What constitutes falsifying documentation?

[physioex]

I know of a nurse who put her initials on a flow sheet for her entire shift ahead of time. She was in orientation and was never told by preceptor or coworkers that this constituted falsification of documentation. She was terminated for doing it on 3 occasions. She never falsified assessments, v/s, outcomes, plans of care, only initialed her flowsheet for her entire shift before it was actually that time. She'd been complaining of coworkers being viscious, making false accusations, and tattle telling about non-nursing related matters. She'd had felt like she was being watched closely to get fired and now it came true!! Can she really be terminated for this? Is this really falsification if she did the actually charting at the real time, but only initialed ahead of time?

[talaxandra]

I'm a little conflicted about this. On one hand, I completely agree that pre-timed documentation is wrong for a number of reasons, the specificity of which depends on what kind of pre-timing's done.

On the other hand, overwhelmed grads often think they've hit on a way of saving time that nobody's thought of before, and don't have the perspective or experience to see a bigger picture.

Though I agree nobody ever told me not to steal, lie, divert drugs, kill patients etc, I can see how an inexperienced nurse struggling to cope with an overwhelming workload could frame this as time saving and purely technical, unlike those other examples.

So they see the time saving nature of, for example, pre-initialling, but not that the seconds saved are more than outweighed by the potential problems of having documentation on a patient who may crash, die, abscond, be transferred or sent off for a procedure during the pre-signed period.

Though significantly more serious and with ramifications, it's not unlike newbies who think they've come up with a better way to post, that nobody on boards has ever thought of before, and write in all caps because it's "easier to read."

Depending on the document etc, I'd be more inclined to give a warning, accompanied by an explanation that included a dire scenario (eg patient absconds mid-shift and dies outside the hospital). If the pre-documentation continued then there'd be a problem.

[TheCommuter, BSN, RN]

My state's BON recently placed a nurse's RN license on probation for fabricating a patient's blood pressure on a very busy night. This was a newer RN and his license had never been sanctioned or disciplined previously.

Boards of nursing regard the falsification of documentation as a very serious offense. Prematurely signing off on flow sheets, fabricating someone's blood pressure, and other inaccurate record-keeping can get a nurse in serious trouble if the manager decides to refer someone's license number.

[dudette10, MSN, RN]

So they see the time saving nature of, for example, pre-initialling, but not that the seconds saved are more than outweighed by the potential problems of having documentation on a patient who may crash, die, abscond, be transferred or sent off for a procedure during the pre-signed period.

Thank you for pointing that out.

Depending on the document etc, I'd be more inclined to give a warning, accompanied by an explanation that included a dire scenario (eg patient absconds mid-shift and dies outside the hospital). If the pre-documentation continued then there'd be a problem.

Completely agree with the way it could have been handled if only initials were the issue, not assessment data.

[talaxandra]

I have to add that there is, of course, a massive difference between the kind of pre-documentation I discussed and The Commuter's example. Inventing observations, signing for medications not given, documenting care not delivered (eg dressing) etc are significant, unjustifiable and wholly wrong practices with very real outcomes for the patient. I agree that in these cases disciplinary action is appropriate.

[DeLana_RN, BSN, RN]

I know of a nurse who put her initials on a flow sheet for her entire shift ahead of time. She was in orientation and was never told by preceptor or coworkers that this constituted falsification of documentation. She was terminated for doing it on 3 occasions. She never falsified assessments, v/s, outcomes, plans of care, only initialed her flowsheet for her entire shift before it was actually that time. She'd been complaining of coworkers being viscious, making false accusations, and tattle telling about non-nursing related matters. She'd had felt like she was being watched closely to get fired and now it came true!! Can she really be terminated for this? Is this really falsification if she did the actually charting at the real time, but only initialed ahead of time?

Initialing the flow sheet wasn't the wisest thing to do, but I agree with others that disciplinary action after the first instance could have been an appropriate way of dealing with this nurse; however, it does sound like others were trying to get rid of her (if she knew this, why did she give them the rope...?).

