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Falsifying Medical Records: A Systems Approach Investigation
Case in Point
Falsifying Medical Records: A Systems Approach Investigation Sharon Eli Mercer, MSN, RN, NEA BC, and Ann Tino, BSN, RN, Certified Investigator A charge nurse in Kentucky falsified medical records by writing that she received a verbal order from a physician to administer an anxiolytic to a patient. An investigation by the board of nursing (BON) revealed that the nurse was guilty. However, the investigation also revealed that the work environment created by physicians, nurse managers, and facility managers forced nurses to falsify medical records. Because of this case, when the Kentucky BON investigates a complaint against a nurse today, it also investigates the culture in which the alleged violation took place.
P
eople falsify medical records for many reasons, including drug diversion, a disregard of policy, an attempt to expedite patient care, and a failure of the system to provide an adequate medication ordering process (Institute for Safe Medication Practices, 2004). In this case, falsification resulted because facility and nurse managers not only tolerated but encouraged a culture in which nurses wrote medical orders rather than risk the wrath of physicians. Nurses and physicians working in specialty areas can develop a high comfort level with each other’s approach to care. Nurses may come to believe they know physicians’ prescribing habits so well that they can write an order without talking with the physicians. Physicians can become comfortable with this practice and encourage it for convenience’ sake, especially if this practice minimizes middle-of-the-night phone calls for what the physicians consider simple orders.
A Case of Falsification Mary Smith, BSN, RN, was working as a full-time, night-shift charge nurse in a cardiac unit in a Kentucky hospital. One night in June of 2004, Seth Leggat, who was recovering from cardiac surgery, was becoming increasingly agitated. According to Ms. Smith, the shift was hectic, and she made many calls to Dr. Jones regarding Mr. Leggat and other patients. During one call about pain medicine for another patient, Dr. Jones told her to do whatever she wanted to do. During a later call, he called her “stupid and incompetent.” She had worked with Dr. Jones for several years and knew he ordered lorazepam (Ativan) for agitated patients. Rather than make another call, she wrote a physician’s order in Mr. Leggat’s chart for “Ativan 1 mg IV push now per verbal order from Dr. Jones.” After she administered the drug, the patient’s condition deteriorated, and he was transferred back to the intensive care unit. The next morning, when Dr. Jones reviewed Mr. Leggat’s chart, he emphatically stated that he had not been called for the Ativan order Volume 2/Issue 3 October 2011
and he had not given the verbal order. A complaint was sent to the nurse manager, and an internal investigation began. When questioned by hospital managers, Ms. Smith admitted that she wrote the order. However, she explained that this was common practice in the unit. According to her, everyone knew that charge nurses wrote orders for physicians and that physicians signed the orders the next morning. She said physicians often told charge nurses to make smart decisions, and the physicians would sign the orders later. She also said that nurse managers made clear that if a nurse did not do as a physician wanted—that is, avoid calls in the middle of the night—the nurse would “end up in the office.” Once, when Ms. Smith could not reach a physician for orders, she called the medical director. The next day, her nurse manager told her never to do that again. Ms. Smith was fired, and at the hospital’s direction, she reported the episode to the board of nursing (BON). The hospital filed a formal complaint with the BON, indicating that Ms. Smith was terminated for falsifying medical records and administering medication without a physician’s order
BON Investigation Reporting such incidents to the BON is mandated by statute: “It shall be unlawful for any nurse, employer of nurses, or any person having knowledge of facts to refrain from reporting to the board a nurse who…is suspected of falsifying or in a negligent manner making incorrect entries or failing to make essential entries on essential records” (KRS 314.031 (4) (i)). The BON staff began an investigation. Subpoenas were issued for the patient’s medical record, specifically the physician order sheets, the nurses’ notes, and the medication administration records; the nurse’s personnel file; and the cardiac unit’s policies and procedures related to medication orders. During an investigative meeting with Ms. Smith and her attorney, she again admitted that she wrote the order and expected the physician to sign it when he arrived the next morning. She again stated that www.journalofnursingregulation.com
41
this was common practice in the cardiac unit. The physicians did not want calls in the middle of the night for “little things.” After the meeting, the nurse investigator requested letters of recommendations from Ms. Smith’s peers and other positive information regarding her nursing practice. Ms. Smith submitted a letter of reference from the medical director of the heart and vascular center at the facility; an anonymous letter from a fellow charge nurse at the facility indicating that Ms. Smith was only doing what was expected of her to keep her job; and an acceptable 90-day performance review from her new employer. From the nurse investigator’s standpoint, the case exhibited a clear violation of Kentucky nursing law, which defines registered nursing practice in part as, “The administration of medication and treatment as prescribed by a physician, physician assistant, dentist or advanced practice registered nurse....” This statute also lists as unlawful, “negligently or willfully acting in a manner inconsistent with the practice of nursing.” Because writing a medication order is not within the scope of registered nursing practice, Ms. Smith willfully acted in a manner inconsistent with the practice of nursing (KRS 314.011 (6) (c)). Another Kentucky nursing law gives the BON disciplinary power in cases in which a nurse “has falsified or in a negligent manner made incorrect entries or failed to make essential entries on essential records” (KRS 314.091 (1) (h)).
