untruthful charting....

[DivaNurse2007]

I work at a rehab /LTC facility and im pretty new there .I was recently approached by a nurse who advised me that to stop charting that my residents are independent when they really are!!! It seems the administrator and managers had a meeting and She said that the facility gets more money when we chart that they need help rather being independent.I thought that was really strange and I am ready to leave that facility based on that statement.I understand the logic, but disagree with the untruthfulness and it makes me question one thing, and thats integriy.

Has anybody been told this????

[Bridey]

No, I've never been asked to chart something that's untrue. Nor would I ever comply with such a request. That's fraud and you can go to jail and lose your license if made to testify in court about it. I'd find a new job if I were you.

[deeDawntee, RN]

Get out!! And while you are at it, report their a**es after you are safe and sound in a new job.

[VivaLasViejas, ASN, RN]

Agree with the above.

Never, ever, under any circumstances, document anything less than the absolute truth in a patient's/resident's chart. If it is found out, YOUR license will be on the line---not your supervisor's, not your administrator's, YOURS.

I had an instructor once who told our class to always keep in mind the image of our nurses' notes on an overhead projector, in black and white, eight feet high, in a court of law. That mental picture, along with my normal sense of right and wrong, has kept me honest for a lot of years, even when it's cost me a dressing-down for failing to initial a space or forgetting to chart a blood sugar. It's not worth it........you need to RUN, not walk, away from that place and report 'em when you're safely out of there.

Good luck to you......you will need it.

[pagandeva2000, LPN]

Am not surprized...see it all the time. And, the place I work for is trying to apply for Magnet Status.

[TheCommuter, BSN, RN]

Unfortunately, dishonest documentation is a common occurrence in nursing homes. I would sometimes read the notes written by other nurses, just for my own amusement.

Certain things would be documented that were untrue. "Pt. accepts sips of water at rounds," when this nurse is known for never making rounds. "Pt. remains afebrile," when the sloppy nurse never took vitals all shift! "Pt. denies pain/discomfort," when the patient is demented, nonverbal, aphasic, and incapable of denying anything. "Bruise observed on left heel," when the so-called bruise is really a stage 2 pressure ulcer, but admitting to a pressure ulcer would cause the facility to have a deficiency from the state.

Yes, falsification of medical records is not uncommon in some nursing homes where care is being documented, but often not given!

[pagandeva2000, LPN]

I am not defending nurses that do untruthful charting, but I can understand some of the circumstances that lead to this behavior; especially in nursing homes. An LPN that has 60 patients alone may be tempted to do so, because such a ratio cannot assure that everything can be done daily. I keep going back to the story of one of my friends that started working in LTC that had 40+ patients to give meds to. She was still administering 8:00 meds in the afternoon. No ID bands, no pictures in the MAR. She asked the RN what to do; the RN told her "Do what you have to do". She threw away the pills she could not administer, including the narcartics and signed for them as if she gave them, and left.

If these homes continue with these unsafe ratios, this sort of behavior can be expected. Sad, but true.

[FrustratedLPN]

Having worked in LTC/Rehab for a number of years, it's obvious that management wants anyone to be skilled that can possibly be, since they do receive more payment for skilled care. If a resident requires TWO people to transfer, that is certainly better than one. If the resident has to be fed, or assisted in any way, shape or form, this also gets more money.

If you'll notice, most LTC/Rehab facilities cater to Physical Therapy, Occupational Therapy, Speech Therapy.. why? MORE MONEY from the government. Management KNOWS that the more skilled people they have the more income. Physical Therapy will write an order to provide skilled services for example "balance while sitting", when the resident is not capable of following directions of any kind. The Medical Director or physician of record will sign off on ANY order Physical Therapy, OT, or ST, writes.

And yes, I'll have to agree with several replies to this thread, the DON, ADON, or nursing supervisors will not be held responsible for inaccurate charting.... the prime reason they also tell you NOT to put names in the chart. Whenever there is a problem or issue and I report it to Supervision or the Doctor, I ALWAYS document what time I reported it, To whom it was reported, and what response I received at what time. Management makes certain they are covered, it's up to us to make certain we cover ourselves.

[JONlvn-np2b]

i only chart what i see and what i do. i dont care if a patient has been bed ridden for the past two years and then starts walking on my shift, ill chart that down. or if i hear egophony or bronchophony from a patient that supposedly has 'breath sounds clear bilaterally'', ill send them out and chart it down. lol, all im trying to say is be truthful, you can never go wrong with the truth.

[Bala Shark]

I am not defending nurses that do untruthful charting, but I can understand some of the circumstances that lead to this behavior; especially in nursing homes. An LPN that has 60 patients alone may be tempted to do so, because such a ratio cannot assure that everything can be done daily. I keep going back to the story of one of my friends that started working in LTC that had 40+ patients to give meds to. She was still administering 8:00 meds in the afternoon. No ID bands, no pictures in the MAR. She asked the RN what to do; the RN told her "Do what you have to do". She threw away the pills she could not administer, including the narcartics and signed for them as if she gave them, and left.

If these homes continue with these unsafe ratios, this sort of behavior can be expected. Sad, but true.

The two nursing homes I worked in where very understaffed..I mean, a person would have to be superman or superwoman to do all the stuff in the day shift..I had to pass meds to 50 residents before and take their blood pressure for about 20 of them.....

[LUVyourCNA]

I have worked in LTC for a few years and never have i been asked to chart untruth. Yes, i feel overwhelmed sometimes DON'T MOST NURSES? I don't care where you work all nurses are overworked and under paid!!!!!!!!!!!!! I would not work for any facility that asked me to lie. All through school i was taught (Cover your A##)

[pagandeva2000, LPN]

The two nursing homes I worked in where very understaffed..I mean, a person would have to be superman or superwoman to do all the stuff in the day shift..I had to pass meds to 50 residents before and take their blood pressure for about 20 of them.....

This is what I am saying...situations like what you just mentioned make it easy for a frustrated, tired nurse to lie on a chart if necessary. I cannot comprehend why these homes will compromise the life of the client or the license of the nurse in this manner.