Health care finance week 4

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Chapter 10

Nursing and the Law

LEARNING OBJECTIVES

• Describe how the role of nursing practice continues to evolve.

• Explain the process of obtaining nurse licensure.

• Discuss the various categories of nursing staff and the legal risks of nurses.

• Describe the legal risks of advance practice nurses.

Scope of Practice

• Permissible boundaries of practice for health care professionals, defined in state statutes, which define the actions, duties, & limits of nurses in their particular roles.

• Role of nurse continues to expand due to

– shortage of primary care physicians – ever-increasing specialization – improved technology – public demand – expectations within the profession itself.

Nurses Pressing for More Autonomy

In 11 states, they are pushing legislation that would permit nurses with a masters degree or higher to order and interpret diagnostic tests, prescribe medications and administer treatments without physician oversight. Similar legislation is likely to be added soon in three other states.

–N.C. Aizenman, The Washington Post, March 25, 2012

NURSING DIAGNOSIS

• Various states recognize that nurses can render a nursing diagnosis.

– e.g., Section 335.01(8) of the Missouri Revised Statutes (1975) authorizes an RN to make an assessment of persons who are ill and to render a nursing diagnosis.

CLASSIFICATION NURSE STAFF

• Various states recognize that nurses can render a nursing diagnosis.

– e.g., Section 335.01(8) of the Missouri Revised Statutes (1975) authorizes an RN to make an assessment of persons who are ill and to render a nursing diagnosis.

Nurse Licensure I

• Requirements for Licensure

– Reciprocity

• agreement between states whereby a nurse licensing board in one state recognizes licensees of another state .

– Endorsement

• boards determine if out-of-state nurses' qualifications are equivalent to their own state requirements at the time of initial licensure.

Nurse Licensure II

– Waiver

• When applicants do not meet all the requirements for licensure but have equivalent qualifications, the specific prerequisites of education, experience, or examination may be waived.

– Examination

• Some states will not recognize out-of state licensed nurses & make it mandatory that all applicants pass a licensing examination.

Suspension & Revocation

• Violations may include

– procurement of a license by fraud

– unprofessional, dishonorable, immoral, or illegal conduct

– performance of specific actions prohibited by statute

– malpractice.

Practicing without a License

• Health care orgs are required to verify each nurse's license is current.

• Mere fact that an unlicensed practitioner is hired will not generally in & of itself impose additional liability unless a patient suffered harm as a result of an unlicensed nurse's negligence.

CLASSIFICATION OF

NURSE STAFF

Nurse Managers – I

• Chief nursing officer has responsibility for: – maintaining standards of practice

– maintaining current p & ps

– recommending staffing levels

– coordinating & integrating nursing services with other patient care services

– selecting nursing staff

– developing orientation and training programs.

Nurse Managers – II

• Failure to supervise – can lead to disciplinary action

Registered Nurse

• Graduation from accredited nursing program

• Pass national licensing exam

– National Council Licensure Examination

LPNs & LVN

– Graduation from accredited nursing program

– Pass a licensing exam approved by the state

– Routine nursing care

• vital signs, injections, assist patients, etc.

• under direction of an RN or physician

Certified Nurse Assistant

• Aide who has been certified & trained to assist patients with activities of daily living under the direction & supervision of an RN or LPN.

• Help with positioning, turning, lifting & performing a variety of tests * treatments.

• Case: Failure to follow policy & safe practices

Float Nurse

• Nurse who rotates from unit to unit based on staffing needs.

• Can benefit understaffed unit but also may present a liability as well if they are assigned to work in an area outside their scope of expertise.

• If a patient is injured due to floater's negligence, standard of care required will be that required of a nurse on the assigned patient care unit.

Agency Staff

• Risk for negligent conduct of agency staff.

• Agency workers must have necessary skills & competencies to carry out duties & responsibilities assigned.

• Case: Resuscitation of Choking Child Fails

Special-Duty Nurse

• A health care professional employed by a patient or patient's family to perform nursing care for the patient.

• If a master-servant relationship exists between the org & special-duty nurse, doctrine of respondeat superior may be applied to impose liability on the org for nurse's negligent acts.

Traveling Nurse

• Nurse who travels to work in temporary nursing positions in different cities and states.

– independent contractors or

– elect to work with one or more recruitment agencies

• Opportunities that include higher wages.

• Skills enhanced with exposure to intriguing assignments.

Student Nurse

• Student nurses are entrusted with the responsibility of providing nursing care to patients.

• Students are personally liable for their own negligent acts, & the facility is liable for their acts on basis of respondent superior.

• Student nurse are held to the standard of a competent professional nurse when performing nursing duties

ADVANCED PRACTICE

NURSES

The Role of Nurses Extends Beyond the Hospital Ward

A nurse is a doctor’s best friend, according to Marvin M. Lipman, Consumers Union’s chief medical adviser. This advice was given to him by a hospital ward’s head nurse when he was a third-year medical student making contact with patients for the first time, along with the suggestion that he’d do well not to forget it.