Scope of Culpability Complaints sent to the Kentucky BON often indicate that the person being reported is not the only one who is culpable. In this case, the nurse reported that writing orders without calling the physician was common practice, prompting the nurse investigator to seek more information on the environment in which the incident occurred. In Kentucky, the Credentials Review Panel (CRP), which consists of four BON members, reviews this type of case and provides direction to the BON staff for final resolution of disciplinary complaints that fall outside the scope of available precedent because of factual, evidentiary, legal, or equitable consideration. The CRP, which had access to the nurse’s investigative file, applicable statutes, administrative regulations, advisory opinion statements issued by the BON, and national standards of practice, recommended a reprimand on Ms. Smith’s license for the seriousness of her inappropriate nursing actions. Ms. Smith entered into an agreement with the BON, admitting that she had negligently or willfully acted in a manner inconsistent with the practice of nursing and that she falsified or in a negligent manner made incorrect entries or failed to make essential entries on essential records. She also agreed to pay a civil penalty of $500.00 and attend the BON-sponsored workshop entitled “Nursing Leadership: An Overview of Kentucky Nursing Laws and the Kentucky Board of Nursing.” The BON believed that Ms. Smith worked in an environment that could be perceived as cultivating her inappropriate 42
Journal of Nursing Regulation
nursing actions. However, the Kentucky nursing laws hold each nurse accountable for her or his own actions. One law reads, “All individuals licensed under provisions of this chapter shall be responsible and accountable for making decisions that are based upon the individuals’ educational preparation and experience in nursing and shall practice nursing with reasonable skill and safety” (KRS 314.021 (2)). Another Kentucky nursing law, KRS 314.011(6)(c), states in part that registered nursing practice includes, “The administration of medication and treatment as prescribed by a physician, physician assistant, dentist, or advanced practice registered nurse and as further authorized or limited by the board, and which are consistent either with American Nurses Association Standards of Practice or with Standards of Practice established by nationally accepted organizations of registered nurses.” This statute was prominent in the discussion of the case. Ms. Smith falsified medical records and practiced outside of her scope as a registered nurse by writing physician orders and administering medication without a legitimate order. By falsifying the record, she also breached the American Nurses Association’s Standards of Practice, which are incorporated into Kentucky nursing law. These standards state that accurate record keeping and documentation are essential parts of the nursing process (American Nurses Association [ANA], 2010). The CRP made one referral to the Kentucky Board of Medical Licensure regarding Dr. Jones’s “expectation” that nurses practice outside their scope of practice. The CRP made another referral to the Cabinet for Health and Family Services, Office of the Inspector General, regarding the facility’s expectations for the medical and nursing staff.
Implications This case involves both regulatory authority and standards of practice for the nursing and medical professions. It also raises system issues related to facility leaders, work environment, and corporate culture. Each profession is accountable for the care provided within its scope of practice. Clearly, Ms. Smith was practicing outside her scope of practice. However, the unit manager and the senior administrative nursing staff were also outside their scope because they not only allowed but required this behavior. Standard 7 on Ethics in the American Nurses Association’s Standards of Professional Performance states that the registered nurse practices ethically. One of the competencies is that the registered nurse “takes appropriate action regarding instances of illegal, unethical, or inappropriate behavior that can endanger or jeopardize the best interest of the healthcare consumer or situation.” This standard applied to Ms. Smith as well as the nursing leaders of the facility (ANA, 2010). This case also illustrates the need for collaboration among regulatory entities, such as the discussion and referral that took place between the nursing and medical boards.