Consider these examples of nurses who did NOT get fired or even disciplined (but should have been):

1. Oncology floor, 1998, all manual charting. One 3-11 nurse would copy the day shift nurse's assessment findings (requiring initials on lines or in boxes) right after report - before she had even looked at her assigned patients.

2. Much more recently, I shared a new admit with a preceptor. Hours into the shift we realized that the pt was on hourly neuro checks. Oh, no, I asked my preceptor, what to we do now? Oh, no problem, she said and proceeded to do a neuro check on this pt. Everything's normal, she said, so it must have been normal since his admission. And she proceeded to fill in hourly data on the flow sheet for each hour the pt was on the floor - although none of them had been done. I was horrified (and knew this was not the floor for me!)

I don't condone any of these examples, but clearly making up assessment findings and neuro checks is far worse than writing one's initials in advance...

DeLana

[Ruby Vee, BSN]

i personally know of a new nurse, just off orientation (and doing well, i thought) who was taken out of a patient room by three "senior nurses" after she had initialed her safety check on her patient's flowsheet. they proceeded to grill her about what side of the bed the ambu bag was on, where the suction was located, what mm suction setting the oral suction was on, the expiration dates and times on all her lines (not meds, lines) and where the patient's iv sites were and when dressing changes were due. when the girl couldn't answer all of that, they marched her down to the supervisors' office and had her written up for 'falsifying documentation', because she "didn't really do her safety checks".

i'm not saying that it is ever right to 'pre-chart', because it isn't (though i suspect it's done more often than anyone admits or recognizes.) i am saying there is often more than one side to every story, and while some ethical issues are black and white - some are less so.

my .

this kind of thing is simply "witch hunting" on the part of petty tyrants with a perceived superiority complex.

both the profession and the patients, would be much better off if the focus of initial training was the timeliness and appropriateness of interventions for the current status of the person lying in that bed.

i don't think we have enough information to conclude that the senior nurses were witch hunting, petty tyrants or had a superiority complex. it's entirely possible that the senior nurses were protecting their patients and their licenses from a new nurse who habitually falsified or skipped over her safety checks. we don't know if this incident came out of the blue or if there had been repeated problems that had been addressed with the newbie.

i think that if those three nurses had repeatedly followed the newbie, worked next to her or done charge while she was on and had noticed that they consistently found evidence that the safety checks had not been done even when they were charted as done, they may have been doing the right thing to drag her out of the room and grill her. no one is perfect, and i'm not sure i could answer all of those questions accurately on a moment's notice. but i'm sure that there is an ambu bag with a mask in my room, that the suction was in the correct range, whether or not i need to change my drips, tubings or dressings and roughly where my monitor alarms are set. if i repeatedly followed someone who left no ambu back, expired drips or tubings, loose or dirty dressings and nonfunctional or incorrectly set suction and had brought it to their attention more than once without seeing a change in behavior, i'd talk to some of the other senior nurses to find out if they'd noticed the same thing. and if it was a pattern, perhaps an intervention was in order.

if management is doing their job correctly, the rest of us don't know when someone is being disciplined. this could well have been the last step in a trail of second chances. or not. my point is, we don't know.

[elkpark]

i don't think we have enough information to conclude that the senior nurses were witch hunting, petty tyrants or had a superiority complex. it's entirely possible that the senior nurses were protecting their patients and their licenses from a new nurse who habitually falsified or skipped over her safety checks. we don't know if this incident came out of the blue or if there had been repeated problems that had been addressed with the newbie.

i think that if those three nurses had repeatedly followed the newbie, worked next to her or done charge while she was on and had noticed that they consistently found evidence that the safety checks had not been done even when they were charted as done, they may have been doing the right thing to drag her out of the room and grill her. no one is perfect, and i'm not sure i could answer all of those questions accurately on a moment's notice. but i'm sure that there is an ambu bag with a mask in my room, that the suction was in the correct range, whether or not i need to change my drips, tubings or dressings and roughly where my monitor alarms are set. if i repeatedly followed someone who left no ambu back, expired drips or tubings, loose or dirty dressings and nonfunctional or incorrectly set suction and had brought it to their attention more than once without seeing a change in behavior, i'd talk to some of the other senior nurses to find out if they'd noticed the same thing. and if it was a pattern, perhaps an intervention was in order.

if management is doing their job correctly, the rest of us don't know when someone is being disciplined. this could well have been the last step in a trail of second chances. or not. my point is, we don't know.

ita. as to the situation the op described, while it may certainly be true that someone was looking for a reason to fire the person, unfortunately, she gave the administration legitimate reason to do so.

