Shift nurses in Homecare, a question...

renerian, BSN, RN · Jan 17, 2005

Tough I know to audit files...........shift work is very different like you say. Most companies don't have MARs for meds but it can be in the narrative. Might your information be in a confidential complaint file or incident/accident paperwork that is never part of the file........the investigative piece per say. Are there orders to cover the month gap?

I know alot of nurses keep the home med file/yes there should have been one in the home to be the most current for safety and a complete snapshot on meds.

renerian

hoolahan, ASN, RN · Jan 17, 2005

That is the thing ren, there are orders for that period of time. Also, when we ask for the complete medical record, that should be the complete record. If there is nothing to hide, it shouldn't be a problem.

We have all had difficult patient's/families. But, we document the facts, the quotes, etc...to cover ourselves. I would not expect them to send HR records, but if there was an event, I wonder why it isn't in the record. The q 30 day sup visits are there, they all say family pleased w service, but then poof, one day, for no apparent reason, mom decided to go with another company?? It just doesn't add up.

I have reviewed a few homecare cases, when the charting by the nurses/sup's, negated the complaint made against them. When I find that, and discuss it with ur medical director, we close the file as "no quality issue."

I am going to call the mother and ask for more info. Then I am caling the agency to see why those notes were not included and to discuss their medication transcription policy.

renerian, BSN, RN · Jan 18, 2005

Under legal advice I have never charted an incident or complaint in the record. I have charted concern over blah blah blah and that it would be investigated but I would never put that investigation in a file. Ever. Heard several lawyers say that.

What does the mom say the malpractice issue is? I have done this type of thing on behalf of my family before and had to present a written statement of the issue, the objective data. I have submitted a multi paper statement before.

Could the wound care be on a missing flow sheet? I know where I was the flow sheets were left in the home and at the end of the week the flow sheet for wounds and such would be brought in by the case manager. If the mom suddenly asked the agency to leave they may not have had the chance to get that paperwork.hmmmmmmm.

I agree though something is not quite right. It would seem on either side......

I hope you get more information..........keep us posted..

renerian

hoolahan, ASN, RN · Jan 18, 2005

Really Ren?? When I was a supervisor, I had to document every call in the progress notes, from family anyway.

So, if a family was verbally abusive to you, you wouldn't document that? I always do, in case it happens again, you have more evidence to discharge them if it is a problem.

Well, I don't want to say too much, but the clinical issue was that a drug was given incorrectly, but she didn't say which one, or why she thinks that.

renerian, BSN, RN · Jan 18, 2005

Calls to the family are one thing but in the case of lets say a med error, that would not be part of the chart. It would be external with the med error paper work, counseling or discipline/termination or anything of that nature, HR related? Make sense? Yes I do document family calls, quotes of such but when it comes to thing like the above med errors and such it has always been internal. Kinda like an incident report/which could also be part of med error paperwork, is never part of the chart. Does that help?

I would be wondering if someone did pill counts, is the MAR in the home, wound flow sheets if they have one, where are the missing notes, did the company forget to copy part of the chart/like a missed thinned file and or so? I have had that happen before.....could be.........

I am glad you posted here as I love evaluating stuff like this........

renerian

DDRN4me · Jan 18, 2005

An interesting thread for me..as I have worked as a home care nurse and manager ....if we had an incident with the family that we felt did not belong in the home chart, the nurse was encouraged to either come in and discuss with me (and documented as a case conference) or written on a case conference form and sent in. the manager would then review it, and depending on the sensitivity of the document , either file it in the chart or internally. We did have med sheets in the home, and were required to chart when we were in the home. some nurses would have the parents initilal as well so we knew what was happening..depends on the case. I have had several conversations with parents who are happy with the agency one minute, then decide we are not meeting their needs the next...kinda goes with the territory..they only have so much contriol of their child's life and illness that they lose focus of who is trying to help them, so they can have control. I have also had some"personality conflicts" between the nurses and the parents which boiled down to who was in control. I think speaking to the agency and t he mom might shed some more light on t he situation. good luck..i remember how sticky some of these situations get!

renerian, BSN, RN · Jan 18, 2005

You bring up a good point. I don't like working with high risk peds as I cannot take the parents ability to turn on you on a moments notice. Sometimes it is justified, other times your a close target...........for other "issues".

renerian

hoolahan, ASN, RN · Jan 22, 2005

I agree med erros go on an incident form and do not go in the chart. But say, hypothetically, the nurse charts that she arrived at the home, and was not admitted, because parents said "We didn't know you were coming and made other arrangements." I think it is odd that it would not be addressed further. Personally, as a sup, I would have called the parents the next day and documented that parents werre instructed of proper procedure for change in staffing or not needing a nurse, for the record. I mean they have rights and responsibilities with the agency.

I couldn't reach mom, number disconnected, and we have requested a review of the agencies policies and procedures re medication documentation/discontinuation.

mgallant, your assessment of the whole social environment is great. I have only been a sup/worked for agencies that did visits, not shifts, it's very different. I can see where the parents are torn. I personally don't think I could stand to do shift work in someone else's home. I am flexible, but maybe not that flexible. In that instance, I much prefer the hospital setting, where I have a wee bit more control. And get get relief to pee, eat, etc... which I understand is hard to do in that kind of home care. God bless those peds homecare nurses!!

JustBonny · Jan 23, 2005

I am doing quality reviews for an insurance co, and I had a case where the mom of a child alledged the nurses gave her child a wrong dose of a med.
I read through 6 months of 487's, notes, etc...but I found the documentation very confusing.
In this situation, the child rec'd 7-3 and 11-7 nursing care. Parents did 3-11. So, there was no med kardex where nurses signed out daily doses, I guess because parents would not be expected to do so, and that makes sense.
I did find med lists, but they were very often not updated with the latest orders, and D/C of meds was documented only once out of 20+ changes. I never saw any documentation of dressing/treatment changes in the care plan, only on the 487, and when 485/orders updated every cert period.
**Hi I work in NY as an independent home care provider for shifts. We are required to keep a regular med sheet up to date in the patient's chart. If the meds are administered by someone else ie: Family members, we simply chart
Can you tell me how you track this info? I have to call the child's mother to see if she can give me a specific example of the errors she is referring to, but I suspect the chart has been sanitized. For example, there was one eve when the nurse documented she was refused access to the home. But no follow up call by a supervisor the next day? And mom requests a new agency with absolutely no indication of a problem documented? And a month of nurses notes is missing.
I see the mom signs the nurses notes each shift, so I can understand why nurses would be hesitant to chart negative social issues, but wouldn't there be some kind of documentation in the office record, if you informed your sup about a situation in the home? When I was a sup, I documented calls from the nurses.
I find it odd. What do you think? And how do you track med/treatment changes? What records do you keep in the home, and is there a duplicate record in the office?

Hi

I work as an independent provider of RN shift care within Homecare. We must keep up to date med sheets indicating all meds given. If the meds are given by a family member, we chart

F="Family Responsible or a check mark= for "By Others"

JustBonny · Jan 23, 2005

Hi
I work as an independent provider of RN shift care within Homecare. We must keep up to date med sheets indicating all meds given. If the meds are given by a family member, we chart
F="Family Responsible or a check mark= for "By Others"

PS. I also work as a shift nurse for an agency, and the agency is responsible to maintain all these records. The nursing supervisor is responsible to update the 485 every 2 months and make sure all MD orders come back signed.

renerian, BSN, RN · Jan 23, 2005

That is pretty standard.

renerian