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Question about who is responsible for an incident report

Posted

Specializes in LTC, peds, rehab, psych. Has 8 years experience.

Ok so the other day my wife was working a 12 hour night shift with the first 4 hours on one unit and the following 8 hours on a different unit. She arrived on the second unit around d 11:15 after giving report to the relief on the first unit. During 11 and 11:15 there was a fall on the second unit before my wife had made it to the floor. The nurse who was still on that unit assessed the pt and removed them from the floor and reported it to my wife but did not do an incident report. My wife also did not do an incident report because she was not the nurse who saw the pt on the floor and assessed them. She did write a nursing note for her shift with vitals and follow up assessment.

Her employer is telling her that she is the one responsible for the incident report because it happened after 11 and that it's not their job to pay overtime to the previous nurse to stay and do it although my wife wasn't even on the floor yet when it happened. She was concerned about how this could be used in court against her and that it could be false documentation. Her employer does not care and actually yelled at her for bringing up these concerns. She talked to her supervisor, the ADON and the DON and they are all saying that it is her job and not the other nurse. This makes no sense to me.

At my hospital, the person who finds the pt on the floor is who does the incident report, even if it's a CNA. The nurse may fill out the parts pertaining to medication and dr. Notification and so forth, but the person who finds the pt is who describes the incident.

I know that incident reports are not part of the pt's chart but they can be used for litigation purposes. Am I right in thinking that her facility is a careless place? And are they wrong?

Yes they are wrong. I surely wouldn't document the details surrounding a fall without having been present. To document about an incident that one didn't even witness, wasn't present for, however you want to spin it, is not legal as far as I'm aware.

Usually, a nurse whose shift ends at 11:00, in reality ends at 11:30....the last half hour is used for report and isn't considered overtime. So that excuse is kinda BS.

If I was your wife, I would thoroughly document the situation, patient assesment, VS, etc. as it was from the point that I assumed care of the patient going forward and that's it.

Miss Rayanne

Specializes in LTC/Rehab, Pediatric Home Care. Has 9 years experience.

Good question. I think whomever discovered the incident should feel out the report, but I would consult your company's policy and procedures. Did she put anything in the nurse's notes? I would also advise your wife, that the next time, something happens to a patient and another staff does not fill out an incident report, she should just go ahead and do so. That way no one can accuse her of not doing her job. Sounds to me, that management might be trying to make her a scapegoat.

When feeling out the report, be sure to word it like this. Patient/Staff reports Mrs. Soandso fell. I assessed patient and found, blah blah blah.

Jensmom7, BSN, RN

Specializes in Hospice. Has 36 years experience.

Basically, it's "S/he who finds it gets stuck with the paperwork". Sounds like a very large buck getting passed.

Just to cover her butt, she should fill out an incident report, and word it to the effect that she did not witness the fall or find the patient, but was told of the incident during report. Then go and document what happened after she got there-her assessment, VS done, if she notified family or MD, etc.

Edited by Jensmom7

KelRN215, BSN, RN

Specializes in Pedi. Has 10 years experience.

The person who discovers the incident is responsible for filling out the incident report, regardless of when it happened. It is possible, for example, to discover an incident that didn't happen on your shift and then the onus would be on you to report it. If your wife had walked in and found the patient on the floor at 11:16, she would be responsible for filing the incident report, even though the patient likely fell before she assumed care. But, that isn't what happened and it's the off-going nurse's responsibility.

Why do you expect anything will end up in court? If they insist that she write one, she should simply write "received report from RN Suzy at 11:15. RN Suzy reported that Mrs Smith fell out of bed at 11:12. Per this RN's assessment Mrs Smith was... blah blah blah."

horrorxgirl

Specializes in LTC, peds, rehab, psych. Has 8 years experience.

It's not that I would expect it to end up in court, it's more a question about who should be responsible and if her filling out the details of the report could be considered false documentation.

amoLucia

Specializes in LTC.

I think the general consensus will be that the first nurse SHOULD have initiated the incident report. But having said that, the fact that one was NOT started, it would fall to the second nurse (your wife) to make one out. I'd check out the facility's P&P for specifics, but an incident report is required for the occurrence and should be done ASAP.

Fair? No! But we're talking protocol and legalities to CYA. Many a time, I have had to document something that occurred ahead of me that was not addressed by a previous nurse. All your wife had to do was just start the report with the sentence 'pt found on floor by previous shift'. And fill out whatever she could. Management could follow up with #1 nurse for more details.

Bottom line is that 2 wrongs doesn't make a right. Your wife IS NOT going to win that battle of wills. Failure of #1 nurse to do her part, does NOT give permission for #2 nurse not to do the necessary thing. FWIW, I'd have started the incident report. Just my $0.03.

(I do hope that family & MD were notified as required.)

horrorxgirl

Specializes in LTC, peds, rehab, psych. Has 8 years experience.

Ok. I just wanted to make sure that they weren't trying to make her do something illegal.

I've worked at many facilities and I've never seen one not require the witnessing party be the one to fill out the report. When I tried to look up the legalities of it I couldn't find anything specific to the situation and wasn't sure.

KelRN215, BSN, RN

Specializes in Pedi. Has 10 years experience.

It's not that I would expect it to end up in court, it's more a question about who should be responsible and if her filling out the details of the report could be considered false documentation.

