A charge nurse is observing a licensed practical nurse assist a client who has dysphagia while eating. Which of the following actions by the LPN should the charge nurse identify as providing safe care?

A.Documenting the time of the error is important for accurately recording when the event happened and for assessing potential impacts on patient care.

B.Including specific details about the medication involved and the dosage is crucial for understanding the nature of the error and for evaluating its potential consequences.

C.Incident reports are confidential and should not be copied for personal records. They are used for internal review and quality improvement purposes and should be handled according to the facility's policies on confidentiality.

D.The incident report should not be placed in the client’s medical record. It is a separate document intended for internal use and quality improvement, not part of the client’s clinical record.

E.No order from the provider is needed to complete an incident report. The report is a standard procedure for documenting and analyzing errors and is part of the facility's protocol for ensuring patient safety.

a. Review the chart for nonrestraint alternatives for agitation:

This action involves assessing the client's history, current condition, and any documented alternatives to restraints for managing agitation. While exploring nonrestraint interventions is important, addressing the immediate issue of inappropriate restraint use should take precedence.

b. Inform the unit manager:

Notifying the unit manager about the incident is important for escalating the situation and involving higher-level management in addressing the inappropriate use of restraints. However, before escalating, the immediate needs of the client should be addressed.

c. Speak with the AP about the incident:

Engaging in a conversation with the assistive personnel (AP) who applied the restraints allows for clarification of the situation, identification of any misunderstandings or training needs regarding restraint use, and immediate removal of the restraints if necessary. However, ensuring the client's safety should be the first priority.

d. Remove the restraints from the client’s wrist:

In situations where restraints are applied without a prescription or appropriate authorization, it is crucial to remove the restraints promptly to prevent potential harm to the client. However, it is essential to address the root cause of the inappropriate use of restraints and ensure that the client receives appropriate care and monitoring following restraint removal.