Three Requests at 11 PM
It is 11:00 PM on a 30-bed unit. The licensed nurse is in a resident's room with someone who has chest pain, and she calls to you, "Do the dry dressing change on bed 12 while I'm in here - it's just a quick one." At the same time, Mr. D in bed 14 buzzes and asks for "the laxative in my top drawer, I always take it about now." Walking past the desk, you see another aide charting "repositioned q2h, skin intact" for four residents she has not gone into since 8:00 PM. Your facility's policy lists dressing changes as a licensed-nurse task, and you are not a certified medication aide.
1. Sort the three situations into what you may do, may not do, and must act on, with your reasoning for each.
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May not do - the dressing change. Policy assigns it to the licensed nurse, and "dry" is not the point: a dressing change requires assessing the wound, aseptic technique, and deciding whether the wound has changed. Doing it because the nurse is busy would put my certification and the resident's skin at risk.
May not do - the laxative. I do not administer medication; I am not a certified medication aide, and a resident's "I always take it about now" is not an order I can verify. Even if a laxative appears on the MAR, it is not mine to give. I can offer what is in my role - water, positioning, ambulation if allowed - and report the request.
Must act on - the falsified charting. Charting care that was not given is falsification and it can hide a pressure injury or a developing wound. Four residents may be lying in one position for hours while the record says otherwise. This cannot wait until morning.
What I may do: take vital signs on bed 12, stay with that resident, get them a drink, and answer lights - real help inside my scope.
2. Write what you say to the nurse when you decline the dressing change.
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Close to word for word, and quietly, so the resident in the room does not hear it as a dispute:
"I can't do the dressing change - that's a licensed task under our policy, and it's not in my training or my scope. What I can do is take vitals on bed 12, stay with them, get them a drink, and keep the lights answered until you're out. Do you want me to call the charge nurse to cover it?"
Why it is phrased that way: I lead with the limitation, not with "I don't want to"; I immediately offer what I can do, so the nurse is not left with nothing; I name a route to get the task covered; and I do not argue about how quick or simple the task is. If the nurse pressures me or says "just this once," I hold the line and escalate to the charge nurse - "just this once" is how scope violations become habits, and I am the one who is accountable for what I do with my hands.
3. What do you do about the other aide's charting, and what are your own documentation obligations tonight?
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About the aide: report it to the charge nurse or supervisor tonight, not next shift. Stick to facts - "At 11:05 PM I saw aide ___ charting q2h repositioning and 'skin intact' for rooms 3, 7, 9, and 11; I had not seen her enter those rooms since 8:00 PM." I do not confront her in front of others, I do not alter the record, and I do not chart anything for her. Falsification that conceals missed repositioning is potentially neglect, and aides are mandated reporters.
Also practical: those four residents still need to be repositioned. I tell the nurse and, if I am able, I do the turns myself and chart my own.
My own charting tonight: only care I personally gave, with times, in objective terms. I document the dressing change as not done and why, that I notified the nurse of the laxative request, and what I did instead. I never write "care given" for another person's work, and I never backdate or add a late note without labeling it as a late entry.