So this is a vent. A few nights ago we had a newish PCT work with our night rotation. She normally works with our other night rotation. She's still in her probationary period.
I had one patient who was s/p CVA who was a turn q2, aphasic, contracted, the works. Blood pressures never dipped below 180. The doctor was aware and was not treating it. Anyway my 2000 vitals on him were 199/75. pretty normal for him. I wasn't concerned. The family members in the room actually told me before I saw the sheet from the PCT.
At 2200 I noticed he was not turned so I turned him. No problem he was an easy turn.
For 0000 vitals I had noticed the PCT was making her rounds and was passed his room while I had did my q2 rounding. When I went into his room he was again not turned and I had asked the family member, who by the way was sitting by his bed holing his had, if his blood pressure had went down. She had told me that they had not come to check his vitals since 1930. I thought to myself maybe she was saving him for last so she could check him to make sure he was not dirty. I turn him before I leave.
One of my other patients had just gotten out of the bathroom when I made rounds on him and had asked for the PCT to go in his room to take his vitals because he was in the bathroom when she went to his room. I called her on her phone and she said ok. I went back to the desk. She gave me my vitals about 20 minutes later. She had not gone back into my patients room who was up in the bathroom, I know this because he was across from the nurses station and I could see his room, but of course I had vitals on him. At this point I'm mad. I ask her to re-do his vitals, which she did. I then noticed that my CVA patient had a blood pressure of 131/50. I go into his room and ask the family member if his blood pressure was taken, and she tells me "no". I take his blood pressure myself and its 180/50. Now I'm fuming. I confront the PCT who tells me "I took them". I roll my eyes at her and then let the charge nurse know about it.
For 0200 rounds I follow her a few rooms apart. Pt. not turned. I turn him. Still mad.
At night it is at the nurses discretion whether or not 0400 vitals should be taken. I request for my CVA patient's vitals to be taken. The PCTs normally start vitals at 0430 so they can collect I&Os and do vitals at the same time. When I get my I&O's and vitals my CVA patient, who was pretty much comatose, had an intake of 270 and a blood pressure of 130/50. I take a deep breath before I blow up. I go into the patients room take his vitals and I get 195/50. I can also feel heat radiating off his body. His temp was 101.2 axillary, the PCT had 97.5 written down. I ask the family member who about the vitals and she tells me all the PCT did was empty his foley bag and leave.
When I look at my other I&O sheet all of my patients have intakes of 270. and most of them were wrong after I go and ask the patients myself. I don't even talk to the PCT again. I tell the charge nurse again and she makes copies of all the sheets.
When my nurse manager arrives in the morning I show her all the sheets and tell her what had happened during the night. She takes my papers and pulls the PCT in the office. Of course the PCT does not get fired. The NM tells me they are working with her because she is a "good" PCT who shows up and picks up shifts when we need her to. OMG is she serious. They are keeping someone because she shows up. What she did was falsify medical records which was ground for termination. I can not trust her with any of my patients. Especially when she says she took the patients blood pressure when the family member said she didn't.