LAW IS NEXT
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lesson4cont.pptxChapter 11
Nursing and the Law
1
Learning Objectives
Describe how the scope of nursing practice continues to evolve.
Describe common categories of nursing staff.
Explain the process of obtaining nurse licensure.
Describe the variety of legal risks nurses encounter.
Describe the ways in which a nurse is a patient advocate.
Scope of Practice
Permissible boundaries of practice for healthcare professionals
Statutes define the actions, duties, and limits of nurses
Role of nurses expand
Shortage of primary care physicians
Ever-increasing specialization
Improved technology
Public demand
Expectations within the profession itself
Nursing Practice (1 of 6)
1901: New York begins to organize passage of nurse practice legislation.
1903: North Carolina: first nurse registration act
1905: Columbia University: certification for nurse leaders
1937: American Nurses Association (ANA) recommends use of their professional organization to improve working conditions.
Nursing Practice (2 of 6)
1938: New York requires mandatory licensure.
1946: ANA Convention calls for higher wages.
1952: All states enact nurse practice acts.
1955: ANA approves model definition for nursing.
1957: California: nurses supported to perform venous punctures.
Nursing Practice (3 of 6)
1966: Michigan: use of defibrillators by nurses
1968: Hawaii: nurses perform cardiopulmonary resuscitation
1970: ANA: nursing practice to include “nursing diagnosis”
1971: Idaho: scope of practice for nurse practitioners (NPs) includes diagnosis and treatment.
Nursing Practice (4 of 6)
1972: New York: expanded Nurse Practice Act; broader definition of nursing
1973: ANA: first guidelines for geriatric NPs
1975: Missouri: nursing diagnosis scope expands
1980: ANA publishes model NP act for state legislators to provide consistency for state nurse practice acts.
Nursing Practice (5 of 6)
1985: New York: nurses provide primary healthcare services
1989: New York: NPs diagnose, treat, write prescriptions
1990: ANA amends model definition of nursing to include advanced NPs.
2014: Doctor of nursing programs continue to expand.
Nursing Practice (6 of 6)
2015: Evolving responsibilities
2015: Expanded role at Massachusetts General Hospital
2016: VA wants expanded nursing roles
Nursing Diagnosis: States Recognition
Various states recognize that nurses can render a nursing diagnosis.
Nursing Diagnosis: Case (1 of 2)
Cignetti v. Camel
Physicians ignored nurse’s assessment (diagnosis)
Contributed to delay in treatment and injury
Nurse testified physician told patient’s signs and symptoms
Were not associated with indigestion
Physician objected to nurse’s testimony
Physician stated: Statement constituted a medical diagnosis
Argument against nursing assessment
What was the court’s decision?
Nursing Diagnosis: Case (2 of 2)
Missouri Revised Statutes (1975) authorizes an RN to make an assessment of persons who are ill and to render a nursing diagnosis. The Trial Court decision was affirmed.
Nurse Licensure: Requirements for Licensure
Reciprocity
The nurse licensing board in one state recognizes licensees of another state.
Endorsement
Boards determine if nurses’ qualifications are equivalent to their own state requirements at the time of initial licensure.
Waiver
Nurses with equivalent qualifications can be waived in as licensed nurses.
Examination
Some states make examination mandatory.
Nurse Licensure: Suspension and 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
Healthcare organizations are required to verify that each nurse’s license is current.
The mere fact that an unlicensed practitioner is hired will not generally in and of itself impose additional liability unless a patient suffered harm as a result of an unlicensed nurse’s negligence.
Nursing Careers
Registered nurse
Traveling nurse
Licensed practical nurse
Nurse manager
Certified nursing assistant
Float nurse
Agency nurse
Special duty nurse
Student nurse
Registered Nurse
A nurse who has graduated from an accredited nursing program, has passed a state registration examination, and is licensed to practice nursing
Traveling Nurse
A nurse who travels to work in temporary nursing positions in different cities and states
Licensed Practical Nurse
A licensed practical nurse (LPN), as well as a licensed vocational nurse (LVN), provides routine nursing care (e.g., vital signs, injections, assisting patients with personal hygiene needs, and wound dressings).
