Legal Aspects of Nursing Prepared by: John J. Teodoro PTRP, RN Definition of Terms oard of Registered Nursing !

ach state has a oard of Registered Nursing organi"ed #ithin the e$ecuti%e branch of the state go%ernment. Primary Responsibilities of the RN include the administration of the Nurse Practice Act as applied to registered nurses. Authori"ation to Practice Nursing To legally engage in the practice of nursing, an indi%idual must hold on an acti%e license issued by the state in #hich he or she intends to #or&. Nurse Practice Act A series of statutes enacted by each state legislature to regulate the practice of nursing in that state. Topics that are included are the follo#ing a. scope of nursing, education, licensure, grounds for disciplinary actions ' related topics. a. Pro%ides legal authority for nursing practice including delegation of nursing tas&s. b. (any boards of nursing also pro%ide decision and delegation chec&list. c. )et educational re*uirements for the nurse distinguishing Nursing Practice from (edical Practice ' defines the )cope of Nursing. ANA +American Nurses Association, of -./0 1ncorporates the follo#ing elements that demonstrate in a nurse: a. 2uman dignity ' uni*ueness of indi%idual regardless of health problems ' socio3economic status b. (aintain patients right for pri%acy ' confidentiality c. (aintain competence through ongoing professional de%elopment ' consultation. !thical Principles of io3ethics A philosophical field that applies ethical reasoning process for achie%ing clear ' con%incing reasons to issues ' dilemmas + conflicting bet#een t#o obligations, -. Autonomy: the right of the patient to ma&e one4s o#n decision 3 !$ample: Religious Practices ' 5ultural eliefs + lood Transfusion ' 6rgan Donation, 7. 8eracity: the intention to tell the truth - Ne%er gi%e false reassurance to another person 9. eneficence %ersus Non3malfeasance

eneficence : duty to do good b. Non3malfeasance: duty to a%oid e%il :. 5onfidentiality: social contract in &eeping one4s pri%acy )tandards of 5are ;uidelines for determining #hether nurses ha%e performed duties in a appropriate manner ' guidelines in #hich the nurse should practice Patient4s ill of Rights Right for appropriate treatment that is most supporti%e ' least restricti%e Right to indi%iduali"ed treatment plan, sub<ect to re%ie# ' treatment Right to acti%e participation in treatment #ith the ris& and side effect of all medications and treatment Right to gi%e and #ithhold consent=contracts 5ontracts ' 5onsent: it is the meeting o the minds bet#een t#o or more persons #hereby one binds himself #ith respect to the other to gi%e something or to render some ser%ice. Pre3re*uisites of a 8alid 5onsent and 5ontract +6P!N3 8, 63 6pportunity to as& *uestions +possible conse*uences of the procedure, P3 Physically ' (entally 5ompetent ' (ature + -/ years old ' up , !3 !$plained the Procedures ' Treatment )pecifically N3 Nothing should be misunderstood by the patient +the patient should not be allo#ed to sign the informed consent if she = he is pre3medicated or under the influence of alcohol or drugs or mentally incapacitated 838oluntary (ade +absence of force, fraud, deceit or duress + force, !$ceptions to an 1nformed 5onsent +(!(63), ( >(arried ' (ature (inors !3 !mancipated minors +to release a child from the control of his parents, !mergency 5ases (inors see&ing birth control or pre3natal treatment 63 6%er specific age +e$. -7 years old ' abo%e, may gi%e consent for )TD, 218 testing, A1D) treatment, drugs ' alcohol treatment ?1T26@T parents consent.

a.

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)e$ually abused minors ' adolescents

Right to refuse Treatment -. Ad%ance Directi%es: Legal, #ritten or oral statements made by a mentally competent person about treatment. 1n the e%ent the person is unable to ma&e these determinations, a surrogate decision3ma&er can do so, e$ample: sudden serious illness. 5haracteristics of Ad%ance Directi%es -. allo#s clients to participate in choosing health care pro%iders +5hoosing his = her o#n nurses ' doctors, 7. allo#s also in choosing the type of medical treatments the client desires. 9. Allo#s clients to consent or refuse treatments The Patient Determination Act of -..0 +P)DA, is a federal la# that imposes on states and pro%iders of health care certain re*uirements concerning Ad%anced Directi%es as #ell as client4s right under la# to to ma&e decisions concerning medical care.