Work Environment
Cultivating an environment that encourages or forces nurses to perform acts outside their scope is detrimental not only to the provision of safe nursing care but also to all nurses who practice in the environment. As Ms. Smith reported, physicians expected nurses to write physician orders, and nursing leaders reinforced the practice. Nursing laws are developed and enforced to protect the public. An environment that bypasses these laws puts nurses in a difficult situation. If they do not participate in the environmental culture, they face the implied threat of losing their jobs. In turbulent economic times, this threat can be devastating. For relatively new nurses who are just finding their footing, confronting a manager is almost impossible. Facility leaders allowed an atmosphere in which physicians could demean nurses instead of fostering an environment in which physicians treated nurses with respect. This toxic atmosphere made it easier for a nurse to write an order rather than to call for one and risk a physician’s fury. This case and similar ones over the years illustrate the need to review each case holistically. Regulators must review a nurse’s actions, but they should do so within the system and environment where the actions took place. In seeking the means to use a holistic approach, the Kentucky BON began researching and developing the use of the Just Culture model (Marx, 2001). BON members reviewed a 2006 survey conducted by the Kentucky Hospital Association that assessed items affecting nurses’ satisfaction in the workplace (Knight & Cronin, 2007). Two of the five lowest-rated items were “The leadership at my facility values open and honest two-way communication” and “Physicians at this facility show respect for the skill and knowledge of the nursing staff.” The BON also convened a meeting of stakeholders, including staff nurses, nurse leaders at all levels, quality managers, and others, to discuss the situation of nurses such as Ms. Smith. After considering relevant data and receiving input and recommendations from constituents, the BON now considers not only the individual but also the system. When system issues are discovered in the course of an investigation, the BON sends a letter to the facility administrator and chief nursing officer, detailing the problem. The facility is asked to respond to the BON on any planned corrective action.
provides guest speakers for professional, academic, and community groups.
Conclusion Nurses such as Ms. Smith begin each day with the best intentions to provide quality care to their patients. However, on any given day, the conditions and events they encounter can lead to poor decision making that places patients at risk. The falsification of medical records remains an issue of utmost importance to BONs. Having a framework that differentiates willful misconduct from errors, knowledge deficits, and system issues is a vital first step toward addressing this issue in a consistent regulatory manner.
References American Nurses Association. (2010). Nursing: Scope and Standards of Practice (2nd ed.). Silver Spring, MD: Author. Institute for Safe Medication Practices. (2004). Intimidation: Practitioners speak up about this unresolved problem. Retrieved from http:// www.ismp.org/Newsletters/acutecare/articles/20040311_2.asp Knight, J., & Cronin, S. N. (2007). Enhancing patient care delivery systems through improved nursing engagement. KB Nursing Connection, 12, 26–29. Marx, D. (2001). Patient safety and the “just culture”: A primer for health care executives. New York, NY: Columbia University.
Sharon Eli Mercer, MSN, RN, NEA BC, is the Nursing Practice Consultant for the Kentucky Board of Nursing. She has also served as Executive Director for the Kentucky Nurses Association and owns her own consulting business. She has served in the regulatory arena both at the nursing board and in the state Medicaid program. Ann Tino, BSN, RN, is a Certified Nurse Investigator for the Kentucky Board of Nursing. Ms. Tino’s experience includes over 10 years as a nurse investigator in the Consumer Protection Branch. She attended and completed the Council on Licensure, Enforcement, and Regulation basic investigator training in 2002 and specialized training in 2005. Disclaimer: Although disciplinary action taken by the Board is a matter of public record, the identity of any nurse referenced in this article will not be revealed.
