Legal Aspects of Nursing Legal Aspects of Nursing

Definition of Terms
Board of Registered Nursing
Each state has a Board of Registered Nursing organized within the executive branch of
the state government !rimar" Responsibilities of the BRN include the administration of
the Nurse !ractice Act as applied to registered nurses
Authorization to !ractice Nursing
To legall" engage in the practice of nursing# an individual must hold on an active license
issued b" the state in which he or she intends to wor$
Nurse !ractice Act
A series of statutes enacted b" each state legislature to regulate the practice of nursing in
that state Topics that are included are the following a scope of nursing# education#
licensure# grounds for disciplinar" actions % related topics
a !rovides legal authorit" for nursing practice including delegation of nursing tas$s
b &an" boards of nursing also provide decision and delegation chec$list
c 'et educational re(uirements for the nurse distinguishing Nursing !ractice
from &edical !ractice % defines the 'cope of Nursing
ANA )American Nurses Association* of +,-.
/ncorporates the following elements that demonstrate in a nurse0
a 1uman dignit" % uni(ueness of individual regardless of health problems
% socio2economic status
b &aintain patients right for privac" % confidentialit"
c &aintain competence through ongoing professional development % consultation
Ethical !rinciples of Bio2ethics
A philosophical field that applies ethical reasoning process for achieving clear %
convincing reasons to issues % dilemmas ) conflicting between two obligations*
+ Autonom"0 the right of the patient to ma$e one3s own decision
2 Example0 Religious !ractices % 4ultural Beliefs )Blood Transfusion % 5rgan
Donation*
6 7eracit"0 the intention to tell the truth
2 Never give false reassurance to another person
8 Beneficence versus Non2malfeasance
a Beneficence 0 dut" to do good
b Non2malfeasance0 dut" to avoid evil
9 4onfidentialit"0 social contract in $eeping one3s privac"
'tandards of 4are
:uidelines for determining whether nurses have performed duties in a appropriate
manner % guidelines in which the nurse should practice
!atient3s Bill of Rights
Right for appropriate treatment that is most supportive % least restrictive
Right to individualized treatment plan# sub;ect to review % treatment
Right to active participation in treatment with the ris$ and side effect of all medications
and treatment
Right to give and withhold consent<contracts
4ontracts % 4onsent0 it is the meeting o the minds between two or more persons whereb"
one binds himself with respect to the other to give something or to render some service
!re2re(uisites of a 7alid 4onsent and 4ontract )5!EN2 7*
52 5pportunit" to as$ (uestions )possible conse(uences of the procedure*
!2 !h"sicall" % &entall" 4ompetent % &ature ) +- "ears old % up *
E2 Explained the !rocedures % Treatment 'pecificall"
N2 Nothing should be misunderstood b" the patient )the patient should not be
allowed to sign the informed consent if she < he is pre2medicated or under the influence of
alcohol or drugs or mentall" incapacitated
727oluntar" &ade )absence of force# fraud# deceit or duress ) force*
Exceptions to an /nformed 4onsent )&E&52'*
& =&arried % &ature &inors
E2 Emancipated minors )to release a child from the control of his parents*
Emergenc" 4ases
&2 &inors see$ing birth control or pre2natal treatment
52 5ver specific age )ex +6 "ears old % above* ma" give consent for 'TD#
1/7 testing# A/D' treatment# drugs % alcohol treatment >/T15?T
parents consent
'2 'exuall" abused minors % adolescents
Right to refuse Treatment
+ Advance Directives0 Legal# written or oral statements made b" a
mentall" competent person about treatment /n the event the person is unable to ma$e
these determinations# a surrogate decision2ma$er can do so# example0 sudden serious
illness
4haracteristics of Advance Directives
+ allows clients to participate in choosing health care providers
)4hoosing his < her own nurses % doctors*
6 allows also in choosing the t"pe of medical treatments the client
desires
8 Allows clients to consent or refuse treatments
The !atient Determination Act of +,,. )!'DA*
2 is a federal law that imposes on states and providers of health care certain re(uirements
concerning Advanced Directives as well as client3s right under law to to ma$e decisions
concerning medical care
The 4onsolidated 5mnibus Budget Reconciliation Act )45BRA* of +,,.