only addresses medical screening ' stabili"ation of patients before transport or the determination of ability to pay for ser%ices rendered. a. Li%ing ?ill: legal document stating person does not #ish to ha%e e$tra3 ordinary life sa%ing measures #hen not able to ma&e decisions about his o#n care. 3applicable A6R L1A! )A81N; TR!AT(!N T 6NLB. !$ample: 5PR, antibiotics ' dialysis #ill be used or not b. Durable Po#er of Attorney: legal document gi%ing designated person authority to ma&e health care decisions on the client4s behalf #hen the client is unable to do so. Right to obtain Ad%ocacy Assistance Patient Ad%ocate: is a person #ho pleads for a cause or #ho acts on the client4s behalf. !$ample: nurse ;oal of Ad%ocacy: help client gain greater self3determination ' !ncourage freedom o choices, increase sensiti%ity ' responsi%eness of the health care, social, politi3 cal systems to the needs of the client. !$ample: ad%ocates for 218 client rights for proper treatment ' <ob opportunities 5R1(!) AAA!5T1N; N@R)!) 1. 5rime 3 Act committed in %iolation of social la#.

The 5onsolidated 6mnibus udget Reconciliation Act +56 RA, of -..0 3 (edical )creening of patients cannot be delayed until insurance co%erage or the ability to pay has been determined. This is to assure that the patients are not denied care based on their ability to pay , patients must be medically screened ' stabili"ed before their ability to pay is determined. Aailure of a 2ospital to comply may result in denial of (edicare funding. !$ample: All women patients having labor contractions must be medically screened & stabilized before transfer to another facility. ?hether it is ob%ious that the patient is in labor or not, the patient must be medically screened ' e$amined before the decision is made to transfer the patient to another facility. The emergency department does not ha%e the right to refuse treatment to a patient before medically screening the patient. 3 1t does not address payment for ser%ices as part of the admission procedure. 1t

a. Tort +fraud, negligence ' malpractice, 3 Legal #rong committed against a person, his rights ' property. -. Araud > misrepresentation of fact #ith intentions for it to be acted on by another person + such as falsifying graduate nursing programs, 7. Negligence 9. (alpractice Negligence Definition: Definition: 3 @nintentional failure of an indi%idual misconduct #hich person to perform an act or omission conduct that exceeds to do something that a reasonable prudent ones professional stanperson would do or not do. going beyond the conte$t 3 (ost common unintentional tort of allo#ed nursing practice 3 Aailure to obser%e the protection of one4s injurious or non-injurious interest, the degree of care, and %igilance conse*uences. of circumstances. 3 stepping beyond ones authority %ersus

63 o#ed specific nursing duty limits of the standards of care D3 defendant breach the duty Assault

!3 e$ceeds the

1ntentional Torts attery 3(ental or physical threat 3physical harm through #illful touching of

!$ample: !$ample: a. 1ncorrect sponge counts a. prescribing drugs b. burns: heating pads ,solutions ' steam gi%ing anesthesia %apori"ers doing surgery c. failure to ta&e ' obser%e appropriate actions > forgetting to ta&e %ital signs to a ne#ly post >operati%e client. d. Aalls: side rails left do#n, baby left unattended e. loss of or damage to a patient4s property f. failure or ignore to report to the superiors or client4s family g. mista&en identity, #rong medicine, dose ' route !L!(!NT) 6A N!;L1;!N5! LA?)@1T + 3R363D, 6A (ALPRA5T15!+p3r3e,

person or clothing #ithout consent. !$ample (alpractice !$ample a. threatening or attempting to do a. actually touching or #ounding a person in %iolence to another offensi%e manner 3 any professional b. forcing a medication or treatment b. hitting or stri&ing a client in%ol%es any #hen the patient doesn4t #ant it c. immediately in<ecting a surgical needle the limits ofc. threatening children to ta&e the medication #ithout informing the patient about dards the said procedure or scope Aalse 1mprisonment resulting to 3 occurs #hen the person is not allo#ed to lea%e a health care facility #hen there is no legal <ustification to detain the client. 3 occurs #hen restraining de%ices are used #ithout an appropriate clinical need. 3 The intentional confinement #ithout authori"ation by a person #ho physically constricts another using force , the threat of force or confining structures and or clothing , e%en #ithout force or malicious intent to detain another #ithout b. consent in a specified area constitutes grounds or a charge of false person from harming self c. or others if it is necessary to confine to define one self , others or property or to effect a la#ful arrest. !$amples: a. A 2ispanic American patient undergo TA2 )6 and has no (edicare or 2(6 card nor nor any petty cash to pay hospital bills. The nurse put the patient in a room until the relati%es of the former arri%e to pay the bills.