[PedsDrNurseTheo, ADN, BSN, MSN, DNP, RN, EMT-P, NP]

ITA. As to the situation the OP described, while it may certainly be true that someone was looking for a reason to fire the person, unfortunately, she gave the administration legitimate reason to do so.

I agree that if the administration was looking for a reason, the OP's exemplar gave them that reason. However, if a newbie nurse is consistently falsifying safety checks, and the required items are not in the room even if charted as such, then the proper course of action is to correct, document, discipline, and terminate.

I promise you that if I chart a safety check, I have checked drip concentrations, expirations, line change dates/times, sites, ambu bag, suction, spare trach set in the room if required, extra adjunct airway on a critical airway patient, and so forth. If you grabbed me and pulled me out of the room, could I tell you exactly where they were or what the dates/times were? No way. But in that room, I guarantee I can lay my hands on any item I need within seconds. When it comes to patient safety, I am uncompromising.

What happened to the nurse in my post was "gotcha" politics, plain and simple. Even if she was in the wrong, and I am not saying she wasn't, you simply don't do things that way. It's poor management, it's underhanded, it reduces morale among the rest of the team because everyone wonders who is next - and it borders upon the unethical. It perpetuates the hoary old cliché about offspring and the eating thereof; it is lateral violence, and therefore it should never be condoned or excused.

Did I mention it ticks me off?

Getting off the soapbox now. Oh, and sorry for the threadjack.

[steelydanfan]

$1,000 says that she was not terminated for what was described.

The falsifying docs was the excuse (the paper trail) used to remove her. She was either doing something else that was difficult for leadership to officially remove her for or she rubbed the wrong person the wrong way.

I'll see and raise you $5,000,000.00 Charting out of time is a firing offense in ANY hospital I have ever worked in. It is ok to chart late on vital signs, it is DEFINITLY NOT ok to chart ahead during a proceedure.

We had a nurse fired for charting ahead that the pt. tolerated the proceedure well. Unfortunatly, the pt. crashed and coded during the last 5 minutes. The nurse had a VERY hard time defending her crossed out and redacted notes. So much so that she was fired.

[nursel56]

The only time I've ever gone to my manager over someone, was when I saw the completely filled out q 2 hr vital signs sheet covering 8 hours 90 minutes after our shift started. That was bad enough really, but (as an aside) she later showed me her drawer full of hemostats she planned to steal and sell as roach clips. Why she did that I will never know.

This situation is not as egregious as hers was imo, but in a 24 hr job any loss of trust is a huge issue! If the blank hits the blank- they look at everybody.

[HamsterRN, ADN, RN]

That' s nothing compared to where I work: We are required by policy to chart medications as "Given" in the computer before even walking into the patient's room with the meds, we've questioned this and been told it's ok, it's policy.

[oramar]

That' s nothing compared to where I work: We are required by policy to chart medications as "Given" in the computer before even walking into the patient's room with the meds, we've questioned this and been told it's ok, it's policy.

Now there are people here that have posted that pre-charting ANYTHING is grounds for dismisal at any instituton. Here is an account of an institutions REQUIRING it. Guess what, I have run into this before. I worked one night at a city hospital that required night nurses to sign off all their meds by 1am because the computer was down from 2 to 7a every night. They didn't want anyone hanging around waiting for the computer to come back up to sign off meds and running up overtime. They gave me a real hard time because I refused to comply with their rule. They didn't want me back and I would not have gone anyway. Some nurses fall into bad habits because they were taught them by bad institutions. I still have issues with people here that think nurses that make judgement errors like precharting should be hung, drawn and quartered. I think there is room for reeducation, at least for the first offense.