if questioned later?

EmmaG, RN · Mar 27, 2008

So if the CNA charts the VS as being done at 2000 but you didn't address abnormal VS until told about them at 2130, how do you cover yourself with the apparent delay in caring for the patient? Do you document in a nursing note the time the abnormal VS were reported to you and your actions taken at that time? Would this work if questioned later?

She would tell us just as soon as she got the abnormal--- that I appreciated and expected her to do. It wasn't a matter of her not telling us right away. She did do that. The problem was, she was falsifying the times on the patient record as to when she actually took the VS. For example, she took them at 2200, but charted them as 2000. Or she'd be still doing midnight VS at 0130, but recording the times on the charts as 2400. And she'd chart that she notified the nurse. Taken together, it appeared as though nothing had been done for x amount of time (sometimes upward of 2 hours). It took a lot of discussion with her to finally get her to see why this was wrong to do. Even so, she'd fall back into the habit now and then.

EmmaG, RN · Mar 27, 2008

Another issue I had similar to this was at one of my travel assignments. Everything was on computer. The techs would do VS, then sit down and chart all of them, then come tell us if there was anything abnormal. There was a space for them to chart "nurse notified" under their VS charting.

Now in this case, the techs were timing their entries with the correct time. BUT, by charting they'd notified the nurse under the same time stamp, it again made it appear we'd ignored the issue for however long.

As an example... they'd take a patient's VS at 2330, and something was abnormal. Instead of notifying us right away, they'd continue to take the rest of their patients' VS and do whatever else they needed to do on their first rounds, then sit down and chart everyone's VS (using the correct time stamp and including the notation 'nurse notified'), then actually notify us of any abnormals.

This was often upwards of 2 hours after the fact. They were charting they'd gotten VS at 2330--- which they had--- but also that they'd notified us at the same time, when in reality we were being told of these abnormals much later. So like the example above, it appeared we waited for hours to act.

Does that make sense too? lol

november17, ASN, RN · Mar 27, 2008

Just an example, I was at a clinical site doing med pass. Mrs X's med was to be held with a BP lower than XXX/XXX, the aid assigned to the pt was told by her floor nurse to get the pts BP for us. She huffed and grumbled about it but ended up snatching the cuff and scope off the desk and went to the pts room. She was back in a flash..too soon in my opinion, giving me the slightly high BP but not alarming (pt had HTN). My instructor and I headed into the pts room to administer the med and my gut told me to take the BP myself. I got something like 90/70 but the CNA had given me me something way way higher. Trying to give the benefit of the doubt, I grabbed the cuff and stethescope she used and lo and behold, the steth was broken and the cuff's knob was tightly closed..uhh so how did she take this bp?? When her floor nurse confronted her the CNA blatently stated "I WAS going to take it but the stethescope was broken and I didn't feel like walking all the way down the hall to get a new one, then walk all the way back to take the BP, then all the way back again to give it to the student" She was written up and discipline. And shoots daggers at me everytime she sees me. Oh well.

We've both been aides so I think we can agree. Being overworked sucks, eh?

It is too bad that the aides that can't handle it end up doing crap like you just mentioned. Instead of quitting and finding another line of work. It's a shame because it puts people's lives at risk.

bagladyrn, RN · Mar 27, 2008

Another issue I had similar to this was at one of my travel assignments. Everything was on computer. The techs would do VS, then sit down and chart all of them, then come tell us if there was anything abnormal. There was a space for them to chart "nurse notified" under their VS charting.
Now in this case, the techs were timing their entries with the correct time. BUT, by charting they'd notified the nurse under the same time stamp, it again made it appear we'd ignored the issue for however long.
As an example... they'd take a patient's VS at 2330, and something was abnormal. Instead of notifying us right away, they'd continue to take the rest of their patients' VS and do whatever else they needed to do on their first rounds, then sit down and chart everyone's VS (using the correct time stamp and including the notation 'nurse notified'), then actually notify us of any abnormals.
This was often upwards of 2 hours after the fact. They were charting they'd gotten VS at 2330--- which they had--- but also that they'd notified us at the same time, when in reality we were being told of these abnormals much later. So like the example above, it appeared we waited for hours to act.
Does that make sense too? lol

Just so you know - if a question ever arises concerning this - these systems not only record the time the person puts in (as in VS @ 2330) but also notes the actual time that the charting was done,(for ex: 0130) even though this doesn't show up in the note. It can be accessed any time there is a question about a discrepancy such as this. Doesn't help in terms of the pt. getting timely care, but can help to show where the problem is.

medsurgrnco, BSN, RN · Mar 27, 2008

I've worked with such computer systems too. But I've had situations where CNAs would take all VS, then put them all in the computer, and not tell me about abnormal VS. After numerous times of checking to see if VS were in the computer yet, I'd find out 2-3+ hours after the time the CNA recorded VS were taken that I needed to address abn VS. There's no proof of when - or if - you were informed of abn VS, or when you found out about them through the computer. I've also had CNAs take VS on an admit, and then not tell me what they were or record them in the computer for 5+ hours! And then have an attitude when I repeatedly tried to obtain that info. So where's our protection for our nursing licenses if something happens when the CNA didn't tell you timely about abn VS or record VS timely?

casi, ASN, RN · Mar 28, 2008

Maybe I'm over enthusiastic, but whenever I get vital signs, not only do I report abnormals I give the nurses a copy of the normals too.

