What To Do About False Notes and Charting

Specialties Private Duty

Published

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.

Specializes in Peds(PICU, NICU float), PDN, ICU.
She takes the client to HER home for overnight stays? What parent allows this?

Hmmm, free check for the kid, no responsibility for the kid...yep, sounds like gene donors rather than parents.

Specializes in Pediatrics, Emergency, Trauma.

I never get what makes nurses do this...when the ish hits the fan....bye bye license... :no:

Taking the patient to the nurse's home is no different than the client that demands that I remove the patient from the home for "outings" so that the client can nod off in peace or leave the home at will, which they do anyway. Just keep that check rolling in and the nuisance gone from underfoot.

Nurses have told me that they will take me to their house "just for fun." This made me veeerry uncomfortable. Of course, I told my parents about it. But, I'm lucky, I can talk. What if the kiddo couldn't talk? There's been some pretty scary stuff out there and someone's got to protect them. :unsure:

Specializes in HH, Peds, Rehab, Clinical.

are you a nurse or in nursing school?

Nurses have told me that they will take me to their house "just for fun." This made me veeerry uncomfortable. Of course, I told my parents about it. But, I'm lucky, I can talk. What if the kiddo couldn't talk? There's been some pretty scary stuff out there and someone's got to protect them. :unsure:
Specializes in Complex pedi to LTC/SA & now a manager.

I believe she is a patient that receives PDN services. Just like vent mommy is an experienced mom of special needs children. Both offer insight from "the other side".

Specializes in HH, Peds, Rehab, Clinical.

But ventmommy is also a nurse, isn't she?

Specializes in Complex pedi to LTC/SA & now a manager.
But ventmommy is also a nurse, isn't she?

Nope. Though I believe she is or was a medic. Just an experienced parent of trach/vent kiddos who offers some great insight

Specializes in Pediatric Private Duty; Camp Nursing.
Nurses have told me that they will take me to their house "just for fun." This made me veeerry uncomfortable. Of course, I told my parents about it. But, I'm lucky, I can talk. What if the kiddo couldn't talk? There's been some pretty scary stuff out there and someone's got to protect them. :unsure:

Teacup, I see that you've recently joined up, we'll be so glad to have you here, welcome!! It's going to be great to get the perspective of things from a client's point of view! Please jump in any time. One of my clients is an alert and oriented young adult, and I learn so much from her.

Sorry about not responding sooner. I am on the patient side of things. :) Sorry for the confusion.

Sorry to ask,but how are you billing Medicaid and working for an agency?

Are you an independent contractor?

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