case study

Medical-Legal & Ethical

Issues in Nursing

Alexa Schneider, PhD, PsyD, RN, FNP, LNCC, NY-SAFE

Objectives

 Describe how current and future healthcare trends will impact legal and ethical issues in nursing, patient care technicians, social workers, and office personal.

 Describe “best practices” that protect your license and position, influence quality of care and reduce risk.

 Examine medical malpractice cases and the impact on the nurse and the various roles in the acute, long term care & outpatient setting.

Current and future healthcare

trends

 Role of nurse continues to expand & is influenced by

many aspects.

Trends

Best Practices that protect your license, influence quality of care and reduce risk.

School:

Learn to obtain license

After school:

Learn to maintain/protect/keep license

Medications

 Giving meds on time – not when convenient for nurse

(Heparin, Antibiotics, and etc.) Giving med and

scanning med at a later time.

 Proper wasting of narcotics

 5 rights

 No over riding system unless absolutely necessary.

 Don’t cover up if medication error occurs.

DNR

 Know your patients DNR status

 Legal order signed by the Doctor

 View original paperwork

Patient confidentiality

 Never leave paper chart/computer screen in a public place

 Discuss contents only with persons directly involved in patient’s care or those authorized by the patient. They should be listed by name. (Don’t assume partners have access to information)

 Ask for ID prior to providing information

 Do not discuss pt or pts info in public, places, elevators, cafeteria, or at parties.

 Don’t view patient’s information not in your care: family; friends; celebrities and etc.

Patient Falls & Restraints

 Among senior citizens, falls represent the 5th leading

cause of death, and the mortality rate from falls

increases significantly with age.

 Cases

 Failure to follow policy

 Failure to raise bedrails

Criteria for Incident Reports

 Should be completed for any usual, unexpected, or

unanticipated occurrences, and for any event which has

or may have an adverse patient outcome.

 Patient falls

 Medication error

 Loss of valuables, belongings

 Equipment malfunction

 Property damage

 Near misses

Incident reports

Be Objective

 Do not blame or admit liability

 What did you do?

 Do not include names/addresses of witnesses

 Document time/name of medical provider

 Do not file in chart

 Do not write “incident report made”

Proper handoff

communication  Required to properly “handoff ” your patients to another

qualified professional.

 Tool SBAR:

 S=Situation: patient name, DOB, & medical provider

 B=background: date of admission, diagnosis & current condition including test results

 A=Assessment: summary of recent events/changes in condition or treatment and any anticipated changes in condition or treatment.

 R=Recommendations: state your nursing recommendations with any new treatment in the plan of care by the medical provider.

Abandonment

 Termination of patient care without assuring the

continuation of care at the same or higher level.

 In various medical venues (office/clinic practice; walking off

the job; leaving pt without transferring pt to another nurse;

refusing overtime) (6)

Sexual Misconduct

Controlled Substances

 Self-prescribing controlled medication for one’s own use

or for family members.

 Diversion

Social Media

 Facebook

 Twitter

 Texts

 E-mails

Info about & from patients

Telephone calls  Office scenario

 Date and time of call

 Advice you gave

 Who you spoke with and if other caregivers notified

Hospital scenario

Date and time of call

Provider name

Client’s chief complaint

Information you provided

Orders received/not received

 Nurses who disagree with a provider’s order should not carry out an obviously erroneous error.

Pitfalls for Staff

Red Flag Complaints

Documentation

Documentation

 Written evidence of interaction between and among health professionals, patients, and their families; the administration of procedures, treatments, and diagnostic tests; the patient’s response to them and education of the family support unit.

 Major purpose of medical record is to document the care given to the patient.

 Nurse Practice Act states the general duty is to “record pertinent information including the response to interventions”.

 Also a legal document. Courts have issued a warning to nurses & medical personnel that the availability of accurate medical records is NOT a technicality but IS a legal requirement.

 Chart is a persuasive witness because it’s a description of the facts at the time.

 Should be no unanswered questions to the patients chart that the plaintiff attorneys can use to construct their version of what happened.