2 &edical 'creening of patients cannot be dela"ed until insurance coverage or the
abilit" to pa" has been determined This is to assure that the patients are not
denied care based on their abilit" to pa" # patients must be medicall" screened %
stabilized before their abilit" to pa" is determined @ailure of a 1ospital to compl" ma"
result in denial of &edicare funding
Example0 All women patients having labor contractions must be medicall" screened %
stabilized before transfer to another facilit" >hether it is obvious that the patient is in
labor or not# the patient must be medicall" screened % examined before the decision is
made to transfer the patient to another facilit"
The emergenc" department does not have the right to refuse treatment to a patient before
medicall" screening the patient
2 /t does not address pa"ment for services as part of the admission procedure /t
onl" addresses medical screening % stabilization of patients before transport
or the determination of abilit" to pa" for services rendered
a Living >ill0 legal document stating person does not wish to
have extra2ordinar" life saving measures when not able to ma$e decisions about his own
care
2applicable @5R L/@E 'A7/N: TREAT&ENT 5NLA
Example0 4!R# antibiotics % dial"sis will be used or not
b Durable !ower of Attorne"0 legal document giving designated
person authorit" to ma$e health care decisions on the
client3s behalf when the client is unable to do so
Right to obtain Advocac" Assistance
!atient Advocate0 is a person who pleads for a cause or who acts on
the client3s behalf Example0 nurse
:oal of Advocac"0 help client gain greater self2determination %
Encourage freedom o choices# increase sensitivit"
% responsiveness of the health care# social# politi2
cal s"stems to the needs of the client
Example0 advocates for 1/7 client rights for proper treatment % ;ob
opportunities
4R/&E' A@@E4T/N: N?R'E'
/ 4rime
2 Act committed in violation of social law
a Tort )fraud# negligence % malpractice*
2 Legal wrong committed against a person# his rights % propert"
+ @raud = misrepresentation of fact with intentions for it to be acted on b" another person
) such as falsif"ing graduate nursing programs*
6 Negligence
8 &alpractice
Negligence versus &alpractice
Definition0 Definition0
2 ?nintentional failure of an individual 2 an" professional misconduct which
person to perform an act or omission involves an" conduct that exceeds
to do something that a reasonable prudent the limits of one3s professional stan2
person would do or not do dards means going be"ond the context
2 &ost common unintentional tort or scope of allowed nursing practice
2 @ailure to observe the protection of one3s resulting to in;urious or non2in;urious
interest# the degree of care# and vigilance conse(uences
of circumstances 2 stepping be"ond one3s authorit"
Example0 Example0
a /ncorrect sponge counts a prescribing drugs
b burns0 heating pads #solutions % steam b giving anesthesia
vaporizers c doing surger"
c failure to ta$e % observe appropriate
actions = forgetting to ta$e vital signs to
a newl" post =operative client
d @alls0 side rails left down# bab" left
unattended
e loss of or damage to a patient3s propert"
f failure or ignore to report to the superiors or
client3s famil"
g mista$en identit"# wrong medicine# dose % route
ELE&ENT' 5@ NE:L/:EN4E LA>'?/T )B2R252D* ELE&ENT' 5@
&AL!RA4T/4E)p2r2e*
B2 breach of dut" was the cause of the !2 professional '!E4/@/4 standards of care
plaintiff3s in;ur" is re(uired
R2 Real or actual proof in;uries R2 re(uired obedience
to the standards of care
52 owed specific nursing dut" E2 exceeds the limits of the standards of care
D2 defendant breach the dut"
/ntentional Torts
Assault Batter"
2&ental or ph"sical threat 2ph"sical harm through willful touching of
person or clothing without consent
Example Example
a threatening or attempting to do a actuall" touching or wounding a person in
violence to another offensive manner
b forcing a medication or treatment b hitting or stri$ing a client
when the patient doesn3t want it c immediatel" in;ecting a surgical needle
c threatening children to ta$e the medication without informing the patient about
the said procedure
@alse /mprisonment
2 occurs when the person is not allowed to leave a health care facilit" when there is no
legal
;ustification to detain the client
2 occurs when restraining devices are used without an appropriate clinical need
2 The intentional confinement without authorization b" a person who ph"sicall" constricts
another using force # the threat of force or confining structures and or clothing # even
without
force or malicious intent to detain another without consent in a specified area constitutes