Under the direction of a registered nurse or physician
Nurse Manager
Chief nursing officer has responsibility for:
Maintaining standards of practice
Maintaining current policies and procedures
Recommending staffing levels
Coordinating and integrating nursing services with other patient care services
Selecting nursing staff
Developing orientation and training programs
Failure to supervise
Can lead to disciplinary action
Certified Nursing Assistant
A certified nursing assistant (CNA) is certified and trained to assist patients with activities of daily living.
The CNA assists with positioning, turning, lifting, and performing a variety of tests and treatments.
Cases
Failure to Follow Policy
Patient Fall
Patient Transfer
Leaving Patient Unattended
Float Nurse
Rotates from unit to unit based on staffing needs
“Floaters” can benefit an understaffed unit, but they also may present a liability if they are assigned to work in an area outside their expertise.
If a patient is injured because of a floater’s negligence, the standard of care required of the floater will be that required of a nurse on the assigned patient care unit.
Agency Nurse
Hospitals are at risk for negligent conduct of agency staff.
It is important that the organization be sure that agency workers have necessary skills and competencies to carry out duties and responsibilities assigned by the organization.
Special-Duty Nurse
A healthcare professional employed by a patient or patient’s family to perform nursing care for the patient
If a master–servant relationship exists between the organization and special-duty nurse, the doctrine of respondeat superior may be applied to impose liability on the organization for a nurse’s negligent acts.
Student Nurses
Entrusted with the responsibility of providing nursing care to patients
Students are personally liable for their own negligent acts, and the facility is liable for their acts on the basis of respondeat superior.
Student nurse are held to the standard of a competent professional nurse when performing nursing duties.
Advance Practice Nurses
Nurse practitioner
Clinical nurse specialist
Certified registered nurse anesthetist
Certified nurse midwife
Nurse Practitioner
Nurse practitioners (NPs) are registered nurses (RNs) who have completed the necessary education to engage in primary healthcare decision making.
They are trained in delivery of primary health care and assessment of psychosocial and physical health problems such as the performance of routine examinations and ordering of routine diagnostic tests.
NPs’ negligence is imputed to the physician.
Adams v. Krueger
Clinical Nurse Specialist (1 of 2)
A clinical nurse specialist (CNS) is a professional RN with an advanced academic degree, experience, and expertise in a clinical specialty (e.g., obstetrics, pediatrics, psychiatry).
The 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 and makes recommendations to establish standards of care for those patients.
Clinical Nurse Specialist (2 of 2)
The CNS functions as a change agent by influencing attitudes, modifying behavior, and introducing new approaches to nursing practice.
The CNS collaborates with other members of the healthcare team in developing and implementing the therapeutic plan of care for patients’ standard of care.
Certified Nurse Anesthetist (1 of 2)
Administration of anesthesia by a nurse anesthetist requires special training and certification.
Nurse-administered anesthesia was the first expanded role for nurses requiring certification.
Oversight and availability of an anesthesiologist are required by most organizations.
Certified Nurse Anesthetist (2 of 2)
Major risks for nurse anesthetists include:
Improper placement of an airway
Failure to recognize significant changes in a patient’s condition
Improper use of anesthetics
Nurse anesthetist: Medical supervision required
Certified Nurse Midwife (1 of 2)
Nurse midwives provide comprehensive prenatal care, including delivery for patients who are at low risk for complications.
They often manage normal prenatal, intrapartum, and postpartum care.
Provided that there are no complications, normal newborns are also cared for by a nurse midwife.
Nurse midwives often provide primary care for women’s issues from puberty to postmenopause.
Certified Nurse Midwife (2 of 2)
Cases
Practicing without a license
Morris v. Dep’t of Prof’l Regulation
Standard of care required
Ali v. Community Health Care Plan, Inc.
LEGAL RISKS OF NURSES
Dilemma: Two Standards of Care
Restrictive standard
Less-restrictive standard
Adopting less-restrictive standard is risky.
Risk of patient injury
Organization’s increased exposure to lawsuits
Patient Misidentification
Proper identification prior to performing a procedure
Meena v. Wilburn
Surgical staples removed from the wrong patient
Misidentifying infants
De Leon Lopez v. Corporacion Insular de Seguros
Hospital was negligent in delivering two babies to the wrong mothers
Patient Monitoring & Observation (1 of 3)
Nurses responsibility for patient care
Report any pertinent findings to the attending physician
Eyoma v. Falco
Failure to note changes in patient’s condition
Nurse A assigned to monitor a postsurgical patient left patient & failed to recognize patient stopped breathing.
