What To Do About False Notes and Charting

[cook78]

I am on a private duty case that is awesome. Love the work, have handled an emergency and also made helpful observations about the patient that the Dr. appreciated.

Of course a problem has to arise and this is one I don't know how to solve. The nurse on the other shift started leaving rude notes for me and family members and documenting total lies about rashes and inflammations that did not exist. Family members and I conferred on the false documentation and noted it in the clinical notes. She then wrote a doctor order for an OTC med, wrote it into the MAR, left a note ordering me to administer the med and never faxed the doctor for confirmation. Of course I did not administer the med. I phoned the agency twice and no one called back. I left a message stating that I was concerned and that it involved giving OTC meds with no doctor order.

This is a rural area without many PDN's available and the patient's family have been through several and gone weeks at a time with none, so they are reluctant to dismiss any nurses. It has become obvious to me in the last couple of weeks that this PDN is bringing the patient to her home and also trying keep the patient overnight and bill for two day shifts. ( Also trying to get my shift switched around to accomodate her. ) She is documenting care that is clearly not taking place. The patient requires certain equipment for their care and it has not been moved. There is other definate proof of this. A family member has told me what a great day the patient has had at that nurses house, several times when I report on. The patient has medical kits for use in an emergency that were always kept in the same place. I discovered them missing and asked where they were and the family assured me they would "find" them. They reappeared the next day, but what if I hadn't noticed them missing and had an emergency ? Other less essential supplies are not there anymore.

Now what ? This situation feels like an accident waiting to happen. If I finally get someone at the agency to talk with me, will anything change since they won't even return calls after I leave a detailed message? Do I notify The Board Of Health Professions in my state, notify Medicaid ?

I also will hate to lose this case. Any action I take will probably destroy my chances of keeping this case, the whistleblower seems to always get blamed along with the wrongdoer. She has of course also laid traps to get me in trouble, like telling me in a personal note to give the OTC med with no doctor order. For the sake of time and space I haven't even begun to include all the infractions this nurse has done, but as I say I am becoming worried about something going very wrong and I don't want this patient having complications or getting sick on my shift because of something that may have taken place off site.

Getting another case is a possibility, but that will take time in this area and I need to keep working to survive. Cases are as scarce as nurses where I live. Thank You in advance for any advice.

[systoly]

oh boy, there is a lot of stuff going on here and frankly, some of it doesn't make any sense to me

so i will comment on the issues that seem clear to me

any notes left by another nurse are a actually part of the pt.'s record

that's why some agencies have done away with communication or report books

so when you receive a rude note, first overlook the unprofessionalism and concentrate on any pt. issues

addressed in the note

i would at least once alert the agency about my concerns with regards to the notes and document

if they choose to ignore it it's on them, just make sure you document when you leave voice mails or when and who you talk to

about the rashes - you weren't there and it's possible to have skin irritation or redness come and go

just document what you observe

to be continued , android acting up

[systoly]

do not involve the family in a tug of war between nurses

do not tell the family another nurse made false entries in the chart

do tell the family your factual observations

if you suspect there is an error on the MAR, call the Dr. and write a clarification order and correct the MAR

mistakes happen and whether they are intentional or not does not change how we correct them

the emergency kits are a huge problem

all the above stuff would make me sigh and go on about my day, but i would not rest until i had the emergency kit

not the next day, but now

i'd call the agency every half hour and document, i'd tell the family to get another kit now and call Dr. office and pharmacy

if needed

as far as going on from here, first and foremost, concentrate on your job

relay your concerns in a factual manner to the agency

keep your communication with the family focused on facts and what goes on during your shift

you can address your concerns with the family in the form of teaching so that you can document stuff like

"...educated family on equipment needed for care and need to have equipment with pt. at all times, familly

member states i understand we need xyz machine for abc situation..."

[meanmaryjean, DNP, RN]

A nurse cannot take a patient to their home and bill for that time. It's called fraud, and can result in disciplinary action with the BON up to and including license suspension. IF your agency does not take immediate action when you report this to them, report it to the BON. You do NOT want to be caught up in knowing about this and not acting on the knowledge.

[SDALPN]

I've seen this a lot. I would notify the agency by email so there is proof you contacted them and I would subtly include that you called in the email as well. You can't report anything you didn't actually see. People can come up with lots of reasons (excuses) to cover for things. You could report to their insurance company. But be ready to have proof. If the family has seen things and discussed it with you, you would have to convince them to mention it to the supervisor. If its hard to staff, the agency will do what they can to keep the nurse there. I agree with the person above that said call until you have emergency supplies. I will add that you are responsible to accept or decline your assignment. If you accept an unsafe work assignment, you will be held responsible if things go wrong. Sorry to hear you're in this position. I've been there myself in the past. Its not good. If you can find a way out, get out...obviously easier said than done! Good luck!

[nursel56]

I feel that there are a few things one must have in any PDN case regardless of how shady things are, and one of them is that you are able to communicate with them somehow in a reasonable amount of time. I wouldn't leave a detailed voicemail unless I sent a detailed email to go along with it and document my attempts to reach a case manager, supervisor or whatever. The agency has contracted to provide care for this person. The expectation of reasonable communication applies to whatever the content of that communication might be.

If you are working on a case and are not sure if emergency supplies are available at the beginning of your shift you are putting yourself and the patient at tremendous risk especially in a rural area where 911 may take a while to get there. Your flow sheet may have a check-off box indicating ambu bag, spare vent circuit, etc are present.

I wouldn't bother myself over the non-order for the rash that isn't there because she apparently never tried to get a legal order and the parents aren't observing what she claims is there. You could leave her a note asking her to detail her observations in the narrative part of the note and what she did to contact the doctor or case manager.

You're right that a whistleblower often loses their job . . .but it sounds like so far you don't have enough detail about the patient transferred to the nurse's house to know exactly what to report. This is related to the problem of lack of ability to communicate with your agency. I'm really hearing you on the "don't want to lose the case" issue so I'm hoping you can find a way to resolve these multiple issues without doing that!

[kiszi, RN]

It concerns me that your agency is not easy to communicate with. I don't know how far the agency is from you, but if it were me I would march right into the office and speak to a supervisor, then escalate up the chain of command, reporting to BON if necessary.

As for the OTC med I would absolutely verify the order with the doc. If it was a PRN med I would document my assessment and "no need for PRN med determined" or some such.

Nobody is going to tell me how to provide care for my patient.

In the meantime, document well and stick to the facts.

[ceebeejay]

How in the world do you take a patient home with you? Not you, but in general. Wow. You have received much excellent advice already. I agree, the lack of emergency equipment/supplies is a tantamount issue not to be dismissed.

[caliotter3]

Take the steps previously mentioned to protect yourself and your patient; start a job search for a new case and/or a new agency. It concerns me that the agency refuses to communicate at all. This is a red flag for all future interactions with that employer and it does not bode well for you.

[systoly]

How in the world do you take a patient home with you? Not you, but in general. Wow. You have received much excellent advice already. I agree, the lack of emergency equipment/supplies is a tantamount issue not to be dismissed.

that was my thought exactly, and honestly, i didn't buy it at first, but apparently it does happen

i don't even want to know how and why

[SDALPN]

that was my thought exactly, and honestly, i didn't buy it at first, but apparently it does happen

i don't even want to know how and why

That happens often. I've heard, witnessed it so many times over the years.

[BuckyBadgerRN, ASN, RN]

She takes the client to HER home for overnight stays? What parent allows this?