grounds or a charge of false person from harming self or others if it is necessar" to
confine to
define one self # others or propert" or to effect a lawful arrest
Examples0
a A 1ispanic American patient undergo TA1B'5 and has no &edicare or 1&5 card nor
nor an" pett" cash to pa" hospital bills The nurse put the patient in a room until the
relatives of the former arrive to pa" the bills
B a 1ong Bong 5@> was suspected of having 'AR' The ground dut" nurse put the
patient
in a secluded room without doctors order and chec$ed for other manifestations to confirm
the presence of 'AR' After , hours# it was ;ust an ordinar" cough and colds
c A client was tested positive for 1/7 Nurse 1amilton learned that this is highl"
contagious
% communicable disease The nurse loc$ed the client inside a room
Legal aspect regarding Restraints
Restraints are protective devices used to limit the ph"sical activit" of a client or to
immobilize a client or an extremit"
!h"sical restraints0 restrict client movement through the application of a device
4hemical restraints0 &edications given to inhibit a specific behavior or movement
?nder 5mnibus Budget Reconciliation Act0 an" client or patient has the right to be free
from !h"sical )such as restraint ;ac$ets* and chemical )sedation# ps"chotropic drugs*
restraints
/mposed for the purpose o discipline or convenience and should not be re(uired to treat
medical
or ps"chiatric s"mptoms
Lawful Re(uirements % Nursing Actions for ?sing Restraints
According to )C4A15* Coint 4ommission on A44RED/ATAT/5N 5@
1EALT14ARE 5R:AN/DAT/5N'
+ RE'TRA/NT' '15?LD N5T BE ?'ED !RNEEE
6 /nformed consent and a Doctors order is needed to use restraints
8 Doctors orders for restraints should be renewed within a specific time frame
according to the agencies policies
9 Restraints should not interfere with an" treatments or affect the client3s health
problems
F Document the following0
Reason for the restraints
&ethod of restraints
Date and time of application
Duration of use and clients response
Release from the restraints )ever" 8. minutes* with periodic exercise and
4irculator"# neurovascular and s$in assessment
Evaluation of client3s response
G D5N3T A'B !ER&/''/5N /@ T1E !AT/ENT 1A' AN ALTERED LE7EL
5@ 45N'4/5?'NE''EEE
H /f the client is unable to give consent to a restraint procedure# then consent of prox"
must be obtained A@TER @?LL D/'4L5'?RE 5@ ALL R/'B AND BENE@/T'
- ?se a clove hitch $not so that restraint can be changed and release easil" and ensure
that there is enough slac$ on the straps to allow some movement o the bod" part
, Never secure restraints to bed rails or mattress 'ecure restraints to parts of the bed or
chair that will move with client % not constrict movement
ALTERNAT/7E' T5 RE'TRA/NT'
+ Before restraints offer explanations# as$ someone to sta" with the client# use cloc$s#
calendars# T7 % radio ) to decrease disorientation* or an" relaxation techni(ues
6 ?se LE'' restrictive methods first RE'TRA/NT' should alwa"s be the last
8 Assign confuse and disoriented clients to rooms near the nurse3s station
9 &aintain toileting routines % institute exercise and ambulation schedules as the client
condition allows
I?E'T/5N0 4an / put restraints on a patient who is combative / there is no order for
thisJ
5nl" in an E&ER:EN4A# for a limited time )no longer than 69 hours*
@or the limited purpose of protecting the patient from in;ur" = N5T @5R
45N7EN/EN4E 5@ !ersonnel Notif" the attending &D immediatel"# consult
with another staff member# obtain patients consent if possible# and get a co2
wor$er to witness the record RE'TRA/NT' 5@ ANA DE:REE &AA 45N'T/2
T?TE @AL'E /&!R/'5NE&ENT @reedom from an" ?NLA>@?L restraint is a
Basic human right protected b" law /n Cul" +,,6 the @DA )@ood and Drug Admi2
nistration* issued a warning that the use of restraints is = N5 L5N:ER
RE!RE'ENT' RE'!5N'/BLE !R/&ARA &ANA:E&ENT of a client3s
behavioral problem
>riting an /ncident Report
2 A tool used as a means of identif"ing and improving client care The" are usuall" made
immediatel" after its occurrence and validated immediatel" b" co2wor$ers
2 the real purpose is to provide accurate documentation of occurrences affecting the client
as
to have basis for its intervention
2 it is usuall" made as a comprehensive % accurate report on an" unexpected or
unplanned
occurrence that affects or potentiall" affects his famil" or other members of the health
team
The following are common situations that re(uire an incident report0
&5'T 5@ T1E& ARE NE:L/:ENT N?R'/N: A4T'
a @alls # Burns % medication error
b Brea$ in the aseptic techni(ue
c /ncorrect sponge count during surger"
d @ailure to report the clients condition
Rules in /ncident Report
Don3t use the word error or include lawful ;udgment or inflammator" words
