Legal Aspects of Nursing Practice and Documentation for

Legal Aspects of Nursing Practice and Documentation for Peri-Anesthesia Nursing Consultation On-Call, LLC © 2018

The information and recommendations in this presentation are based on extensive research and information obtained from medical and nursing authorities. To the best of my knowledge, the information presented reflects current recommendations and practices. Please be reminded all interventions must be based on individual patient situations and must be implemented within your scope of practice and facility policy and procedure. The author disclaims responsibility for any adverse effects, directly or indirectly from the suggested recommendations or from the reader’s misunderstanding of the information or context thereof. Pam Collins, RN, MSN, Consultant

Objectives • Identify common sources of litigation for Peri. Anesthesia Nursing Practice • Discuss common pitfalls in Nursing Documentation • Discuss strategies for writing legally defensible notes • Discuss how to document high-risk situations • Discuss key elements of the South Carolina Nurse Practice Act

Statistics on Lawsuits • 60% Acute Care Hospitals • Med/Surg Nurses • OB Nurses • CC, ICU, Peds, RR, ED • • 18% 9% 8% 2% Long-Term Care Facilities Advanced Practitioners Psychiatric Facilities Home Health Agencies Croke, Sept 2003

Common Sources of Lawsuits for Peri-anesthesia Nursing • Inadequate patient monitoring/assessment – WNL or NOT? • • Time Out Procedures Failure to recognize patient allergies Non-adherence to policy/procedure Provider notification – Patient Advocacy • Chain of Command

Common sources of Lawsuits cont’d • Patient Safety Issues – Patient positioning – Medication errors – Failures in instrument reprocessing – Specimen collection errors – Hand-off communication

Contributing factors to Errors Noise Rushing Intimidation Process inconsistencies “this is the way I do it” • Documentation • • – *Unapproved abbreviations

Law 101 • Required elements for a lawsuit – Duty owed – Duty breached – Harm – Causation

Facts on Litigation • Documentation most frequent source of litigation for health professionals • Documentation makes or breaks the Case If you didn’t chart it, you didn’t do it • Nurse’s actions compared with the standard of care and policies and procedures The Medical Record is “the witness that never dies and never lies” www. ucop. edu/riskmgt/documents/pldocumentation

Nursing Documentation • Nursing Documentation- written account by nurses involving a patient’s health status, nursing care/actions and patient response. The nurse must make/keep accurate, intelligible entries in the patient’s medical record South Carolina Board of Nursing (SCBON)

The Nursing Process Is it Evident in Your Documentation? Assessment Follow up to interventions Evaluation Implementation Nursing Diagnosis Outcome Planning I&O, SCDs, Ambulation, Incentive spirometry, TCDB, etc. Plan of Care

Common Pitfalls in Documentation • Vague descriptions • Omissions – Blank spaces • Time issues • Inconsistencies – Wickliffe v. Sunrise Hospital, 1988

How to Document High Risk Situations

Patient Positioning Instead of… “Placed on table, arm padding in place, no complaints. ” (signature) Document… Transferred to table from stretcher with assist X 2. Left arm placed on arm board with padding placed under bony prominences, pt. states “comfortable. Table tilt 30 degrees (left) with pillow placed between lower extremities. (signature)

Patient Refusal Instead of… – “Refused pain med” Document – “patient refused pain medications, explained purpose of pain control, potential consequences, verbalized understanding, stated “I still don’t want it, I’ll just hold off”. Repositioned, alternative measures implemented to facilitate comfort.

Pain 1000: c/o RUQ pain, throbbing, rates as 9, nonradiating, worse with movement, onset 10 min. ago, denies other symptoms. (signature) 1008: morphine 4 mg. given IV. (signature) 1045: sleep, no distress present. (signature)

Provider notification • Instead of… Dr. Jones aware of O 2 sat, vital signs, • Document 1313: Dr. Jones informed of O 2 sat, vital signs, assessment findings 1314: O 2 increased to 3 L/nc, 500 ml bolus given…

Provider notification Chain of Command • Document 1313: Dr. Jones informed of O 2 sat, vital signs, assessment findings (signature) 1316: Dr. Smith informed of patient’s vital signs, O 2 sat, assessment findings (signature) 1320: (Document subsequent interventions)

Hand-off Communication • Your Proof of Safe Transfer of Care • Licensed to licensed • All you need is Date/Time: Report given to P. Collins, RN (signature) Date/Time: Report received from C. Johnson, RN (signature)

And Last but not Least… • How safe is Electronic Documentation? • Very safe if… – Utilized as intended – No blank spaces – Progress notes used as indicated – Reflect appropriate communications – It tells the Story!

