are nurse managers required to report when a nurse falsifies patient documents

by Prof. Laurine Ondricka 6 min read

Falsification in nursing: It’s a legal line you should not cross

23 hours ago  · In most states, disciplinary actions include a reprimand, censure, probation, suspension or revocation of the nurse’s license. “When anyone falsifies information about themselves, it is a serious matter, as it is obviously misleading, deceptive and reflects on your trustworthiness. But it is extremely serious when a nurse does this.”. >> Go To The Portal


Depends on the manager and if s/he reports it to the RN Board. It really is a shame when someone has to falsly document a B/P, however, I will say that I've been in that same situation.....and never do I falsify records. If for example I don't have "time" to get a b/p I admit it.

Full Answer

What happens if a nurse falsifies a nursing report?

Falsification by nurses is not only unethical, it shatters legal parameters. Initially, criminal charges on the state or federal level may be brought against the nurse.

What are the laws for nurses and mandatory reporting?

Nurses and Mandatory Reporting Laws. Federal and state laws require that certain individuals, particularly those who work in health care, with the elderly, with children, and other vulnerable populations, have an affirmative duty to report to a specified state agency when violence occurs against those populations. Nurses are listed in most,...

What happens if a nurse fails to report domestic violence?

Indeed, if you as a nurse fail to report an instance of violence when required to do so, you could face professional disciplinary action by the state board of nursing, a loss of any certifications you hold (e.g., certification as a school nurse), and criminal prosecution (usually a misdemeanor). 2

Is there such a thing as falsification of documents in nursing?

Unfortunately, falsification of documents in nursing is not a new phenomenon. A 2012 article in the Journal of Nursing Regulation by Latrina Gibbs McClenton, discusses two cases of falsification of licensure applications by two separate candidates applying for RN licensure in Mississippi.

What happens if a nurse falsified documentation?

If your facility participates in Medicare or Medicaid, charting falsifications can be prosecuted as federal criminal offenses. The nurse who falsifies the record could lose her license and possibly serve prison time.

What are the legal responsibilities of a nurse manager?

Because the nurse manager is an employee of the health care facility, he or she isn't liable for the negligent acts or omissions of the registered nurses. However, he or she is liable for decisions relating to duty assignments and supervision of care, and negligence in providing direct patient care.

Is falsifying medical records a Hipaa violation?

A violation of HIPAA committed under false pretenses, such as disclosing a patient's information for a reason the provider knows to be untrue (such disclosing a patient's protected health information on the premise that the patient is an imminent threat to the public when the provider knows this to be false), can carry ...

What can happen if a healthcare professional falsifies information in a healthcare record?

Healthcare providers may also lose accreditation, eligibility for federal reimbursement programs, and loss of trust if they are found to have falsified a patient's medical record. Finally, knowingly falsifying medical records is a felony crime with a potential fine of $250,000 or five years in prison.

Who does a nurse manager report to?

Nurse managers typically report directly to the Director of Nursing (or possibly the Chief Nursing Officer, depending on the size of the organization). As a bedside nurse, you're responsible for yourself and possibly a CNA or two – as a nurse manager, you're responsible for many nurses (anywhere from 10 – 100+).

What are the most common potential legal liabilities for nurse managers?

The most common source of legal liability for nurses and nurse managers is a tort—that is, a wrongful act (other than breach of contract) committed against another person or organization or their property that causes harm and can be remedied by a civil (rather than criminal) lawsuit.

What are the 3 types of HIPAA violations?

Top 10 Most Common HIPAA ViolationsKeeping Unsecured Records. ... Unencrypted Data. ... Hacking. ... Loss or Theft of Devices. ... Lack of Employee Training. ... Gossiping / Sharing PHI. ... Employee Dishonesty. ... Improper Disposal of Records.More items...•

What is a deliberate violation of HIPAA?

