What to do in a situation where a CNA documents lies

[megananne7]

I am a new RN (LPN w/ one yr experience, only in assisted living) and I just started on Med Surg at a hospital that has computer charting. Last week I was preparing my meds for the couple of patients and my preceptor told me to look up the vitals to make sure nothing had to be held. I noticed the BP was something like 104/38:uhoh3: and there was a note tagged to it by the CNA. Note saying "NURSE NOTIFIED OF BP". Uh, since when?

I said to my preceptor "She didn't notify me of anything." She kind of blew it off and said "Yea, you'll figure out they lie" and a couple minutes later she asked me if the aide had given me a paper with the VS written on it. No, I hadn't. I don't even know what the girl looked like at that point in the morning.

It really irked me that the aide documented that and didn't tell a soul.

Of course, we did have problems with this aide later on in the day. We do VS Q 8hr, and this aide was floating from Outpt Recovery, around 3p she was no where to be found. Of course, I'm sure its tough to be floated where you don't know anyone and don't know what to do.

[kellye]

same experience....i approached cna. explained that if looking at the chart it would appear that she told me of an abnormal vs and i did nothing about it. also included that it was falsification of legal document (lying). i was nice about it but included that if it happened again if would be forced to write it up. no problems since then. good luck!

[squeakykitty]

She will probably need to be counseled, and if it continues, write her up. And go up the chain of command if it becomes necessary. What she is doing can be dangerous.

[nyapa, RN]

You document in the patient's notes that you were NOT told, and that the supervisor has been made aware. Should there be consequences then you have covered your back.

I do not think this behaviour is peculiar to CNA's. People are people, and if you read enough through these pages you'll see that all health worker ranks contain ppl such as these.

Have you spoken to this person? She needs to be confronted. Ask her did she forget to tell you?

[TheCommuter, BSN, RN]

Heck, there are even a handful of nurses who have lied by documenting that they notified the physician (when they have not). Nobody is immune to lying, which is why you must protect your butt by covering it appropriately!

[pagandeva2000, LPN]

You document in the patient's notes that you were NOT told, and that the supervisor has been made aware. Should there be consequences then you have covered your back.

I do not think this behaviour is peculiar to CNA's. People are people, and if you read enough through these pages you'll see that all health worker ranks contain ppl such as these.

Have you spoken to this person? She needs to be confronted. Ask her did she forget to tell you?

While I agree with you, I think that documenting this in the patient's notes may not be a wise idea, because it looks like negative charting. I would document what time the vitals were done by the CNA, and what time (and how) you were made aware, and that the supervisor was notified because it essentially says the same thing, but not actually saying it. Or you may say " Ms. CNA documented at 12:00pm, nurse notified of abnormal vital signs at 2:00pm, supervisor Ms. Nurse made aware" and what you did to follow through. And, actually, I think that I would ask the supervisors or a nurse that you trust how to go about doing this. I just say this because I remembered so well hearing in school that charting should not reflect a flame war between disciplines. Also, once, I documented something similar, and the staff ed nurse reminded me of this and told me how to reword it to say the same thing, basically. The reader should be able to figure it out if they read between the lines.

[nyapa, RN]

" Ms. CNA documented at 12:00pm, nurse notified of abnormal vital signs at 2:00pm, supervisor Ms. Nurse made aware" and what you did to follow through. And, actually, I think that I would ask the supervisors or a nurse that you trust how to go about doing this.

:yeahthat:

I agree with you. I wouldn't have documented aggressively, just simply stated the facts as you have. And I certainly wouldn't have used an upper case 'NOT'. I simply used that as an emphasis for my post. Sorry if I created any confusion...

[espritjolieRN]

Oh well you're gonna love this one. I was working med-surg in a small town hospital where everyone knows everyone and none of the staff is drug tested if that tells you anything. My husband at the time was a police officer there and well known by some of the staff d/t their off-work activities. One aid was always sweet to my face so I figured she wasn't going to hold it against me that I was married to the town sheriff. That is until the day I realized she was giving me erroneous VS on my patients. She would come up to me and say "Room 8's BP is 200/100" or "Room 10's temp is 101.5" knowing that most nurses act off that information immediately... i.e. start looking up meds/labs/calling docs etc.. Or if the pt had a true high reading she'd conveniently FORGET to tell me.

[squeakykitty]

Oh well you're gonna love this one. I was working med-surg in a small town hospital where everyone knows everyone and none of the staff is drug tested if that tells you anything. My husband at the time was a police officer there and well known by some of the staff d/t their off-work activities. One aid was always sweet to my face so I figured she wasn't going to hold it against me that I was married to the town sheriff. That is until the day I realized she was giving me erroneous VS on my patients. She would come up to me and say "Room 8's BP is 200/100" or "Room 10's temp is 101.5" knowing that most nurses act off that information immediately... i.e. start looking up meds/labs/calling docs etc.. Or if the pt had a true high reading she'd conveniently FORGET to tell me.

I hope she got written up. It's flat out dangerous to lie about vital signs.