Friday, August 8, 2014

Bloody Mess

This falls under the "If it's not documented, it wasn't done" argument.

Patient bumped his arm in his room.  He's a bleeder, so there was blood on his arm, his clothes, his bed, and his floor.

The actual skin tear wasn't large or deep.  Doctor looked at it, nurse cleaned it up and bandaged it.  Documented in chart.

Idiot supervisor wasn't satisfied.  "What about the blood on the floor of his room?  Did you notify housekeeping?"

Me:  "Yes.  Everything has been taken care of."

Supervisor:  "You know why I'm asking, right?"

Me:  [Thought:  Because you are an idiot who has no idea what to do.  But I didn't say anything.  Proud of me.]

Supervisor:  "You did not document that housekeeping cleaned the room, or that the sheets were removed, and how the floor was disinfected."

Me:  "Correct, I documented about the care rendered to the patient, not the floor or the sheets."

Supervisor:  "Well, part of the care rendered to a patient is keeping the environment clean.  I'm just looking out for you.  If somebody were to read your note, they would probably think that the blood was left in the room.  That creates an unsafe environment for every patient here."

Me:  "I have never documented that housekeeping cleaned anything.  No rational person would read a chart and conclude that the patients were staying in a garbage dump because the nurse did not provide detailed notes about efforts of the housekeeping staff."

Supervisor:  "Part of the care rendered to a patient is housekeeping, so you need to document that as well."

Me:  "No, the nurse does not have to document that housekeeping cleans.  Besides, I did not personally see that the housekeeper cleaned the blood, so I can't document that he did."

Supervisor:  "That is the other part of your problem.  You did not bother to stay in the room to make sure that housekeeping cleaned the room consistent with the policy on cleaning a blood spill."

Me:  "No, instead of staying in the room to take care of the floor, I stayed with the patient to take care of him."

Nurses and fellow healthcare workers:  Does your employer require you to document in your notes that housekeeping cleaned?  For example, in the emergency department, after a bloody trauma has been sent up to surgery, do you document that housekeeping cleaned the room?

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