!L!(!NT). a 2ong Cong 6A? #as suspected of ha%ing )AR). The ground duty nurse put the patient in a secluded room #ithout doctors order and 3 breach of duty #as the cause of the P3 professional )P!51A15 chec&ed for other manifestations to confirm standards of care the presence of )AR). After . hours, it #as <ust an plaintiff4s in<ury ordinary cough and colds. is re*uired R3 Real or actual proof in<uries R3 re*uired c. A client #as tested positi%e for 218. Nurse obedience 2amilton learned that this is highly contagious to the standards of care

' communicable disease. The nurse loc&ed the client inside a room. Legal aspect regarding Restraints ALT!RNAT18!) T6 Restraints are protecti%e de%ices used to limit the physical acti%ity of a client or to immobili"e a client or an e$tremity. Physical restraints: restrict client mo%ement through the application of a de%ice. 5hemical restraints: (edications gi%en to inhibit a specific beha%ior or mo%ement. @nder 6mnibus udget Reconciliation Act: any client or patient has the right to be free from Physical +such as restraint <ac&ets, and chemical +sedation, psychotropic drugs, restraints 1mposed for the purpose o discipline or con%enience and should not be re*uired to treat medical or psychiatric symptoms. La#ful Re*uirements ' Nursing Actions for @sing Restraints According to +J5A26, Joint 5ommission on A55R!D1ATAT16N 6A 2!ALT25AR! 6R;AN1DAT16N) -. R!)TRA1NT) )26@LD N6T ! @)!D PRNEEE 7. 1nformed consent and a Doctors order is needed to use restraints. 9. Doctors orders for restraints should be rene#ed #ithin a specific time frame according to the agencies policies. :. Restraints should not interfere #ith any treatments or affect the client4s health problems. F. Document the follo#ing: Reason for the restraints (ethod of restraints Date and time of application Duration of use and clients response Release from the restraints +e%ery 90 minutes, #ith periodic e$ercise and 5irculatory, neuro%ascular and s&in assessment !%aluation of client4s response G. D6N4T A)C P!R(1))16N 1A T2! PAT1!NT 2A) AN ALT!R!D L!8!L 6A 56N)516@)N!))EEE H. 1f the client is unable to gi%e consent to a restraint procedure, then consent of pro$y must be obtained AAT!R A@LL D1)5L6)@R! 6A ALL R1)C AND !N!A1T). /. @se a clo%e hitch &not so that restraint can be changed and release easily and ensure that there is enough slac& on the straps to allo# some mo%ement o the body part. .. Ne%er secure restraints to bed rails or mattress. )ecure restraints to parts of the bed or chair that #ill mo%e #ith client ' not constrict mo%ement. R!)TRA1NT) -. efore restraints offer e$planations, as& someone to stay #ith the client, use cloc&s, calendars, T8 ' radio + to decrease disorientation, or any rela$ation techni*ues. 7. @se L!)) restricti%e methods first. R!)TRA1NT) should al#ays be the last. 9. Assign confuse and disoriented clients to rooms near the nurse4s station. :. (aintain toileting routines ' institute e$ercise and ambulation schedules as the client condition allo#s. I@!)T16N: Can I put restraints on a patient who is combative I there is no order for this 6nly in an !(!R;!N5B, for a limited time +no longer than 7: hours, Aor the limited purpose of protecting the patient from in<ury > !"# $"% C"!&'!I'!C' "$ (ersonnel) Notify the attending (D immediately, consult #ith another staff member, obtain patients consent if possible, and get a co3 #or&er to #itness the record. R!)TRA1NT) 6A ANB D!;R!! (AB 56N)T13 T@T! AAL)! 1(PR1)6N!(!NT. Areedom from any @NLA?A@L restraint is a asic human right protected by la#. 1n *uly +,,- the $.A /$ood and .rug Administration0 issued a #arning that the use of restraints is > N6 L6N;!R R!PR!)!NT) R!)P6N)1 L! PR1(ARB (ANA;!(!NT of a client4s beha%ioral problem. ?riting an 1ncident Report 3 A tool used as a means of identifying and impro%ing client care. They are usually made immediately after its occurrence and %alidated immediately by co3#or&ers. 3 the real purpose is to pro%ide accurate documentation of occurrences affecting the client as to ha%e basis for its inter%ention. 3 it is usually made as a comprehensi%e ' accurate report on any une$pected or unplanned occurrence that affects or potentially affects his family or other members of the health team. The follo#ing are common situations that re*uire an incident report: (6)T 6A T2!( AR! N!;L1;!NT N@R)1N; A5T) a. Aalls , urns ' medication error

b.