Legal Rules on Documentation# 4harting % &D3s 5rder
Documentation
2 Legall" re(uired b" accrediting agencies# state licensing laws and state nurse and
medical
practice acts
2re(uired for insurers reimbursement
2 legal documentation that signifies proper communication about the patients condition
Iuestion0 >hat should be written in the nurses notesJ
All facts and information regarding the patients condition# treatment# care# progress and
response to illness and treatment
Document consent or refusal of treatment
Iuestion0 1ow should data be recordedJ Entries should0
+ 'tate date and time given
6 be written# signed % titled b" caregiver or supervisor who observed action
8 follow chronological se(uence
9 Be accurate# factual# ob;ective# complete # precise and clear
F ?se universal abbreviations Example0 prn# bc
G be legibleK blac$ pen
H 1ave all spaces filled in# leave no blan$ spaces
- Avoid ;udgmental or evaluative statements such as L uncooperative clientM
, Do not document for others or change documentation for other individuals
Iuestion0 'hould / accept verbal phone orders from an &DJ
:enerall"# N5 'pecificall"# follow "our hospitals b" laws# regulations and policies
regarding this @ailure to follow the hospital3s rules could be considered NE:L/:EN4E
/n cases when verbal orders are deemed necessar" the following outline ma" find helpful
RE:ARD/N: TELE!15NE 5RDER'0
+ date and time entr"
6 repeat the order to the &D % record the order
8 sign the order# begin with to ) telephone order*# write the &D3s name % then
signature the order
9 if another nurse witnesses the order# that signature follows
F The ph"sician needs to countersign the order within the time frame according to
hospital or agenc" polic"
Iuestion0 'hould / follow an &D3s order if / $now it is wrongJ N
No /f "ou thin$ a reasonable prudent nurse would not follow itK but first inform the &D
and record "our decision Report it to "our supervisor
'hould / follow an &D3s order if / disagree with his or her ;udgmentJ
Aes Because the law does not allow "ou to substitute "our nursing ;udgment for a
doctors medical ;udgment Do record that "ou (uestioned the order and that the doctor
confirmed it before "ou carried it out /n order to be safe# chec$ the agenc" polic" manual
of "our wor$
Iuestion0 >hat can / do if the &D delegates a tas$ to me for which / am not preparedJ
/nform the &D of "our lac$ of medication and experience in performing the tas$ Refuse
to do it /f "ou inform him or her and still carr" out the tas$# both "ou and the &D could
be considered NE:L/:ENT if the patient is harmed b" it /f "ou do not tell the &D and
carr" out the tas$# "ou are solel" liable
Liabilit" for &ista$es
Iuestion0 /s the hospital or the nurse liable for the mista$es made b" the nurse while
following ordersJ Both the nurse and hospital can be sued for damage if a mista$e made
b" the nurse in;ures the patient The nurse is responsible for his or her own actions The
hospital would be liable# based on the doctrine of Respond eat 'uperior
Iuestion0 @or what would / be liable if / voluntaril" stopped to give care at the scene of
an accidentJ The :55D 'A&AR/TAN A4T = protects health practitioners against
malpractice claims resulting from assistance provided at the scene of an emergenc"
) ?NLE'' T1ERE >A' >/LL@?L D5/N:* as long as the level of care provided is the
same wa" as an" other reasonabl" prudent person would give under similar
circumstances /t also encouraged health care professionals to assist in emergenc"
situations without fear of being sued for the care provided These laws limit liabilit" and
offer legal immunit" for people helping in an emergenc"# providing the" give reasonable
care
5rgan Donation
Re(uirements0
a An" person +- "ears of age or older ma" become an organ donor b" written consent
b /nformed choice to donate an organ can ta$e place with the use of a written document
signed b" the client prior to death# a will# or a donor card or an advance directive
c /n the absence of appropriate documentation# a famil" member or legal guardian ma"
authorize donation on the descendant3s organs
d /n case of newborns# the" must be full term alread" ) more than 6.. grams*
Laws that !rotect potential donors to Expedite ac(uisition0
+ National 5rgan Transplant Act0 prohibit selling of organs
6 ?niform Anatomical Act0 guidelines regarding who can donate# how donations are to
Be made# and who can receive donated organs
8 ?niform Determination Death Act0 Legal determination of brain death ) absence of
breathing movement# cranial nerve reflex# response to an" painful stimuli and cerebral
blood flow and flat EE:
&anagement of Donor
+ &aintain bod" temperature at :REATER than ,G- @ with room temperature at H. 2-.