 Documentation reflects: character, competency, and the care delivered by the nurse

Documentation Do’s

 Nursing procedures (procedure name; when performed; who

performed; how performed; client tolerated; adverse reactions)

 Phone calls

 Health care team visits

 Don’t wait to chart

 Client refusals

 Client’s subjective data

 Medication omission

 Late entry

 Not applicable

Required to document

 Sudden decline in patient’s condition, actions, outcome

 Patient injuries/medication errors

 Equipment failure/incorrect use

 Failure of provider to respond

 The “red flag” patient or family

 Client/family education/instructions

Documentation Don’ts

 Complaints

 Opinions

 Altering the record

 Chart ahead

 Staffing problems

 Staff conflicts

 Leave empty lines/spaces

 Make reference to incident reports

Documentation

 The following can lead to state licensing board suspending or revoking nurse license:

 Failure to document entries in patient record

 Falsification of patient record

 Making incorrect entries

 Each health care provider is responsible for the ABC’s of recording: Accuracy, brief, complete

Documentation

 The old adage, “If it wasn’t charted it wasn’t done….” is clarified in CBE (charting by exception) as “If interventions, expected outcomes, and patient responses weren't charted using symbols to reflect predefined norms-and variances weren't charted in detail-then it wasn’t done.”

 CBE is a shorthand of documenting normal findings, based on clearly defined normal, standards of practice, and predetermined criteria for assessments and interventions. Significant findings or exceptions to the predefined norms are documented in detail.

 Computerized charting: Protect password security & don’t forget to log off

Common Charting mistakes

 Failing to record pertinent health or drug info

 Failing to record nursing actions

 Failing to record that medications have been given

 Recording on the wrong chart

 Failing to document a discontinued medication

 Failing to record drug reactions or changes in the patient’s condition

 Transcribing orders improperly

 Writing illegible or incomplete records

Effective Documentation

 Wrong: Communication with patient’s family began

today to specify the manner in which his condition is

progressing and suggest a probable consequence of that

progression.

 Correct: I contacted Mr. Schneider’s wife at 1332 hours.

I explained that his cardiac status was worsening and

that he was being prepared for a cardiac cath procedure

scheduled for 1430.

Late entries

 Add late entries at first available space and as soon as

possible if electronic

 Document date and time the event occurred

 Clearly identify the entry as a late one

Red Flags

 Adding information

 Dating the entry

 Dates/times conflict

 Inaccurate information

 Destroying records

Documentation

 Cases usually come to court a long time after the events occurred

 Nurses and other personnel usually have little or no recollection of the events surrounding the case and must rely on their documentation for what occurred.

 Do you feel like your documentation would support you in a court of law?

Implications

2015 Statistics

MEDICAL MALPRACTICE

 Malpractice occurs when improper, injurious, or faulty treatment of a client that results in illness or injury.

Why Claims are Filed

 Upset with the System

 Devastating Injuries

 Unreasonable Expectations

 Unexpected Results

Extent of Suits

Sued the most

Legal Role of the Nurse

 Provider of service

 Ensure that client receives competent, safe, & holistic care

 Render care by “standards of reasonable, prudent person”

 Supervise/evaluate that which has been delegated

 Documentation of care

 Maintain clinical competency

Legal Negligence in Nursing

 Failure to use equipment in a responsible manner

 Failure to assess and monitor and failure to communicate

 Failure to document

 Failure to act as a patient advocate

 Performing nursing procedures incorrectly

 Failing to take appropriate precautions

Responsible &

Accountable  You are responsible and accountable for your actions

based on:

 Your clinical training

 Your title

 Scope of practice

 Standard of care guidelines

 Policies and procedures of your health care facility

Ways to Avoid

Malpractice  Know your own strengths and weaknesses

 Evaluate your assignment

 Delegate carefully

 Exercise caution when assisting procedures

 Document the use of restraints

 Take steps to prevent falls

 Comply with laws about advance directives

 Follow hospital policies and procedures

 Keep policies and procedures up to date

 Provide a safe environment

ELEMENTS OF NEGLIGENCE

 Deviation from the standard of care that results in harm to the patient

 4 elements of negligence

 Duty to act (Nurse – Patient relationship)

 Breach of duty (SOC not followed - reasonably prudent nurse)

 Damage (Physical & Psychological) No damage no case!