An example of a deliberate violation is unnecessarily delaying the issuing of breach notification letters to patients and exceeding the maximum timeframe of 60 days following the discovery of a breach to issue notifications – A violation of the HIPAA Breach Notification Rule.

What is considered a violation of HIPAA?

The Health Insurance Portability and Accountability, or HIPAA, violations happen when the acquisition, access, use or disclosure of Protected Health Information (PHI) is done in a way that results in a significant personal risk of the patient. The regulation concerns just about everyone that works with PHI.

What would you do if you found that a nurse falsified nursing care in the clinical setting?

The nurse certainly could try to report her concerns to the CNO, who should appropriately intervene in the situation. Or the nurse could report the situation to her state board of nursing, which would investigate the matter and determine if disciplinary proceedings should be initiated.

What do you think the consequences of incorrect health care data appearing in a patient's record might be?

The consequences of incomplete medical records are: Lack of clarity in communication between physicians treating the patient leading to failure to follow through with evaluation and treatment plans. Incorrect treatment decisions compromising patient safety. Loss of practice revenue.

What is considered false documentation?

False documentation is the process of creating documents which record fictitious events. The documents can then be used to "prove" that the fictional events happened.

What was N.B.'s job?

N.B., an LPN, worked at a nursing home and was assigned to care for J.E., a Medicaid patient who suffered from seizures, dementia with behavior disturbances , COPD, and bowel problems. He was bed ridden and “characterized as a medical and behavioral high risk” due to his many health problems.1

How many counts of forgery did N.B. have?

N.B. was convicted of four counts of forgery at her trial. She appealed that judgment, alleging that the evidence upon which she was convicted was insufficient to prove intent to defraud and prejudice to another, two essential elements to prove forgery.

How long was surveillance done on J.E.?

The surveillance was done for 2 months. The video of N.B.’s care of J.E. clearly showed that she did not administer some of the medications prescribed but documented them as being given. She also failed to perform nursing care she documented as being done. Vital signs were not taken but made-up results were documented.

Why was N.B. convicted of forgery?

Because her attorney was disqualified from representing her due to a conflict , N.B. alleged she was entitled to a new trial. The Virginia Court of Appeals upheld the guilty verdict against N.B. on the four counts of forgery because the evidence at the trial level proved her guilt beyond a reasonable doubt.

How long did J.E.'s wife have surveillance?

The surveillance was done for 2 months.

What is a yes or no answer for a nursing license?

Each licensure form or document, whether an initial application for licensure, an applicationby endorsement, or a renewal application, contains questions that require a “yes” or “no”answer. These forms contain several questions that may affect the ability of an individualto function safely as a nurse. In addition, these forms require individuals to provideinformation to determine if the individual meets the practice requirements for nursinglicensure. Answers to these questions are used by the Board to determine the individual’sfitness for licensure.

What is falsification of credentials in nursing?

Generally, the falsification of an application to an employer, school of nursing, or othernursing training program is the responsibility of the employer, school, or training programto resolve, unless the falsification involves misrepresentation of the individual’s credentials,competencies, or work experience. The misrepresentation of an individual’s credentials toan employer will be investigated and viewed by the Board in the same way that lying orfalsification within nursing practice is viewed. Further, a student nurse who falsifies patientrecords or engages in other dishonesty in patient care gives the Board reason to suspectthat the individual may continue similar dishonest acts after licensure. If the Board is madeaware of such acts committed as a student, the Board will initiate an investigation of theindividual’s conduct once the student submits an application for licensure to the Board. Depending on the particular circumstances, disciplinary action may be warranted.

What is the duty of a nurse?

Nurses, by virtue of the license issued to them by the Board, have a duty to their patientsto provide safe, effective nursing care and to demonstrate good professional character atall times. The nurse-patient relationship is a dependent one, and patients under the careof a nurse are, by their very nature, vulnerable. This is especially true of the elderly,children, persons with mental disorders, sedated or anesthetized patients, patients whosemental or cognitive ability is compromised, and patients who are disabled or immobilized.

