Notes on a nursing scandal

Directing another nurse to write inaccurate notes is a serious matter, as this case study illustrates.

The making of nursing notes is an important task that nurses undertake as part of their duties. Their importance cannot be stressed enough, not least for the fact that they outline the history of any incident that may have occurred. Any inaccuracy of a note, whether by what is written or what is left out, is a serious matter. The seriousness is not diminished if a nurse directs another to make a note in such circumstances.

About 3pm on 31 May 2011, a 76-year-old woman suffering dementia, who was a resident (the resident) in a dementia unit (the Unit) at a nursing home in Melbourne (the Facility), was walking unattended in the grounds of the Unit’s internal courtyard. The courtyard included a path, a garden bed on both sides and a water fountain adjacent to the path. The resident wandered into the garden bed near the fountain, and when returning to the path knocked over a garden light adjacent to the path with her knee. Continuing to walk onto the path the resident tripped on the knocked over garden light and fell headfirst into the pond section of the fountain, striking her head. The resident remained motionless, lying face down with her face and torso in the base of the water-filled fountain from the time of the initial fall.

At 3:51pm, the registered nurse in charge of the Unit, who I will call S, attended to the resident, in response to the alarm being raised. The resident was lying face down in the fountain with part of her face submerged in the water and was deceased. Another staff member joined S to assist in quickly lifting the resident’s head out of the water.

The second RN, referred to as C, was the aged care facility manager who arrived about a minute after S. She was present as staff moved the resident from the fountain onto the ground next to the fountain. C gave directions to staff, including directing another staff member to telephone the resident’s general medical practitioner to advise of what had happened. After about 10 minutes, the resident’s body was removed from the courtyard and then dried, dressed and placed in bed.

It is clear on the facts that C was aware that, with the resident having been found lying in the fountain with her face partially submerged, falling and/or drowning were likely or possible contributory factors in their death. Despite this, C and S had a conversation about what to write in the resident’s medical file about the circumstances of the death. C directed S to make an entry in the progress notes (the note) at 4:45pm, which stated:

[Resident was] found in the courtyard at 1600 hrs lying on the ground, nil pulse, nil respiration, lips cyanotic, appears to have a massive MI.

Importantly, the note:

1. Did not record that the resident was found lying face down in the fountain with her face partially submerged.
2. Did not record that a fall and/or drowning were potential causes of death or potential contributing factors to a death.
3. Incorrectly recorded the resident having been found on the ground in the courtyard rather than partially submerged in the fountain.

A few days later, a whistleblower raised the matter of the possibility of confusion or a cover-up. This led to enquiries being made by senior nursing home management and the police. Arising out of these investigations, the inaccuracy of the note was uncovered. This led to a disciplinary hearing concerning C’s actions and behaviour.

At the hearing, the Nursing Board alleged that on or about 31 May 2011, C engaged in professional misconduct and/or unprofessional conduct, in that she directed S to make the note, which she knew, or ought to have known, to be false, misleading and/or inaccurate, and/or omit from the note information that she knew, or ought to have known, was relevant and required to be included. The evidence given by C was that she admitted directing S to make the false entry into the progress notes.

The tribunal stated that:

[Nurses] are expected, as the Code [of Ethics] summarises, to independently and accurately record events close to the time they occur, even though they have been placed under significant stress and strain. Registered nurses are also expected to independently discharge their duties and to repel improper suggestions as to what they should record with respect to any incident, including a critical incident.

The tribunal found that:

C’s conduct in recording the note was, on any view, substantially below what might reasonably be expected of the health practitioner by the public or the practitioner’s professional peers.

The tribunal therefore found the more serious charge of professional misconduct (as opposed to unprofessional conduct) of having been committed. Accordingly, the tribunal reprimanded and suspended C’s registration for three months.

This case demonstrates the seriousness of directing another to make inaccurate and misleading nursing notes in relation to their professional and ethical responsibilities. Giving a direction to another, in such circumstances, does not absolve them of their responsibilities required as a nurse. The directing nurse cannot hide behind the fact that they physically did not make the entry.

Scott Trueman is a lecturer in the School of Nursing, Midwifery and Nutrition at James Cook University.

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