Education
This case makes evident the need for ongoing education of nurses, physicians, and administrators on scope of practice, appropriate documentation, communication, standards of practice, and leadership. BONs also have a responsibility to educate stakeholders regarding the hazards identified in the health care environment and the impact on the provision of care. As the regulatory agency for nurses in Kentucky, the Kentucky BON is committed to providing education to nurses through leadership conferences held throughout the state on an ongoing basis. The BON also Volume 2/Issue 3 October 2011
www.journalofnursingregulation.com
43
Falsifying Medical Records: A Systems Approach Investigation Sharon Eli Mercer, MSN, RN, NEA BC, and Ann Tino, BSN, RN, Certified Investigator A charge nurse in Kentucky falsified medical records by writing that she received a verbal order from a physician to administer an anxiolytic to a patient. An investigation by the board of nursing (BON) revealed that the nurse was guilty. However, the investigation also revealed that the work environment created by physicians, nurse managers, and facility managers forced nurses to falsify medical records. Because of this case, when the Kentucky BON investigates a complaint against a nurse today, it also investigates the culture in which the alleged violation took place.
P
eople falsify medical records for many reasons, including drug diversion, a disregard of policy, an attempt to expedite patient care, and a failure of the system to provide an adequate medication ordering process (Institute for Safe Medication Practices, 2004). In this case, falsification resulted because facility and nurse managers not only tolerated but encouraged a culture in which nurses wrote medical orders rather than risk the wrath of physicians. Nurses and physicians working in specialty areas can develop a high comfort level with each other’s approach to care. Nurses may come to believe they know physicians’ prescribing habits so well that they can write an order without talking with the physicians. Physicians can become comfortable with this practice and encourage it for convenience’ sake, especially if this practice minimizes middle-of-the-night phone calls for what the physicians consider simple orders.
A Case of Falsification Mary Smith, BSN, RN, was working as a full-time, night-shift charge nurse in a cardiac unit in a Kentucky hospital. One night in June of 2004, Seth Leggat, who was recovering from cardiac surgery, was becoming increasingly agitated. According to Ms. Smith, the shift was hectic, and she made many calls to Dr. Jones regarding Mr. Leggat and other patients. During one call about pain medicine for another patient, Dr. Jones told her to do whatever she wanted to do. During a later call, he called her “stupid and incompetent.” She had worked with Dr. Jones for several years and knew he ordered lorazepam (Ativan) for agitated patients. Rather than make another call, she wrote a physician’s order in Mr. Leggat’s chart for “Ativan 1 mg IV push now per verbal order from Dr. Jones.” After she administered the drug, the patient’s condition deteriorated, and he was transferred back to the intensive care unit. The next morning, when Dr. Jones reviewed Mr. Leggat’s chart, he emphatically stated that he had not been called for the Ativan order Volume 2/Issue 3 October 2011
and he had not given the verbal order. A complaint was sent to the nurse manager, and an internal investigation began. When questioned by hospital managers, Ms. Smith admitted that she wrote the order. However, she explained that this was common practice in the unit. According to her, everyone knew that charge nurses wrote orders for physicians and that physicians signed the orders the next morning. She said physicians often told charge nurses to make smart decisions, and the physicians would sign the orders later. She also said that nurse managers made clear that if a nurse did not do as a physician wanted—that is, avoid calls in the middle of the night—the nurse would “end up in the office.” Once, when Ms. Smith could not reach a physician for orders, she called the medical director. The next day, her nurse manager told her never to do that again. Ms. Smith was fired, and at the hospital’s direction, she reported the episode to the board of nursing (BON). The hospital filed a formal complaint with the BON, indicating that Ms. Smith was terminated for falsifying medical records and administering medication without a physician’s order
BON Investigation Reporting such incidents to the BON is mandated by statute: “It shall be unlawful for any nurse, employer of nurses, or any person having knowledge of facts to refrain from reporting to the board a nurse who…is suspected of falsifying or in a negligent manner making incorrect entries or failing to make essential entries on essential records” (KRS 314.031 (4) (i)). The BON staff began an investigation. Subpoenas were issued for the patient’s medical record, specifically the physician order sheets, the nurses’ notes, and the medication administration records; the nurse’s personnel file; and the cardiac unit’s policies and procedures related to medication orders. During an investigative meeting with Ms. Smith and her attorney, she again admitted that she wrote the order and expected the physician to sign it when he arrived the next morning. She again stated that www.journalofnursingregulation.com
41
this was common practice in the cardiac unit. The physicians did not want calls in the middle of the night for “little things.” After the meeting, the nurse investigator requested letters of recommendations from Ms. Smith’s peers and other positive information regarding her nursing practice. Ms. Smith submitted a letter of reference from the medical director of the heart and vascular center at the facility; an anonymous letter from a fellow charge nurse at the facility indicating that Ms. Smith was only doing what was expected of her to keep her job; and an acceptable 90-day performance review from her new employer. From the nurse investigator’s standpoint, the case exhibited a clear violation of Kentucky nursing law, which defines registered nursing practice in part as, “The administration of medication and treatment as prescribed by a physician, physician assistant, dentist or advanced practice registered nurse....” This statute also lists as unlawful, “negligently or willfully acting in a manner inconsistent with the practice of nursing.” Because writing a medication order is not within the scope of registered nursing practice, Ms. Smith willfully acted in a manner inconsistent with the practice of nursing (KRS 314.011 (6) (c)). Another Kentucky nursing law gives the BON disciplinary power in cases in which a nurse “has falsified or in a negligent manner made incorrect entries or failed to make essential entries on essential records” (KRS 314.091 (1) (h)).
