An RN submitted a question about her patient care technicians not signing off on their work and sometimes not taking patients’ vital signs.
Repeated reporting of these omissions to her supervisor resulted in no change. In fact, the RN stated she had been written up for complaining to the PCTs.
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| Nursing Conference, Australia |
In addition, since she states she is unable to “close shifts” at the end of the day, she also was written up for not doing so. Her supervisor told her to document the information and sign the PCTs’ names to any labs, meds or care. The reader asked if this constitutes falsifying documentation. The simple answer is, “Yes.”
Any time you sign another person’s name on a patient record with the intent to deceive another person or entity, falsification occurs. It is seen as a felony under criminal law and is especially a concern when the person doing so falsifies a legal record to obtain financial gain.
The reader said her supervisor told her not closing the shift results in the healthcare entity’s parent company losing money.
In addition to the potential for criminal liability, the nurse also can face disciplinary action by the state board of nursing. Most nurse practice acts list falsification of a patient record or document required by his or her nursing practice (e.g., time cards) as a basis for professional discipline. Last, but by no means least, any falsification involved within your nursing practice is unethical.
What can you do to protect yourself?
Rather than handle the PCTs’ refusal to fulfill their job responsibilities as the supervisor suggests, the nurse does have several options, and they all rest on principles of good supervision of delegated patient care and good documentation.
The PCTs are supervised by the RN. Their care is delegated by her and they are required to report to her concerning the care that she has delegated. So, at least verbally, she should regularly receive information about patients’ statuses.
For example, the RN might document: “Mary L, PCT, reported to me [or this RN] at 2:30 p.m. that patient John Jones’ blood pressure readings were 150/80 at 8:30 a.m. and 135/80 at 2 p.m. – Nurse Smith, RN.”
The reader did not include how the PCTs “sign off” their work, but it is assumed if they do not document directly in the patient record that they document their findings on “worksheets,” which may or may not become part of a patient’s record.
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