Nurse charting stuff she did not do.

I work in LTC/RH and we are having to deal with family of a resident over a wound. There is talk of lawyers, suits and what not. I found out that the documentation for this "wound" was poor if at all. There was a signature that another nurse has preformed a skin audit the same day and it was negative, yet did not fill out the paperwork for skin audits ( she never does, even after repeated complaints to the DON.) There are several resident she charts that she does treatments on and I know they are not getting done. I feel this is another treatment that she signed off on and did not actually do.

Has anyone had this happen and what was the outcome. This RN has been there many years and feels she is un-fire-able. I would really like to see this person reprimanded for her actions, simply so things change for the sake of the patients. I believe in education first and discipline second, but she has been told multiple times about skin audit forms and just refused to take part in any change.
I do not have any advice about colleagues not doing things they are supposed to but I do have some experience with families that seem to be falling short of caring for their dependents.Be objective in your charting for your shift. Instead of writing "Pt's diaper was not changed" I write something like "Pt's diaper is heavily soiled, perineal area moist and red...." You could also mark and date the dressings you apply so that you can plainly state "Dressing states "11/15/11 (your initials and time of change). Dressing removed. Wound (looks worse than before ew yuck but be objective hehe)."

Address this with the nurse......if no improvement, report her. This is a disaster waiting to happen

There are times when I think the best solution is to talk to the nurse before talking to administration, just as a sign of respect. But having seen a patient die of wound sepsis because a nurse didn't change dressings, while documenting all the time that she had, and despite numerous complaints to administration about her overall sloppiness in every area, I've had a change of heart. I can see that every now and then a skin tear dressing might not get changed because of a crazy shift, or a skin audit might not get done, but it sounds like this nurse has been talked to numerous times to no avail. Follow up on this with management. At the very least to get your voice on record so that if this situation blows up you can demonstrate that you took this seriously and went through the proper channels to address it.

Your DON needs to know of the "talk" of lawsuits, etc. immediately, as well as anything you have on the state of the resident's wound and any documentation relating to it.What is your position? Co-worker? Supervisor?

Do you have any proof that this nurse is charting treatments that she's not actually doing? If so, write an incident report, each and every time that she does this.

worked with a nurse who was caught charting ahead (same idea) and was fired on the spot. It is against the NPA in my state to falsely document. It is also required that if an RN has knowledge of this, it will be reported to the BON. The idea is to protect the patient, not the nurse. In this case, she is actually harming or has the potential to harm someone. I would check the meds too. Is she diverting or just lazy?

Quote from PeetzI work in LTC/RH and we are having to deal with family of a resident over a wound. There is talk of lawyers, suits and what not. I found out that the documentation for this "wound" was poor if at all. There was a signature that another nurse has preformed a skin audit the same day and it was negative, yet did not fill out the paperwork for skin audits ( she never does, even after repeated complaints to the DON.) There are several resident she charts that she does treatments on and I know they are not getting done. I feel this is another treatment that she signed off on and did not actually do. Has anyone had this happen and what was the outcome. This RN has been there many years and feels she is un-fire-able. I would really like to see this person reprimanded for her actions, simply so things change for the sake of the patients. I believe in education first and discipline second, but she has been told multiple times about skin audit forms and just refused to take part in any change.

Quote from SuesquatchRNYour DON needs to know of the "talk" of lawsuits, etc. immediately, as well as anything you have on the state of the resident's wound and any documentation relating to it.What is your position? Co-worker? Supervisor?

Quote from classicdameworked with a nurse who was caught charting ahead (same idea) and was fired on the spot. It is against the NPA in my state to falsely document. It is also required that if an RN has knowledge of this, it will be reported to the BON. The idea is to protect the patient, not the nurse. In this case, she is actually harming or has the potential to harm someone. I would check the meds too. Is she diverting or just lazy?

I don't know what else u can do except keep complaining.This is why I refuse to work LTC or in nursing homes now. I have found meds - some of them multiple meds including diazepam etc - not given but which have been signed for. It happens a lot. I think the nurses jut get busy & sign everything at the end of the night, & have forgotten to chuck the med packets away or take them home. Drug stealing in NHs/LTC is so easy to do.I reckon if the DON doesn't do anything, file a complaint re this nurse with your nurses board.

Quote from peetzi work in ltc/rh and we are having to deal with family of a resident over a wound. there is talk of lawyers, suits and what not. i found out that the documentation for this "wound" was poor if at all. there was a signature that another nurse has preformed a skin audit the same day and it was negative, yet did not fill out the paperwork for skin audits ( she never does, even after repeated complaints to the don.) there are several resident she charts that she does treatments on and i know they are not getting done. i feel this is another treatment that [font="arial narrow"]she signed off on and did not actually do. has anyone had this happen and what was the outcome. this rn has been there many years and feels she is un-fire-able. i would really like to see this person reprimanded for her actions, simply so things change for the sake of the patients. i believe in education first and discipline second, but she has been told multiple times about skin audit forms and just refused to take part in any change.

This in my opinion is not something that warrants a "courtesy reminder" to the nurse. Any falsification of the documentation imo is an immediate incident report. I always write it like Cuddles stated. Something like if pt is alert and oriented " pt denies dressing being changed today. Dressing observed to be soiled. Date on dressing 11/30/11 initials ABC. Dressing removed, wound observed to be (accurate measurements and description of wound and peri wound area. Dressing change performed per x orders."