@ warming blan$ets# warmer for /7 fluids
6 &aintain greater than +..O !a56 and suction< turn % use )!EE!* positive End
expirator" pressure to prevent h"poxemia caused b" airwa" obstruction % pulmonar"
edema
8 &aintain 47! )4entral 7enous !ressure* at - to +. mm 1g and s"stolic blood pressure
at greater than ,. mm 1g to prevent 1"potension
9 &aintain @luid % Electrol"te balance due to volume depletion
F !revent infections due to invasive procedures
Religions that have different views regarding organ donations
+ Russian 5rthodox0 permits all donations EP4E!T T1E 1EART
6 Cehovah3s >itness0 D5E' N5T ALL5> organ donation and all organ to be
transplanted must be drained of blood first
8 Cudaism0 The" permit organ donation as long as with RABB/N/4AL
45N'?LTAT/5N
9 /slam0 will N5T ?'E 5R:AN 'T5RED /N 5R:AN BANB'
Do not Resuscitate )DNR*
@actors in giving order of resuscitation0
+ 4lient3s will and advance directives
6 Disease !rognosis such as cancer or 1/7
8 4lient<s abilit" to cope
9 >hether 4!R will be given or not
Reasons for refusing to perform resuscitation
+ Epidemic or widespread disease or debilitating condition % that 4!R is not beneficial
6 4!R will aggravate or prolong the agon" of the client
8 against cultural % religious suffering
9 Advance directives % >ill
7oluntar" Admission versus /nvoluntar" Admissions
7oluntar" Admissions0
Re(uirements % B" Laws
a Lawful or of legal age
b /f the client is too ill# a guardian is possible
c 4lient agrees to accept the treatment
d The client is free to sign him or herself out of the hospital2 1as the right to demand %
receive RELEA'E
/nvoluntar" Admissions
Re(uirements % B" Laws
a Deemed necessar" for the following reasons % criteria0
+ Danger to self % others
6 need ps"chiatric or ph"sical care
8 'tate laws have been determined legall" b" the state
b The client who is involuntaril" admitted does not lose his or her right of informed
consent
Iuestion0 >hat is the meaning of 4onditional ReleaseJ
2 usuall" re(uires outpatient treatment for a specified period of time to determine the
client3s compliance with medication protocol # abilit" to meet basic needs and abilit"
to reintegrate to communit"
5ther Laws to be Remembered
Tarasoff Act2 if there are manifestations that a patient has some suicidal tendencies# it is
the dut" 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
5ccupational 'afet" % 1ealth Act2 re(uires that an emplo"er provide a safe wor$ place
for emplo"ees according to regulations Emplo"ees can confidentiall" report ?N'A@E
>5RB/N: 45ND/T/5N' that violate regulations A !ER'5N >15 D5E' N5T
RE!5RT ?N'A@E >5RB/N: 45ND/T/5N' 4AN BE RETAL/ATED A:A/N'T BA
T1E E&!L5AER
&3Naghten Rule )+-86* 2 a person is guilt" if0
a person did not $now the nature and (ualit" of the act
b !erson could not distinguish right from wrong# if the person does not $now what she <
he is doing or a person does not $now it was wrong
/rresistible /mpulse Test )used together with &#Naghten Rule* = person $nows right from
wrong# but0
a Driven b" impulse to commit criminal acts regardless of conse(uences
b Lac$ premeditation in sudden violent behavior