do you think I should be written up?

Nurses General Nursing

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I want an opinion if you will....I am an LPN in a nursing home working the evening shift. A nurse on the day shift took an order from a dr. to start a resident on an antibiotic a month prior. She passed onto to me in report the order was taken and the med was ordered from the pharmacy. I have a med tech that passes meds on my shift so never saw the EMAR. I charted in the progress notes that resident continued on antibotic therapy and was afebrile. A month later I find out after the resident has a uti that has festered for a month, that the day nurse never entered the order in the computer or ordered the med from the pharmacy, but, because I charted that entry, I am written up for "falisifying information" because I charted something that wasnt true. I am told it was my fault for not checking on the other nurses order. What do you think? I dont think I am at fault. do you?

Specializes in Med Surg - Renal.

You only got written up?

Count your blessings, learn from the mistake and move on.

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Specializes in OB (with a history of cardiac).

I think a lot of people dropped the ball on this situation. Did you look in the patient's chart at all? It seems that if you had, maybe there would have been something from pharmacy, confirming the order...or not. I wouldn't leave it in the hands of a med-tech. No way. I always look to see what meds my patients are on, even if I know they have no meds to be given overnight. Since I'm on a cardiac floor it's important, and it's important in a SNF too.

One night I had a patient, and her blood sugars were sky high, and I think that's actually why she was admitted. Anyway, she was supposed to be on 0.45% Normal Saline. So I walk into her room, and I happen to catch out of the corner of my eye, the bag that was running- it was D5W! Straight D5W! GAH! I nearly disconnected that bag while it was still running. The point is- how long had that goo been running?!

That said, I hope you aren't the only one getting spanked for this- did the doctor not notice anything either? Wouldn't they have rechecked the urine after a week or two?

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Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
i want an opinion if you will....i am an lpn in a nursing home working the evening shift. a nurse on the day shift took an order from a dr. to start a resident on an antibiotic a month prior. she passed onto to me in report the order was taken and the med was ordered from the pharmacy. i have a med tech that passes meds on my shift so never saw the emar. i charted in the progress notes that resident continued on antibotic therapy and was afebrile. a month later i find out after the resident has a uti that has festered for a month, that the day nurse never entered the order in the computer or ordered the med from the pharmacy, but, because i charted that entry, i am written up for "falisifying information" because i charted something that wasnt true. i am told it was my fault for not checking on the other nurses order. what do you think? i dont think i am at fault. do you?

i personally do not understand the current zeal for "writing someone up." however, i do think that you should have double checked that the medication order was on the mar. and i don't understand how you can be charting on a patient's medications without looking at the mar.

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this situation is truly scarey.....first, you are ultimately the one responsible in making sure the patient is receiving the prescribed atb as ordered and monitoring his/her reaction to said medication. secondly, anyone on an atb for a uti is always rechecked after it's concluded to assess as to whether the issue has been resolved, this order would be placed in the treatment book. third, there is an obvious lack of communication within the facility regarding care/treatment of its patients. sounds as if your facility should incorporate a "communication book" so that these issues don't reoccur. the nurse who relayed the information to you regarding the order and that she had "orderd the medication" should also be written up as she did not carry through (continuity of care). but to think that the nurse receiving the order had not worked that floor/unit again in the week following and not notice that the patient was not on the atb she had just taken an order for the previous week should have raised a "red flag" . please forgive me, but issues such as this is extremely disheartening, a huge huge issue in ltc facilities is sepsis..from uti's !!!please for your license and safety of your patients follow through even if you yourself are not the one who took the order make sure it was charted, recorded in the mar, follow - up u/a in the treatment book, new order written in the "communication book", temperature q shift, fluids pushed (charted), vs, and changes in loc (or not) recorded in nurses notes along with all of the previous i just mentioned. this is not double charting !!! this is summarizing pertinent information regarding the care/treatment of your patient which enables "continuity of care". no one, has the time to go through every bit of paperwork to collect all of this information at the beginning of each shift, that's why "charting" in the nurses notes is vital. and when you do chart you should state the antibiotic the patient is on by name ie; receiving 250mg of cipro po as prescribed for uti. where was the don in all of this? an incident report should have been filed, the physician called and the hcpoa (since they should have been called the minute the order was received).............i'm sorry but yes you should have been written up and so should the nurse who received the initial order and the dayshift nurse for the following day since you would have been the one passing the information regarding the intiation of an atb for a uti on to her at the end of your shift. sorry.....but you are a supervisor, monitoring , reviewing, assessing, charting, follow-up, investigating is your responsibility:twocents:.

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Specializes in Chemo.
i'm deeply sorry that this happen to you. however, what troubles me is that for an entire month, this patient continued to deteriorate and no one from any of the shift, took the time to revise the emar. moreover, try not to forget the golden rules regarding meds. it's one responsibility to follow through always. therefore, you should count your blessings that you weren't let go, keep in mind, that it's your license on the line every time you sign for meds. or doctors orders. lastly, i'm sorry this had to occur in order to give a wake-up call to the entire staff regarding the emar. wishing you the best always...aloha~

yes you are at fault, but so is an entire staff, you shouldnot bear the responsibility alone. there should be some sort of chart check thatis done every 24 hours. this is what we do in my hospital plus a12 hour for dayshift. my question to you did anybody elseget in trouble. is there some sort of chart review process???

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I want an opinion if you will....I am an LPN in a nursing home working the evening shift. A nurse on the day shift took an order from a dr. to start a resident on an antibiotic a month prior. She passed onto to me in report the order was taken and the med was ordered from the pharmacy. I have a med tech that passes meds on my shift so never saw the EMAR. I charted in the progress notes that resident continued on antibotic therapy and was afebrile. A month later I find out after the resident has a uti that has festered for a month, that the day nurse never entered the order in the computer or ordered the med from the pharmacy, but, because I charted that entry, I am written up for "falisifying information" because I charted something that wasnt true. I am told it was my fault for not checking on the other nurses order. What do you think? I dont think I am at fault. do you?
You charted that someone was receiving an antibiotic when you never even verified they were getting it. It is falsified documentation, whether or not you should be written up depends on your employer's policy.
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I agree with everyone else. It happens but you always have to follow up and verify when you delegate. You also have to ensure that everything you note in the chart is 100% factual.Don't let it eat you up though. Learn and move on.

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Specializes in LTC.

I work in long term care so I can see how this may happen. Yes it is partially your fault. However, don't think it is the end of the world. I highly doubt you will be sued.

I have med techs too so therefore I'm not scanning the MAR for all 30 of my residents. If someone is starting a new dose of ABT I make it my priority to make sure it has been sent from pharmacy. Delay in treatment is never good.

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I work in long term care so I can see how this may happen. Yes it is partially your fault. However, don't think it is the end of the world. I highly doubt you will be sued.

I have med techs too so therefore I'm not scanning the MAR for all 30 of my residents. If someone is starting a new dose of ABT I make it my priority to make sure it has been sent from pharmacy. Delay in treatment is never good.

Delay in treatment can be FATAL especially with the elderly !!

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We can make mistakes and we can get caught up in other peoples mistakes.

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