Maybe it's a matter of asking the nursing assistants what the vital signs were.

medsurgrnco, BSN, RN · Mar 28, 2008

Sounds like you're a great CNA. I don't see why CNAs can't just xerox the VS and give them to the nurses (or put them at an expected place in the nurses' station). I've tried asking CNAs about VS, but typically CNAs don't want to take the time to tell me VS or don't have their paper sheet handy or are busy doing something else so that freq doesn't work.

NewNurseyGirl2009 · Mar 28, 2008

Ok so this tread to me seems like an attack on CNA's. I am and CNA and a tech. I have been in the same situation as an aide. A nurse has not given me crutial information on a patient. Once I had a patient and it was not reported to me that they were DNR and his resps were 4. The nurses are supposed to report this to us but are busy as we are. Because of this, I walked in the room and called a code. I also one time had a nurse freeze in a code and leave. I was the one there to report to the dr. the nursing sup, and the other code team members as I was the one taking the vitals. You know we are all worked an overstaffed. You may have 5 pts but we may have 3 nurses which total 15 patients. It is ultimatly your responsibility to check the chart as it is your license on the line. That being said I ALWAYS report anything questionable. I am a very good aide and I work the the OR so I have to be on top of my game. I could kill someone, however we all need to work together and forgive. We all check eachother and remind eachother of stuff. So before you give a hypertensive med, your darn right you better check the chart and make sure the pt's bp is not low. Other nurses do this to eachother too so dont just single out CNA's. If one person does this out of malice then it is that co-worker and not their title that did it.

pagandeva2000, LPN · Mar 28, 2008

Sometimes, nurses have to jump into things as soon as we get to the floor, and don't have time to go to the CNA. CNAs are taught to report anything abnormal to the nurse while in training and I am sure during orientation to their facility.

This really is not a thread to downtalk CNAs, although I can see how it can be interpeted that way. If the CNA does go and tell the nurse what happened that is abnormal, then, it is the nurse's decision on how and when to act (the critical thinking and prioritization we are taught in our training). There is a tech that works with us in the clinic and she is phenomenal. She comes to us with everything that appears to need attention. I remember once, she told me two things, an argumentative patient needed clonidine, and another one needed a nebulizer treatment. I told her that I needed to address the nebulizer first, even though the clonidine one was basically getting on all of our nerves. I took her to the side later and explained how we prioritize care and since then, she has sort of done the same thing...told me that one person needed clonidine STAT, and someone's pressure was high (I had to recheck it myself to be sure) and that showed me this girl has initiative and is a team player. She knew that with the clonidine, the patient was already assessed by the doctor and that the other high one can wait for just a few minutes more. This is not to say that all aides are lazy or that they should think like nurses...but that we really need their assistance. They are not doing vital signs in vain, that information is really needed for us to act.

Funduhmental101 · Mar 28, 2008

Had to post on this one

It seems like many fingers are being pointed and this is a common scenario constantly playing out when it comes to patient care. I mean come on how much time does it take to get a set of vital signs even if it is two sets a few minutes apart- one set taken by the CNA, and one set taken by the RN (You can never be too sure). If the patient's vitals are a key component to the medication process I would want my own set of vitals if I was the RN, because YES it would be my livelihood on the line. Delegation can be a very slippery slope with many feelings attached to it. I would give my opinion to never delegate something that you wouldn't do yourself and to make sure the job/task at hand is completely understood by the person you are asking of. We all have co-workers who show up for a paycheck C.N.A.'s and R.N.'s alike so for those of us that care, first and foremost, for the patient's needs it is important to recognize these people and give them a reality check because afterall it IS a person's life that COULD be on the line here. Like most others here I can go on and on about situations that come up like this but i am sure we can all name a few off the top of our heads. Why do we emphasize communication so well when it comes to patients and then we could care less when it comes to our colleagues? Why dont we use the same communication to help support a positive work environment that EVERYONE can feel good to be apart of? Who knows, maybe delegation would be easier and maybe the jobs/tasks would be done efficiently(what a silly concept).