State Survey...?

[HopeOnTheRocks]

I am currently a CNA (I'm studying for my RN, and needed a job to get myself through college) in a LTC. Today there were rumors of state (California) coming in tomorrow at some point. I am not working tomorrow, however tonight, after an extremely hectic shift, I realized I forgot to chart ADLs for one of my patients. This patient (We'll call her Mrs. X for now.) is not technically on my unit, however, after a patient requested not to have me as her CNA, I traded a coworker, and took on Mrs. X for my assignment. I guess my question is, at 1:00am (my shift ended at 11:00pm), should I be considering going back to fix it? Is this an offense my facility will be severely fined for, and will I be fired? My facility is under new management, and I have worked here for a month, meaning I am still on probation. I am really nervous and am losing sleep over this... what should I do?

[classicdame, MSN, EdD]

there is probably a policy to cover late entries but you will need to talk to your supervisor before editing the chart. Would sure look suspicious otherwise.

In our facility, we must contact our Department Director and the Safety Officer (Risk Management). With their permission we may chart. Since it is done on computer a print out will read that at 0900 on Sept. 2 I charted that on Sept 1 at 0100 such-and-such occurred. I cannot get around the computer "telling on me".

[nurse4ever08]

If still paper charts go back but let house supervisor know you are coming. Call and ask if computer charting.

[VivaLasViejas, ASN, RN]

Try not to sweat this too much. You are human, you made a mistake.....it's not the end of the world, and if you were to be fired for a first-time charting error you don't want to work for that place anyway. Don't worry about the facility being fined, either; a single piece of omitted CNA charting is not usually a cause for a citation. (I was a surveyor myself for a short time. We only cited it if there was a pattern.) Take it easy, you're doing fine.