Xtreme1

Well, I found another chart in which the nurse removed another med incident that happened on July 8th. The same RN took/ tore the charting out and re-wrote others charting, but omitted a lot of other information that had been charted. I knew this because copies of the chart were in another location that she wasn't aware of. Then, when she re-wrote the incident, which happened on 7/8/2003, she mistakenly wrote 9/8/2003! It sticks out like a sore thumb! I showed this to the Admin and admin made copies. This RN told one of my co-workers that she had "shredded" some of the charting because it wasn't written right and that she was doing the organization a favor by shredding the charting as what was written, by another employee, was not proper, so she was actually doing the organization a favor!!! She said that the reason that she did not call the employees in, but instead, forged their names was because she didn't want to "bother them" The admin called her and she refused to come in, but told them that she was doing them a favor by removing the charting and by forging the sigs as she didn't want to bother the employees. The kicker....tonight, while at work, the RN calls me and threatens me! She tells me that I committed a federal offense because I had photocopies of the charts, which I made and took directly to Admin and that I could go to jail!!! I told her that I took the info/copies to admin after I discovered what she had done, nothing more, and that that's where the copies are today and that they didn't seem to have problems with it...in fact they also made copies. She was VERY threatening and was trying to intimidate me. I am an ex-police officer of 18 years who worked undercover drug investigations and professional patient cases, so I do not intimidate easily. I told her that we would see what the BON would say about her actions. Her answer: She did nothing wrong by removing the charting and the forged signatures were done to avoid bothering the employees. She says that ANY NURSE would have removed the charting in question if they didn't think it was written right.....SO, what does everyone think? Bottom line: Irregardless of whether or not the charting was done correctly, can it be romoved, destroyed, altered & forged by the charge nurse??? I think not! Let me know what you think. Greg

I went to Admin this a.m., haven't been to sleep yet! I also contacted the BON and one of their investigators, we'll see where it goes from here. Now, I fear some type of retribution once she finds out! I REALLY appreciate all of your insights! Thanks a lot! Greg

I came to work and while making rounds, a pt, 75, who was 5 days post-op from a pacer install told me that 24 hours earlier that he had been given a wrong med, Ditropan XL 5mg p.o., which was another residents RX. He also told me about how the aide tried to talk him into letting her stick her finger down his mouth to induce vomiting! I had heard about this, so i knew that it had happened. When I checked, there was nothing charted...nothing! I charted..by hand, what the pt told me and that I could not find any documentation anywhere, so i referred it to the RN in charge on a.m.'s. She left me a voice mail saying that I should not have written any of what I was told. When I came to work last night, the RN had torn my charting out completely and re-created the top of tyhe chart, with two entries by other staff, forging their writing and signatures. Trouble is...I had made copies of my charting and when you compare them, it is obvious what she has done. Sooo, what would you all do?? Thanks! Greg