rea& in the aseptic techni*ue c. 1ncorrect sponge count during surgery d. Aailure to report the clients condition Rules in 1ncident Report Don4t use the #ord error or include la#ful <udgment or inflammatory #ords

7. repeat the order to the (D ' record the order 9. sign the order, begin #ith t.o. + telephone order,, #rite the (D4s name ' then signature the order :. if another nurse #itnesses the order, that signature follo#s F. The physician needs to countersign the order #ithin the time frame according to hospital or agency policy. Iuestion: 5hould I follow an 6.s order if I 7now it is wrong M No. 1f you thin& a reasonable prudent nurse #ould not follo# itJ but first inform the (D and record your decision. Report it to your super%isor. 5hould I follow an 6.s order if I disagree with his or her judgment Bes. ecause the la# does not allo# you to substitute your nursing <udgment for a doctors medical <udgment. Do record that you *uestioned the order and that the doctor confirmed it before you carried it out. 1n order to be safe, chec& the agency policy manual of your #or&. 2uestion3 1hat can I do if the 6. delegates a tas7 to me for which I am not prepared 1nform the (D of your lac& of medication and e$perience in performing the tas&. Refuse to do it. 1f you inform him or her and still carry out the tas&, both you and the (D could be considered N!;L1;!NT if the patient is harmed by it. 1f you do not tell the (D and carry out the tas&, you are solely liable. Liability for (ista&es Iuestion: Is the hospital or the nurse liable for the mista7es made by the nurse while following orders oth the nurse and hospital can be sued for damage if a mista&e made by the nurse in<ures the patient. The nurse is responsible for his or her o#n actions. The hospital #ould be liable, based on the doctrine of %espond eat 5uperior. Iuestion: $or what would I be liable if I voluntarily stopped to give care at the scene of an accident The ;66D )A(AR1TAN A5T > protects health practitioners against malpractice claims resulting from assistance pro%ided at the scene of an emergency + @NL!)) T2!R! ?A) ?1LLA@L D61N;, as long as the le%el of care pro%ided is the same #ay as any other reasonably prudent person #ould gi%e under similar circumstances. 1t also encouraged health care professionals to assist in emergency situations #ithout fear of being sued for the care pro%ided. These la#s limit liability and offer legal immunity for people helping in an emergency, pro%iding they gi%e reasonable care. 6rgan Donation Re*uirements: a. Any person -/ years of age or older may become an organ donor by #ritten consent.

Legal Rules on Documentation, 5harting ' (D4s 6rder Documentation 3 Legally re*uired by accrediting agencies, state licensing la#s and state nurse and medical practice acts. 3re*uired for insurers reimbursement 3 legal documentation that signifies proper communication about the patients condition Iuestion: 1hat should be written in the nurses notes All facts and information regarding the patients condition, treatment, care, progress and response to illness and treatment. Document consent or refusal of treatment. 2uestion3 4ow should data be recorded 'ntries should3 -. )tate date and time gi%en. 7. be #ritten, signed ' titled by caregi%er or super%isor #ho obser%ed action 9. follo# chronological se*uence :. e accurate, factual, ob<ecti%e, complete , precise and clear F. @se uni%ersal abbre%iations. !$ample: prn, b.c. G. be legibleJ blac& pen H. 2a%e all spaces filled in, lea%e no blan& spaces. /. A%oid <udgmental or e%aluati%e statements such as K uncooperati%e clientL .. Do not document for others or change documentation for other indi%iduals 2uestion3 5hould I accept verbal phone orders from an 6. ;enerally, N6. )pecifically, follo# your hospitals by la#s, regulations and policies regarding this. Aailure to follo# the hospital4s rules could be considered N!;L1;!N5!. 1n cases #hen %erbal orders are deemed necessary the follo#ing outline may find helpful R!;ARD1N; T!L!P26N! 6RD!R): -. date and time entry

