Violation?

[she_who_cares]

I charted on an incident that happened last night. Didn't cause the pt's problem, but it definitely aggravated it and made it worse.Pt was supposed to be in visual contact of NA at all times. I stated that she was unsupervised and calling out for help which in turn I helped her. Of course that's kind of self-explanatory that someone wasn't doing their job, but how is that my fault? I feel that it's obviously RELEVANT to her health condition as it triggered the pain even more. And then I also charted the part where another NA told me not to help her change clothes even though she was obviously in a great deal of pain and struggling on her own. They stood there watching and didn't do anything after a few minutes, so I stepped in. I ignored the comment made by the other NA and continued helping the pt. The ELDERLY pt too by the way. I did not use the names of those present. I used their titles. I did not put my opinion on the situation or anything that I didn't feel was relevant to what occurred. Only what I seen and what I heard. Not what I thought. Not my place to say what I thought although it did piss me off. So so I get to work today, and everyone is talking about me. That's fine. Ignore it and keep on doing my thing. I come back to the nurses station for something, and everyone is looking at the charts. I mean, you're not looking at it to document patient care considering you JUST got here and the shift had not begun yet. I feel like this is a HIPAA violation since their intent was to pry on what someone wrote in the chart and not to document pt care or look for updates on the pt. And unfortunately, I will probably get written up for writing what happened in the chart. I didn't realize until someone told me that I probably should've filled out an incident report (management didn't teach me any of this stuff by the way which is pretty frustrating and makes me look dumb). But I was professional and only stated the facts. Nothing more and nothing less. But the management around here sucks. So I will be the one to get in trouble and not the ones who weren't doing their job. But it's our job to care for them and when safety becomes an issue.. Well, it's obvious that something needs to be done. And not to mention that the girl who told me not to help the pt change, she confronted me today. Thankfully it was in front of someone else, but she accused me of lying on her and trying to be sneaky by thinking no one would know. Ummm, I'm pretty sure that I'm well aware that it would be seen by anyone who is providing care for her. And I signed my name to it. I may not know everything, but im not that stupid to think it wouldn't be seen lol. We are adults here, so I don't understand why we can't act like it. But whatever. Just curious about the HIPAA violation part though. Thanks in advance!

[JustBeachyNurse, LPN]

What you wrote belongs in an incident report. Manager or charge should have been notified ASAP of insubordination that adversely affects patient care or welfare.

Do you use paper charting? At the start of the shift chart review is necessary (you are making assumptions on their intent) so that would not be a HIPAA violation. You are assuming they are seeking information to use against you if you reported this it would not look good for you

[JustBeachyNurse, LPN]

Looking at your post history you are likely not going to be hired as a nurse in this facility. As a non nurse it's not your job to document your impression that the neglect of others caused pain. That is assessment. You are working as an unlicensed assistive staff member and should have directed the increased pain to a licensed nurse.

You appear to be looking for reasons to document. You were wrong to write such info in a patient chart and not an incident report

[she_who_cares]

And I did let the nurse know. I put on the chart that the nurse was notified. Then I immediately moved on to documenting her BM. And that's fine if they don't hire me there as a nurse. And although I realize it was wrong now, how was I supposed to know that beforehand until someone on the next shift told me? Management sucks so badly. I've asked the supervisor for help and all I get is rolling eyes and him walking away. Have to chart by a specific time, but NO ONE will sit with my 1:1 pt. These people don't care about the patients. I couldn't possibly expect them to care about me either. I wish I would've had guidance, but apparently that's too much to ask for.

[she_who_cares]

So it takes every single staff member on the current shift and those on the next as well to do "chart review?" And I'm "assuming on their intent" when they walk right by me and say all kind of crap about me and what I just wrote? Yeah, I sure am "assumming."

My point is that only those caring for the patient, nurses, and whoever checks off on the charts should've been looking at it. But there was no reason for the entire unit except the patients to look at the dang charts. And besides, I was told by numerous people to chart what I see when management won't do anything. So I did. That is all.

[JustBeachyNurse, LPN]

My point being is that they won't likely be considered violating HIPAA in this instance. If you reported this, it might backfire on you especially in this facility.

Fundamentals of nursing 1 we covered what goes in a chart vs incident report before we were allowed near a clinical site. Reading posts (not just hours) clearly this is not standard practice but perhaps the facility made the erroneous assumption you did have this knowledge.

You have a lot of emotion involved in this job it may be best for your future career and personal sanity to start looking for other employment now as has been advised in your other threads. Your coworker's have confronted you and are may decide watch you very closely for the tiniest mistake and report away. The issues and concerns you have are not likely to be readily resolved. Your only option may be up file a complaint with the department of health/mental health, office of aging or state ombudsman to protect the residents and resign. It's clear you care for their well being.

You now know charting that a patient's exacerbation was the direct result of another staff member's inaction opened you, the nurses, administration and the facility for legal action. Neglect of an elderly mentally ill client can be a widespread investigation resulting in sanctions & fines including loss of Medicaid/Medicare funding. Incident reports are a way to mitigate complaints to show the incident was noticed and corrective action can be taken.

Be mindful of the deficits in your orientation that way in your next job or your first nursing job you know what questions to ask and what information you need to know

[jadelpn, LPN, EMT-B]

Going forward, make sure that the primary nurse caring for the patient is aware of when the patient is in pain. If there is a 1:1 that is to be happening, and it is not, ensure the immediate safety of the patient, then advise the primary nurse that you did so, and that there is no 1:1 with the patient. (which sounds to me as if the 1:1 person chooses not to do that, knowing when whomever finds this patient in immediate risk will intervene--AND then have to do the 1:1). If you are not being spotted to even use the restroom, then that is a union issue, if you have a union.

These are incident report situations. If the licensed nurses are not responding, then there's a parent company website where you can report risk. If patients are being neglected and abused(meaning that they stand around watching as a patient struggles to dress) then as a mandated reporter, you can and should report to the state and elder affairs.

Take emotion out of this. It is patient safety that is at risk.