–Consumers Union of United States Inc., The Washington Post, May 30, 2011

Nurse Practitioners

• RNs who have completed education to engage in primary health care decision making.

• Trained in delivery of primary health care & assessment of psychosocial & physical health problems such as the performance of routine examinations & ordering of routine diagnostic tests.

• NP Negligence – Responsible for negligent acts

The Role of Nurses Extends Beyond the Hospital Ward

Nurse practitioners . . . Studies have found that their ability to diagnose illnesses, order and interpret tests, and treat patients is equivalent to that of primary-care physicians. They also tend to spend more time with patients during routine office visits than physicians, and they are more likely to discuss preventative health measures. As of 2010, 140,000 NPs were working in the United States.

Clinical Nurse Specialist – I

• Clinical nurse specialist is a professional RN with an advanced academic degree, experience, and expertise in a clinical specialty (e.g., obstetrics, pediatrics, psychiatry).

• CNS acts as a resource for the management of patients with complex needs and conditions.

• The CNS participates in staff development activities related to his or her clinical specialty & makes recommendations to establish standards of care for those patients.

Clinical Nurse Specialist – II

• CNS functions as a change agent by influencing attitudes, modifying behavior, & introducing new approaches to nursing practice.

• CNS collaborates with other members of the health care team in developing and implementing the therapeutic plan of care for patients.ard of care

Certified Nurse Anesthetist

• Education and Certification

• Oversight of an anesthesiologist often required

• Major risks include – improper placement of an airway

– failure to recognize significant changes in a patient's condition

– improper use of anesthetics

Nurse Midwife

• Provide – delivery for patients at low risk for complications

– often manage normal prenatal, intrapartum, & postpartum care.

LEGAL RISKS of

NURSES

Nursing Diagnosis – I

• Defendant physicians ignored nurse's assessment of patient's diagnosis, which contributed to delay in treatment & injury to the patient. Nurse testified that she told the physician that patient's signs & symptoms were not those associated with indigestion. Defendant physician objected to this testimony, indicating that such a statement constituted a medical diagnosis by a nurse. The trial court permitted the testimony to be entered into evidence.

What do you think happened on appeal?

Nursing Diagnosis – II

• Missouri Court of Appeals affirmed lower court's ruling, holding that evidence of negligence presented by a hospital employee, for which an obstetrician was not responsible, was admissible to show events that occurred during patient's hospital stay.

– See text case: Cignetti v. Camel

Medications Errors - I

• Failure to administer drugs

• Failure to document drug wastage

• Administering drugs without a prescription

• Failure to clarify orders

Medications Errors - II

• Administering wrong dosage

• Administering Drugs by the Wrong Route

• Failure to discontinue a drug

• Failure to note a change order

Negligent Injection

• Nurse negligently injected the tetracycline into or adjacent to the sciatic nerve, causing the patient to permanently lose the normal use of the right foot.

Failure to Follow Physician’s Orders

• Nurses caused permanent drop foot to the patient.

• They failed to follow the doctor’s verbal orders to watch the patient closely & to place him in one continuous passive motion machine at a time during physical therapy.

Failure to Record Patient’s Care

Nurse admitted she failed to record site & mode of injection in ED records. According to testimony of two experts, failing to record this information is below standard of care for nursing. Although these omissions could not have affected administration of the injection, they tend to indicate that in this instance the nurse did not follow accepted procedure while performing her job.

Failure to identify Correct Patient

• Surgical staples removed-wrong patient Meena v. Wilburn

– Chart was not checked

– Wrist band was not checked

– Wrist band was not checked against chart

Infections

• Cross Contamination

• Failure to Notify Physician

• Failure to follow established procedures

– Infection control

– Sterile technique

Negligent Care Causes Laceration – I

• Plastic cup as arm guard?

– Morris alleged from personal observation that the laceration to her daughter's arm was caused by the jagged edges of a plastic cup that had been split & placed on her arm to guard an IV site.

• Text case: Morris v. Children’s Hospital Medical Ctr.

• Was this a breach of the standard of care for nurses?

Negligent Care Causes Laceration – II

• A nurse, in her affidavit, who stated her qualifications as an expert, expressed her opinion that the practice of placing a split plastic cup over an IV site as a guard constituted a breach of the standard of nursing care.

Failure to Follow Instructions

• Failure of a nurse to follow the instructions of a supervising nurse to wait for her assistance before performing a procedure can result in revocation of the nurse's license.

• Heart monitor was connected incorrectly & resulted in an electrical shock to the infant.

• Dangers of electric cords are within the realm of common knowledge.

• Record showed the nurse failed to exercise ordinary care in connecting the infant. – Text Case: Cafiero v. North Carolina Board of Nursing

Failure to Report: Physician’s Negligence

• Note changes in patient’s condition

• Report changes in patient’s condition

– Prompt notification required

– Physician failure to respond

– Need to report “all” patient symptoms

Failure to Question Discharge – I

• Premature Discharge

– A nurse has a duty to question the discharge of a patient if he or she has reason to believe that such discharge could be injurious to the health of the patient.