What is the Texas Board of Nursing?

The Texas Board of Nursing (Board) is committed to its mission to protect the public health,safety, and welfare. In keeping with this mission, the Board is concerned about thedeceptive or dishonest conduct of an individual as it relates to the provision of health care. Such conduct includes falsifying documents related to patient care, employment, andlicensure.

What does "falsifying medical records" mean?

While the phrase "falsifying medical records" sounds rather sinister, in fact it covers a number of activities that may not always have a fraudulent intent. For example, a physician may face allegations of wrongdoing if she tampers with the records to make it look like she did something she did not, ...

What happens when medical records are fraudulently falsified?

When medical records are fraudulently falsified, it's usually in response to a medical malpractice suit. For example, a physician who is being sued for damages might alter the records to cover up his wrongdoing and make the records fit his version of the story. These actions will destroy a medical malpractice defense.

What happens if you falsify your medical records?

A healthcare practitioner who is found to have falsified medical records almost certainly will be subject to discipline by the state licensing board , which could range anywhere from a reprimand to a fine to license suspension or even loss of a license.

What happens if a medical practitioner is suspended?

Even if she's not suspended, the practitioner's insurer likely will cancel professional liability coverage. This means the practitioner's legal bills won't be covered if she's sued for medical malpractice, which may harm her ability to defend the case.

Is tampering with medical records a crime?

In some states, tampering with medical records is a criminal offense in its own right. In others, fabricating medical entries is a forgery crime, covered by both state and federal laws. Misdemeanor tampering charges typically will result in fines and jail time up to around a year.

Can you get in trouble for falsifying medical records?

Even non-medical professionals can get in trouble for falsifying medical records. You can't go into the hospital and make changes to your sister's chart, for example, because you want her to get more medication, because you want her released or even because you want to create a beneficial situation for a medical malpractice lawsuit or personal injury lawsuit. Falsifying medical records, whether you're a medical worker or not, is illegal.

What is a fake document?

Falsification of documents generally refers to a criminal offense. This offense involves the: Possessing of a document for unlawful purposes. Common examples of fake legal documents include: Personal checks. Falsifying documents is considered to be a white collar crime, and may be referred to by other names depending on the state.

What is an example of a person being charged with tax evasion?

An example of this would be when a person is charged with tax evasion; or, the person has intentionally acted to defraud the IRS. Tax filers may make a careless mistake; this is not the same as intentionally deceiving the IRS.

What is the meaning of "parole"?

Parole; Substantial fines; and. Restitution, or, paying victims back for their losses. The state in which you live, as well as the specific facts of your case, can influence whether you are likely to be charged with a felony for falsifying documents.

What is the definition of fraud?

The amount of money or property that was stolen as a result of the fraud; and. The person, business, or entity that was the targeted victim. If the defrauded entity is the federal government, there may be heavier penalties to contend with, as well as federal charges rather than state charges.

Do you have to prove that you did not falsify a document?

Additionally, you will need to prove that you did not know that the documents in question were falsified.

Is falsifying a tax return a crime?

Personal checks. Falsifying documents is considered to be a white collar crime, and may be referred to by other names depending on the state. It can even be included as part of other collateral crimes.

Is falsification a crime?

Falsification of a document is a very serious crime and you will want someone to defend your rights. Such an attorney can explain to you your state’s laws regarding the matter, as well as determine if any defenses are available to you based on the specifics of your case. They will also represent you in court as needed.

Question

I am a nurse practitioner and do face-to-face visits for a local hospice agency part time. I was terminated today for misdating four visits. They said I falsified documentation and they are reporting me to the board of nursing. I honestly didn’t remember the date of visit and just signed the wrong day.

Nancy Brent replies

The allegations against you are quite serious, so it is important for you to seek legal representation through a nurse attorney or attorney in your state as soon as possible. It will be important that you present your best defense possible in this situation.

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