Scope of Culpability Complaints sent to the Kentucky BON often indicate that the person being reported is not the only one who is culpable. In this case, the nurse reported that writing orders without calling the physician was common practice, prompting the nurse investigator to seek more information on the environment in which the incident occurred. In Kentucky, the Credentials Review Panel (CRP), which consists of four BON members, reviews this type of case and provides direction to the BON staff for final resolution of disciplinary complaints that fall outside the scope of available precedent because of factual, evidentiary, legal, or equitable consideration. The CRP, which had access to the nurse’s investigative file, applicable statutes, administrative regulations, advisory opinion statements issued by the BON, and national standards of practice, recommended a reprimand on Ms. Smith’s license for the seriousness of her inappropriate nursing actions. Ms. Smith entered into an agreement with the BON, admitting that she had negligently or willfully acted in a manner inconsistent with the practice of nursing and that she falsified or in a negligent manner made incorrect entries or failed to make essential entries on essential records. She also agreed to pay a civil penalty of $500.00 and attend the BON-sponsored workshop entitled “Nursing Leadership: An Overview of Kentucky Nursing Laws and the Kentucky Board of Nursing.” The BON believed that Ms. Smith worked in an environment that could be perceived as cultivating her inappropriate 42
Journal of Nursing Regulation
nursing actions. However, the Kentucky nursing laws hold each nurse accountable for her or his own actions. One law reads, “All individuals licensed under provisions of this chapter shall be responsible and accountable for making decisions that are based upon the individuals’ educational preparation and experience in nursing and shall practice nursing with reasonable skill and safety” (KRS 314.021 (2)). Another Kentucky nursing law, KRS 314.011(6)(c), states in part that registered nursing practice includes, “The administration of medication and treatment as prescribed by a physician, physician assistant, dentist, or advanced practice registered nurse and as further authorized or limited by the board, and which are consistent either with American Nurses Association Standards of Practice or with Standards of Practice established by nationally accepted organizations of registered nurses.” This statute was prominent in the discussion of the case. Ms. Smith falsified medical records and practiced outside of her scope as a registered nurse by writing physician orders and administering medication without a legitimate order. By falsifying the record, she also breached the American Nurses Association’s Standards of Practice, which are incorporated into Kentucky nursing law. These standards state that accurate record keeping and documentation are essential parts of the nursing process (American Nurses Association [ANA], 2010). The CRP made one referral to the Kentucky Board of Medical Licensure regarding Dr. Jones’s “expectation” that nurses practice outside their scope of practice. The CRP made another referral to the Cabinet for Health and Family Services, Office of the Inspector General, regarding the facility’s expectations for the medical and nursing staff.
Implications This case involves both regulatory authority and standards of practice for the nursing and medical professions. It also raises system issues related to facility leaders, work environment, and corporate culture. Each profession is accountable for the care provided within its scope of practice. Clearly, Ms. Smith was practicing outside her scope of practice. However, the unit manager and the senior administrative nursing staff were also outside their scope because they not only allowed but required this behavior. Standard 7 on Ethics in the American Nurses Association’s Standards of Professional Performance states that the registered nurse practices ethically. One of the competencies is that the registered nurse “takes appropriate action regarding instances of illegal, unethical, or inappropriate behavior that can endanger or jeopardize the best interest of the healthcare consumer or situation.” This standard applied to Ms. Smith as well as the nursing leaders of the facility (ANA, 2010). This case also illustrates the need for collaboration among regulatory entities, such as the discussion and referral that took place between the nursing and medical boards.