• See text case: Koeniguer v. Eckrich

Failure to Question Discharge - II Swollen Beyond Recognition

• The hospital's negligence is based on acts of omission, by failing to have the patient examined by a physician and by discharging her in pain.

• The evidence presented a woman conscious of her last days on earth, swollen beyond recognition, tubes exiting almost every orifice of her body, in severe pain, and who deteriorated to the point where she could not verbally communicate with loved ones. – See text case: NKC Hosps., Inc. v. Anthony

Failure to Note Changes in Patient’s Condition – I

• Nurses have responsibility to observe the condition of patients under their care & report any pertinent findings to the attending physician.

• Failure to note changes in a patient's condition can lead to liability on the part of the nurse & organization.

Failure to Recognize Patient Stopped Breathing

• Nurse assigned to monitor a postsurgical patient, left the patient, & failed to recognize the patient stopped breathing. The nurse had been assigned to monitor the patient in the recovery room. She delegated that duty to another nurse & failed to verify the nurse accepted the responsibility. – See text case: Eyoma v. Falco

Failure to Report Deteriorating Condition

• Patient suffered an amputation that the jury determined resulted from the failure of the nursing staff to properly report the patient’s deteriorating condition.

– Utter v. United Hospital Center, Inc.

• Written procedures provided that nurses were responsible for reporting changes in a patient’s condition.

Failure to Report Patient Symptoms

• Accident victim sued hospital & attending physician for their negligence in failing to discover & properly treat his injuries. The court held that there was sufficient evidence to sustain a jury verdict that the hospital’s nurse was negligent in

– failing to inform the physician of all the patient’s symptoms

– to conduct a proper examination & follow physician directions

Timely Reporting of Patient Symptoms

• Court held there was sufficient evidence for the jury to find the nurse was negligent in failing to timely notify the physician that delivery of plaintiff's child was imminent. This delay resulted in an unattended childbirth with consequent injuries.

Failure to Report Defective Equipment

• Failure to report defective equipment can cause a nurse to be held liable for negligence if the failure to report is the proximate cause of a patient's injuries.

• The defect must be known & not hidden from sight.

Incorrect Order Transcription – I

• Periodic contradictions between what physicians claim they ordered & what nurses allege they ordered.

• Orders should be read back for verification purposes.

• Questionable orders must be verified with prescribing physician.

Incorrect Order Transcription – II

• Physicians must authenticate their verbal order(s) by signing the written order in the medical record.

• Nurses who disagree with a physician's order should not carry out an obviously erroneous order.

• Report to the supervisor concerns with a particular order.

Misidentification of Infants

• Switching infants can lead to liability for damages. Damages in the amount of $110,000 were awarded for the inadvertent switching of two babies born at the same time in De Leon – Lopez v. Corporacion Insular de Seguros.

– Follow patient identification process.

– Always verify infant’s identification badge with mother’s.

• Head wedged between mattress & adjacent bed rail

• Failure to follow hospital policy

• Jury found death caused by negligence

Failure to Take Vital Signs Brandon v. HMA, Inc. v. Bradshaw

• Failure to

– properly monitor patient

– report vital information to patient

• Allowed condition to deteriorate

– to critical stage

– before implementing urgent care

– Implementing life support

Surgery

• Foreign Objects left in Patients

– Sponge & Instrument Miscounts

• Whose responsibility? Discuss.

• Nurses & Surgeons Responsible?

Negligent Amputation of Infant’s Finger – I

A nurse employed by the defendant amputated nearly one third of a one-month-old infant’s index finger while cutting an IV tube. $87,000 for past pain & suffering & $50,000 for future damages. The defendant moved to set aside the verdict & sought a new trial.

What do you think the final outcome of this case was?

Negligent Amputation of Infant’s Finger – II

• The appellate court found that the jury's award of damages did not deviate materially from what would be reasonable compensation.

– See text case: Ahmed v. Children's Hospital of Buffalo

Monitor Alarm Disconnected

• Monitor should have been on but was, however, disconnected by the staff & caused patient’s death. – See text Case: Odom v. State Department of Health and

Hospitals

Chance of Survival Diminished – I

Ard v. East Jefferson Gen. Hosp.

• Husband was having difficulty breathing

• Rang the call bell for 1.25 hours before anyone responded

• Code eventually called

• Patient did not survive

Chance of Survival Diminished – II

• Physicians’ progress notes patient high risk for aspiration

– Problem never addressed

– nurses’ care plan or in the nurses’ notes

• Trial judge’s conclusion:

– the nursing staff breached standard of care

– patient would have had a much better chance of survival if he had been transferred to the intensive care unit

REVIEW QUESTIONS – I

1. Describe how the scope of nursing is changing.

2. Describe how the roles of a nurse anesthetist, clinical nurse specialist, nurse practitioner, and nurse midwife differ.

3. Describe the various medication errors that can occur in the administration of medications.

REVIEW QUESTIONS – II

4. If a nurse disagrees with a physician's written orders, discuss what action the nurse should take to protect the patient’s safety.

5. Discuss why it is important to report significant changes in a patient’s condition to the treating physician.