It would not be false documentation if she reported "off-going RN reported to this RN that patient fell at 11:12PM."

heron, ASN, RN

Specializes in Hospice. Has 40 years experience.

If the facility doesn't have a policy on this, it should. In my shop, if the incident happens before the formal start of shift change, ie 22:55, it belongs to the off-going shift. If after, ie 23:05, oncoming owns it. Arbitrary, yes, but it cuts down on this kind of confusion.

NicuGal, MSN, RN

Specializes in NICU, PICU, PACU. Has 30 years experience.

She should fill it out to cover herself. She just documents that the patient was found by GIJane RN, reported to me blah blah. But it should be the person who discovered it since then it is first hand info.

RiskManager

Specializes in Healthcare risk management and liability.

As the person who reads and acts upon the incident reports, I agree with all the comments above regarding doing the incident report and noting that the event was reported to, but not seen, by the person completing the report. I do hope that the first nurse made an appropriate chart note regarding her discovery of the fall, assessment and actions thereto. It is also not unusual that multiple staff complete multiple reports on the same event.

canoehead, BSN, RN

Specializes in ER. Has 30 years experience.

The policies book should be quite clear on who fills out the incident report. I don't think it's politically helpful to your wife to point that out even if she is right, but it'll give her an idea of what kind of workplace she's taken on.

kbrn2002, ADN, RN

Specializes in Geriatrics, Dialysis. Has 19 years experience.

It's not that I would expect it to end up in court, it's more a question about who should be responsible and if her filling out the details of the report could be considered false documentation.

1] It is pretty standard procedure to not ever mention an incident report in charting. This then opens the door for state and/or lawyers to gain access to not only that particular incident report, but all of them. Incident reports are actually the domain of the company and not part of a medical chart. So, unless somebody foolishly mentioned said incident report in the chart, it will not be part of any kind of court proceedings should it come to that.

2] While it's also pretty standard for the nurse witnessing the event to complete the paperwork that doesn't always happen. There is a big grey area...shift change. It's not unusual for the oncoming nurse to complete paperwork when a fall [or other incident] happens when both off-going and oncoming nurses are in report.

3] Incident reports often include information that isn't witnessed by anybody. Pretty often nobody was there to see the fall so all of the information in the report is either by direct observation of the events that were witnessed after the incident, objective findings per nursing assessment post-fall and subjective findings per interviewing the patient and the staff that initially discovered the situation. Any reported findings are simply prefaced with "per report by XYZ" and this makes it perfectly clear that the person actually filling out the report is not the person who witnessed these particular findings.

I am only using a fall as the example since it my experience that the majority of incident reports are fall related, though there can be any number of things that can trigger an incident report being filled out. Since these reports are facility generated and facility property policies and actual reports used will vary.

Edited by kbrn2002
spell check didn't catch it!

ixchel

Specializes in critical care.

In my opinion, it IS the facility's job to keep the nurse on overtime to do the incident report, and your wife was not present for the fall therefore is completely unable to do an incident report. She can only report what she observes, which would be the follow up assessment. She has no way to know that what was reported to her was exactly how it happened. I wouldn't touch that incident report with a 10 foot pole.

Miss Rayanne

Specializes in LTC/Rehab, Pediatric Home Care. Has 9 years experience.

1] It is pretty standard procedure to not ever mention an incident report in charting. This then opens the door for state and/or lawyers to gain access to not only that particular incident report, but all of them. Incident reports are actually the domain of the company and not part of a medical chart. So, unless somebody foolishly mentioned said incident report in the chart, it will not be part of any kind of court proceedings should it come to that.

That is a common belief among healthcare workers, but it is a false one. When there is a survey at your home, administration does not have to produce any incident reports to the state. However, in the event that the facility is sued, either by a private party or the government, an incident report is considered discoverable. Most decent lawyers are aware that making incident reports are a standard procedure for most medical facilities and they will try to gain access to them during discovery.

psu_213, BSN, RN

Specializes in Emergency, Telemetry, Transplant. Has 6 years experience.

Ok. I just wanted to make sure that they weren't trying to make her do something illegal.

No, it would not be illegal. She should simply state "Per report from Sarah Smith, RN, pt was observed on the floor at 2305 on 6/12/2015. See nurse's note by Sarah Smith, RN timed 2308 for details on the incident, pt. assessment and pt. VS."

That way, the incident it forwarded to risk (or whomever deals with these reports) and it is clear that is does not fall (no pun intended) on her.

NurseSpeedy, ADN, LPN, RN

Has 18 years experience.

Every place that I've worked at it's the person who found the patient on the floor who start the incident report. Now, I worked for one place that if the aide found the patient on the floor and a nurse was on duty, they were not to help the patient up but to radio the nurse for assessment. In this case, the nurse who came in saw exactly where the patient was went they fell and proceeded from there with assessing the patient to see if safe to get up or if EMS was necessary. Then, the nurse would fill out the report. If it happened overnight (no nurse) the aide would start the initial report with writing in what had happened and the nurse would then assess the patient for injuries that may not have been noted by the aide and complete the rest of the report, notifications, etc.

If it's change of shift, give report, and then finish your incident report. It should not be left for someone who wasn't there when a licensed nurse tended to the patient on the floor. We cannot document what we have not observed. If your wife is getting issues from management because they want to pinch pennies this badly (especially with a fall, which can result in a legal case if injured) then I would recommend finding a better facility to work for, just my suggestion.