Nurse A delegated that duty to Nurse B.
Nurse A failed to verify the nurse accepted responsibility for the patient
Jury held nurse 100% liable for patient’s injuries
Patient Monitoring & Observation (2 of 3)
Failure to monitor vital signs
Failure to repeat vital signs
Delay in fetal monitoring
Monitor alarm disconnected
Defective monitoring 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
Defect must be known and not hidden from sight.
Patient Monitoring & Observation (3 of 3)
Delay in Reporting Patient’s Condition (1 of 4)
Develop appropriate guidelines
When action or inaction jeopardizes patient safety
Goff v. Doctors General Hospital
Patient bleeding excessively
Failure to take prompt action
Utter v. United Hospital Center, Inc.
Amputation: Nurses failed to report patient’s deteriorating condition
Cuervo v. Mercy Hospital, Inc.
Compromised blood flow to leg, loss of pulse, and sensation.
Nurses unable to reach physician for 6 hours.
Failure to contact a back-up physician
Hiatt v. Grace
Failure to timely notify physician delivery child imminent
Delay in Reporting Patient’s Condition (2 of 4)
Citizens Hospital Association v. Schoulin
Accident victim
Failing to inform the physician of patient’s symptoms
Leblanc v. Walsh
Nurse fails to notify physician of patient’s fluctuating heart rate.
Delay in Reporting Patient’s Condition (3 of 4)
Montgomery Health Care v. Ballard
Failure of nurses to follow adequate nursing procedures in treating decubitus ulcers
Seriousness of such failure was driven home when the court allowed $2 million in punitive damages.
Delay in Reporting Patient’s Condition (3 of 4)
Delay in Treatment
Howerton v. Mary Immaculate Hospital, Inc.
Nurses delayed assessing & notifying physician of patient’s serious condition.
Testimony that if the baby had been delivered sooner, she would have sustained no neurologic damage.
Evidence sufficient to go to trial for nurses delay in notifying physician of patient’s condition.
Failure to follow orders
Written orders
Verbal orders
Verify orders
Supervisor’s orders
Incorrectly Transcribing: Telephone Orders
There are periodic contradictions between what physicians claim they ordered and what nurses allege they ordered.
Orders should be read back for verification purposes.
Questionable orders must be verified with prescribing physician.
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.
Leaving Patient Unattended: Patient Suffered Injury
Vanhoy v. United States
Patient injured as a result of being left unattended
His endotracheal tube became dislodged
Likely extubated more than 21 minutes
Veteran suffered anoxic brain injury
Government required to pay $3,500,000
The delay in treatment resulted in the patient’s injury.
Failure to Record Patient’s Care
Pellerin v. Humedicenters, Inc.
Nurse failed to record administration of medication
Failure to record falls below the standard of care for nursing
Medication Errors (1 of 2)
Medication errors
Failure to administer drugs
Failure to document drug wastage
Administering drugs without a prescription
Administering wrong medication
Failure to clarify orders
Medication Errors (2 of 2)
Administration of wrong dosage
Negligent drug overdose
Administering by the wrong route
Failure to discontinue medication
Failure to identify correct patient
Failure to note order change
Infection Control Procedures
Failure to follow infection control procedures
Cross-contamination
Improper sterilization
Negligent Procedures
Burns from bovie machine
Arm laceration
Negligent injection
Cutting IV tube results in amputation
Foreign objects left in patients
Shared responsibility for sponge counts
Patient Falls
Failure to follow policy
Failure to raise bed rails
Nurse followed safe procedures
Not every fall is a result of negligence
Fall from examination table
Duty to Question Discharge
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.
Koeniguer v. Eckrich
Duty to Report: Physician 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: 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.
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 deteriorated to the point where she could not verbally communicate with loved ones
NKC Hosps., Inc. v. Anthony
Review Questions (1 of 2)
Describe why the scope of nursing has changed.
Describe the various roles of advanced practice nurses.
Describe the various legal risks for nurses.
Describe the various errors that can occur in the administration of medications.
Review Questions (2 of 2)
Discuss why it is important to report significant changes in a patient’s condition to the treating physician.
If a nurse disagrees with a physician’s written orders, discuss what action the nurse should take to protect the patient’s safety.
Discuss under what circumstances a nurse has a duty to question a patient’s care.