b. 1nformed choice to donate an organ can ta&e place #ith the use of a #ritten document signed by the client prior to death, a #ill, or a donor card or an ad%ance directi%e. c. 1n the absence of appropriate documentation, a family member or legal guardian may authori"e donation on the descendant4s organs. d. 1n case of ne#borns, they must be full term already + more than 700 grams, La#s that Protect potential donors to !$pedite ac*uisition: -. !ational "rgan #ransplant Act: prohibit selling of organs 7. 8niform Anatomical Act: guidelines regarding #ho can donate, ho# donations are to e made, and #ho can recei%e donated organs. 9. 8niform .etermination .eath Act: Legal determination of brain death + absence of breathing mo%ement, cranial ner%e refle$, response to any painful stimuli and cerebral blood flo# and flat !!;. (anagement of Donor -. (aintain body temperature at ;R!AT!R than .G./ A #ith room temperature at H0 3/0 A #arming blan&ets, #armer for 18 fluids. 7. (aintain greater than -00N Pa67 and suction= turn ' use +P!!P, positi%e !nd e$piratory pressure to pre%ent hypo$emia caused by air#ay obstruction ' pulmonary edema. 9. (aintain 58P +5entral 8enous Pressure, at / to -0 mm 2g and systolic blood pressure at greater than .0 mm 2g to pre%ent 2ypotension. :. (aintain Aluid ' !lectrolyte balance due to %olume depletion F. Pre%ent infections due to in%asi%e procedures. Religions that ha%e different %ie#s regarding organ donations -. Russian 6rthodo$: permits all donations !O5!PT T2! 2!ART. 7. Jeho%ah4s ?itness: D6!) N6T ALL6? organ donation and all organ to be transplanted must be drained of blood first. 9. Judaism: They permit organ donation as long as #ith RA 1N15AL 56N)@LTAT16N. :. 1slam: #ill N6T @)! 6R;AN )T6R!D 1N 6R;AN ANC).

:. Ad%ance directi%es ' ?ill 8oluntary Admission %ersus 1n%oluntary Admissions 8oluntary Admissions: Re*uirements ' y La#s a. La#ful or of legal age b. 1f the client is too ill, a guardian is possible c. 5lient agrees to accept the treatment d) #he client is free to sign him or herself out of the hospital- 4as the right to demand & receive %'9'A5') 1n%oluntary Admissions Re*uirements ' y La#s a. Deemed necessary for the follo#ing reasons ' criteria: +) .anger to self & others 7. need psychiatric or physical care 9. )tate la#s ha%e been determined legally by the state b) #he client who is involuntarily admitted does not lose his or her right of informed consent.

Iuestion3 1hat is the meaning of Conditional %elease - usually re*uires outpatient treatment for a specified period of time to determine the client4s compliance #ith medication protocol , ability to meet basic needs and ability to reintegrate to community. 6ther La#s to be Remembered Tarasoff Act3 if there are manifestations that a patient has some suicidal tendencies, it is the duty on the part of the nurse of a threatened suicide or possible harm or threat to others. There must be the proper dissemination of information to other members of the health care team. 6ccupational )afety ' 2ealth Act3 re*uires that an employer pro%ide a safe #or& place for employees according to regulations. !mployees can confidentially report @N)AA! ?6RC1N; 56ND1T16N) that %iolate regulations. A P!R)6N ?26 D6!) N6T R!P6RT @N)AA! ?6RC1N; 56ND1T16N) 5AN ! R!TAL1AT!D A;A1N)T B T2! !(PL6B!R. (4Naghten Rule +-/97, 3 a person is guilty if: a. person did not &no# the nature and *uality of the act b. Person could not distinguish right from #rong, if the person does not &no# #hat she = he is doing or a person does not &no# it #as #rong. 1rresistible 1mpulse Test +used together #ith (,Naghten Rule, > person &no#s right from #rong, but:

Do not Resuscitate +DNR, Aactors in gi%ing order of resuscitation: -. 5lient4s #ill and ad%ance directi%es 7. Disease Prognosis such as cancer or 218 9. 5lient=s ability to cope :. ?hether 5PR #ill be gi%en or not Reasons for refusing to perform resuscitation -. !pidemic or #idespread disease or debilitating condition ' that 5PR is not beneficial 7. 5PR #ill aggra%ate or prolong the agony of the client 9. against cultural ' religious suffering

a. Dri%en by impulse to commit criminal acts regardless of conse*uences. b. Lac& premeditation in sudden %iolent beha%ior.