Work Environment
Cultivating an environment that encourages or forces nurses to perform acts outside their scope is detrimental not only to the provision of safe nursing care but also to all nurses who practice in the environment. As Ms. Smith reported, physicians expected nurses to write physician orders, and nursing leaders reinforced the practice. Nursing laws are developed and enforced to protect the public. An environment that bypasses these laws puts nurses in a difficult situation. If they do not participate in the environmental culture, they face the implied threat of losing their jobs. In turbulent economic times, this threat can be devastating. For relatively new nurses who are just finding their footing, confronting a manager is almost impossible. Facility leaders allowed an atmosphere in which physicians could demean nurses instead of fostering an environment in which physicians treated nurses with respect. This toxic atmosphere made it easier for a nurse to write an order rather than to call for one and risk a physician’s fury. This case and similar ones over the years illustrate the need to review each case holistically. Regulators must review a nurse’s actions, but they should do so within the system and environment where the actions took place. In seeking the means to use a holistic approach, the Kentucky BON began researching and developing the use of the Just Culture model (Marx, 2001). BON members reviewed a 2006 survey conducted by the Kentucky Hospital Association that assessed items affecting nurses’ satisfaction in the workplace (Knight & Cronin, 2007). Two of the five lowest-rated items were “The leadership at my facility values open and honest two-way communication” and “Physicians at this facility show respect for the skill and knowledge of the nursing staff.” The BON also convened a meeting of stakeholders, including staff nurses, nurse leaders at all levels, quality managers, and others, to discuss the situation of nurses such as Ms. Smith. After considering relevant data and receiving input and recommendations from constituents, the BON now considers not only the individual but also the system. When system issues are discovered in the course of an investigation, the BON sends a letter to the facility administrator and chief nursing officer, detailing the problem. The facility is asked to respond to the BON on any planned corrective action.
provides guest speakers for professional, academic, and community groups.
Conclusion Nurses such as Ms. Smith begin each day with the best intentions to provide quality care to their patients. However, on any given day, the conditions and events they encounter can lead to poor decision making that places patients at risk. The falsification of medical records remains an issue of utmost importance to BONs. Having a framework that differentiates willful misconduct from errors, knowledge deficits, and system issues is a vital first step toward addressing this issue in a consistent regulatory manner.
References American Nurses Association. (2010). Nursing: Scope and Standards of Practice (2nd ed.). Silver Spring, MD: Author. Institute for Safe Medication Practices. (2004). Intimidation: Practitioners speak up about this unresolved problem. Retrieved from http:// www.ismp.org/Newsletters/acutecare/articles/20040311_2.asp Knight, J., & Cronin, S. N. (2007). Enhancing patient care delivery systems through improved nursing engagement. KB Nursing Connection, 12, 26–29. Marx, D. (2001). Patient safety and the “just culture”: A primer for health care executives. New York, NY: Columbia University.
Sharon Eli Mercer, MSN, RN, NEA BC, is the Nursing Practice Consultant for the Kentucky Board of Nursing. She has also served as Executive Director for the Kentucky Nurses Association and owns her own consulting business. She has served in the regulatory arena both at the nursing board and in the state Medicaid program. Ann Tino, BSN, RN, is a Certified Nurse Investigator for the Kentucky Board of Nursing. Ms. Tino’s experience includes over 10 years as a nurse investigator in the Consumer Protection Branch. She attended and completed the Council on Licensure, Enforcement, and Regulation basic investigator training in 2002 and specialized training in 2005. Disclaimer: Although disciplinary action taken by the Board is a matter of public record, the identity of any nurse referenced in this article will not be revealed.
Education
This case makes evident the need for ongoing education of nurses, physicians, and administrators on scope of practice, appropriate documentation, communication, standards of practice, and leadership. BONs also have a responsibility to educate stakeholders regarding the hazards identified in the health care environment and the impact on the provision of care. As the regulatory agency for nurses in Kentucky, the Kentucky BON is committed to providing education to nurses through leadership conferences held throughout the state on an ongoing basis. The BON also Volume 2/Issue 3 October 2011
www.journalofnursingregulation.com
43