And Last but not Least… HOW SAFE IS ELECTRONIC DOCUMENTATION?

South Carolina Board of Nursing (SCBON) How Well do you Know the Laws?

SCBON • Key Chapters – 33 (Nurse Practice Laws) and 91 (Regulation) • Did you know… – Name badges must be worn – Nurses must adhere to ANA Code of Ethics – Lapses or inactive status requires re-entry criteria – Fines up to $2000. 00 may be imposed for EACH code/law violation https: //www. llr. sc. gov/pol/nursing/

SCBON Policies of the Board • Advisory Opinions • Advisory Opinion Supplement on the Nursing Management of Invasive Devices (Catheters, Lines and Tubes) • Code of Ethics for Nurses • Grounds for Revocation, Suspension or Other Restriction or Limitation on a License • Nurse Practice Act, Chapter 33 • Nurse Regulations, Chapter 91 • Position Statements • Joint Position Statement on Pain Management (pdf) • Nursing Scope of Practice Opinion Request Form (pdf) Board of Nursing Website under “Laws and Policies”

Advisory Opinions • Addresses Scope of Practice Issues – Invasive lines • System specific • RN/LPN: Do’s and Don'ts – Tube management – MD assisted procedures – Resuscitation – Delegation

Position Statements • • • • Age Parameters for Nurse Practitioner Practice Assisting with Medications Code of Ethics (adopted by S. C. Board of Nursing) Delegation of Nursing Care Tasks to Unlicensed Assistive Personnel (UAP) Pain Management Patient Abandonment Pharmacotherapeutics Education Required For Prescriptive Authority Application Practice of Nursing in a School Setting Prescriptions for APRN's with Prescriptive Authority Scope of Practice Decision Tree Simulation as a Teaching Strategy in Nursing Education The Role of the Registered Nurse (RN) in the Management of Patients Receiving IV Conscious Sedation for Short-term Therapeutic, Diagnostic, or Surgical Procedures Use of Samples by APRN's with Prescriptive Authority

Grounds for Disciplinary Action • Misconduct – – Violation of any of the Code of Laws Incompetence Unprofessional conduct Practicing outside of Scope of Practice MISCONDUCT has serious consequences

Examples of Misconduct • • Abandonment Documentation Infractions HIPAA violations Inappropriate assignment/delegation Failing to report incompetence practice to SCBON Unethical Practice Medication Administration infractions – leaving meds at bedside, administering medications without proper knowledge/understanding, improper witnessing

Scope of Practice • RN/LPN • LPN When in doubt, consider the following: – Nursing Process: assessment, analysis, intervention, evaluation – Nursing Diagnoses [plan of care] – Assists with assessment via data collection – Assists with evaluation of responses – Basic teaching for health promotion and maintenance – Delegation – Additional acts as approved by SCBON – Is act within scope of practice? – Are you qualified? – Are you willing to be accountable? Chapter 33, section 40 -33 -20

Licensure Renewal • Renew license by one of the following ways: – Contact hours from continuing education provider recognized by the board [30 hours] during licensure period. – Maintenance of nationally recognized certification – Completion of academic program in nursing or related field recognized by the board. – Employer verification of competency • *Failure to demonstrate competence will result in nonrenewal.

Compact States Who they are and What it Means

Nurse Licensure Compact States As of March 7, 2015 there are twenty-five states participating in the Compact. This includes Montana which has passed legislation to join the Nurse Licensure Compact pending implementation on October 1, 2015

References • Legal Briefs, Positioning, padding and documentation, and the CRNA, October 1998 [AANA] • Nurse’s Legal Handbook, 6 th Ed (2015). Ambler, PA: Lippincott Williams & Wilkins. • Nursing Malpractice (2002) 2 nd Edition, Patricia Iyer. • South Carolina Board of Nursing

Email: pcollins@consultationoncall. com Phone: 803 -980 -0440 Website: www. consultationoncall. com Questions Consultation On-Call, LLC © 2018