Question about who is responsible for an incident report

[horrorxgirl]

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?

[ixchel]

Okay, I stalked. You are new!

Welcome!

Stick around!

Try not to let us crazier people scare you off. We get weird, but we mean well. :)

[psu_213, BSN, RN]

We get weird

Speak for your self...Oh wait, I resemble that remark!

[kbrn2002, ADN, RN]

Well, as the risk manager, I do answer these questions, fill out the interrogatories and get deposed on this. Because there are so many exceptions; specific state statutory and case law unique to each jurisdiction; and the existence of any peer review, quality improvement or work-product privilege; one cannot make a blanket statement that incident reports are not discoverable or incident reports are always discoverable. It all boils down to the facts of the case, the subject matter of the litigation, and if there are alternative means to find the information other than the incident report. Whenever anyone asks me if the incident report is immune from discovery, I always reply: it depends.

I would say that a fairly consistent national trend over recent years has been to chip away at the discovery protection of the incident report. And yes, any plaintiff counsel with experience knows that incident reports are ubiquitous in almost every healthcare setting, and they will often issue a request for product, subpoena duces tecum or the like to try and compel them to be produced.

I ask my staff to fill out the incident reports in a factual manner, with information that allows me to figure out why the incident happened, and I use them to figure out if are there are any lessons I can derive from this in order to change practices to reduce the risk of this incident happening again. Just as I instruct my staff about charting, I ask them to not write anything in the incident report that they would be embarrassed or chagrined to explain in front of the 12 nice people in the jury box or the administrative law judge or disciplinary panel at your license hearing.

Thank you! You answered my questions perfectly! Yet another reason to educate staff on the importance of complete, factual and objective charting. I work in a SNF and we still use narrative charting. Some nurses chart entries are less than stellar and more resemble an exercise in a creative writing class than a nursing note.

[psu_213, BSN, RN]

Some nurses chart entries are less than stellar and more resemble an exercise in a creative writing class than a nursing note.

Yes, I see some of those notes too. Either that or they chart virtually nothing on some sort of an incident.

I don't know the legalities re: incident report, specifically if they can or cannot be evidence for a plaintiff's attorney in court if they are not mentioned in the actual chart. Either way, though, I keep mine short and sweet, and, in the incident report, refer the reader to my nursing note. I don't feel like typing out my assessment again in the incident report when it is all in my NN anyway.