 Causal connection (reasonably close connection between nurses conduct & injury)

All 4 must be proven

State Boards of Nursing

 NYSBON was created to “assist the Board of Regents and

other departments on matters of professional licensing,

disciplinary process and practice of the professions.”

 Ensure public safety from dishonest and incompetent

practitioners

 Ensure that you practice within your scope of practices,

SOC guidelines, and other state statues.

 Ensure that you are not impaired physically or mentally

from drugs and alcohol while practicing.

 Ensure that nursing schools provide you with adequate

education and clinical skills needed to provide quality care.

Nursing Charges

 Most common charges brought against nurses include

 Substance abuse

 Incompetence

 Negligence

State board of nursing is responsible for discipline within the profession.

The Board participates in licensure, disciplinary, restoration, and moral character proceedings.

All members of the State Board and the committee for professional assistance must be dedicated to the public protection, quality professional preparation, and conduct.

THREE CATEGORIES OF

IMPAIRMENT

 PROFESSIONAL

 Deficit in Medical Knowledge, Expertise or Judgment

 BEHAVIORAL

 Includes unprofessional, unethical, or criminal conduct

 MEDICAL

 Conditions which permanently impede or preclude a provider

from safely practicing medicine

Professional Misconduct

 Violating any guidelines set forth by your state nursing board places you at risk of being charged with professional misconduct.

 Obtaining license fraudulently

 Practicing while impaired by ETOH, drugs, physical or mental disability.

 Habitual drunk or dependent on narcotics and other drugs with similar affects

 Refusing to provide professional service to a person based on race, creed, color, or national origin

 Practicing beyond authorized scope, with gross incompetence, with gross negligence on a particular occasion or negligence or incompetence on more than one occasion.

Maintaining License & a

Valid Registration Certificate

 Professional license is “valid for life unless revoked or surrendered for professional misconduct.”

 It’s your obligation & responsibility to be mindful of the following when it comes to maintaining your registration:

 Expiration date. If expired do not practice until renewed.

 Report name or address change to licensing agency for future renewals.

 Answer all questions pertaining to both criminal convictions & terminations of employment truthfully.

 Practice within your scope of practice and standard of care guidelines.

Code of Ethics

 Code of ethics defines the moral principles that govern how you practice nursing and is the foundation on which nursing is built.

 Legal definition: “the minimum standards of appropriate conduct within legal and regulatory parameters involving the duty owed to your patient and other members of your profession.”

 Submitting work vouchers for home care visits not made

 Breach of confidentiality

 Fraud

 Refusing to provide care for patient of specific cultural origin

Grounds for Suspension &

Revocation of License  Incompetent nursing practice

 Professional misconduct

 Conviction of a crime (Homicide; theft; manslaughter; illegible possession of controlled substance; sexual assault; arson; DUI)

Violations may include

 Procurement of a license by fraud

 Unprofessional, dishonorable, immoral, or illegal conduct

 Performance of specific actions prohibited by statue

 Malpractice

Hearings: Moral Character; Disciplinary; Restoration

Actions taken are based upon the severity of the violation. (reprimand or warning; probation; suspension of license; revocation of license)

Be Competent in Your

Practice

 You are always held accountable for their own behavior.

 Refusal to perform procedure for which they have not been prepared.

 Be reminded that the Nurse Practice Act changes ever so often; it is the responsibility of all nurses to be current with the laws that govern their scope of practice.

 “Ignorance of the law is no excuse.”

Impaired

 Referred to PAP (professional assistance panel) if no

harm to patient

 Surrender license while receiving treatment

 Participate in PAP program (SPAN)

 If successfully complete the NYS PAP program

disciplinary charges will not be brought up against you

from the bureau of controlled substance or State

Education Dept.

Cases

Conclusion

 Embrace and participate in current and future trends.

 Maintain “best practices” that protect your license,

influence quality of care and reduce risk.

 Make the most of every day & have a grateful heart.