School Nurses and the Law

N Genell Lee, MSN, RN, JDExecutive Officer

Alabama Board of Nursing

Describe the changes in the regulations that impact school nurses.

Discuss disciplinary actions related to school nurse practice.

Objectives

Standards of Nursing Practice: New Chapter effective December 28, 2009

Definitions Standards of Practice Conduct and Accountability Practice of Professional Nursing Practice of Practical Nursing Documentation Standards Medication Administration and Safety

Chapter 610-X-6

Standards for Moderate Sedation Assessment Standards Patient Care Orders Assignment, Delegation, Supervision Practice Beyond Basic Education: Standardized

Procedures Standards for Wound Care Intravenous Therapy by Licensed Practical Nurses Telecommunication for Pronouncement of Patient

Death

More from Table of Contents

Assessment, Comprehensive: systematic collection and analysis of data including physical, psychological, social, cultural, and spiritual aspects of the patient by the RN for the purpose of judging a patient’s health and illness status and actual or potential health needs. Comprehensive assessment includes patient history, physical examination, analysis of the data collected, development of the patient plan of care, implementation and evaluation of the plan of care.

Definitions:

Assessment, Focused: An appraisal of a patient’s status and specific complaint through observation and collection of objective and subjective data by the registered nurse or licensed practical nurse. Focused assessment involves identification of normal and abnormal findings, anticipation and recognition of changes or potential changes in patient’s health status, and may contribute to a comprehensive assessment performed by the registered nurse.

Definition:

Dual Relationship: Any time a licensed nurse interacts with a patient outside the nurse-patient relationship.

Professional Boundary: Behavior of the licensed nurse in maintaining a therapeutic relationship with a patient for the patient’s benefit rather than behavior that lessens the patient’s care and shifts the focus to the licensed nurse.

Definition

Responsible for monitoring and evaluating quality of patient care delivered by personnel under the individual nurse’s supervision

Practice in compliance with current CDC standards of standard precautions and infection control, including aseptic technique

Practice without discrimination on the basis of age, race, religion, gender, national origin, sexual orientation, patient diagnosis or disability.

Conduct and Accountability

Accept individual accountability and responsibility to avoid personal disruptive behaviors that negatively impact patient care.

Accept individual responsibility and accountability for accurate, complete and legible documentation related to:◦ Patient care records◦ Health care employment◦ Licensure and other credentials◦ CE records

More on Conduct and Accountability

Documentation of nursing care shall be:◦ Legible◦ Accurate◦ Complete: Complete includes reporting and

documenting on appropriate records a patient’s status, including signs and symptoms, responses, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient. A signature of the writer, whether electronic or written, is required in order for documentation to be considered complete.

Chapter 610-X-6-.06: Documentation Standards

Timely:◦ Charted at the time or after the care, including

medications, is provided. Charting prior to care being provided, including medications, violates principles of documentation.

◦ Documentation of patient care that is not in the sequence of the time the care was provided shall be recorded as a “late entry” including a date and time the late entry was made as well as the date and time the care was provided.

More on Documentation

Corrections shall have name and initials of individual making correction.

Mistaken entries shall be corrected by method that does not obliterate, white out or destroy the entry.

Correction/Mistaken Entries

Applied knowledge◦ Drug action◦ Drug classification◦ Expected therapeutic benefit of medication◦ Expected monitoring◦ Indications based on existing patient illness or injury

process◦ Contraindications ◦ Possible side effects & interventions for same◦ Safety precautions◦ Calculation of dosages◦ Storage, particularly of controlled substances◦ Patient education specific to medication

Medication Administration and Safety

If meds should be administered Assessment of patient’s health status and

complaint prior to and after administering meds including PRN meds

When to contact prescriber Education of patient, family, and caregiver

about the medications

Decision-Making Skills

Physical ability to open packaging and access delivery systems

Read, write, comprehend◦ English◦ Scientific phrases relevant to administration of

medication Measuring medication dosages Math calculations Routes of administration Proper use of technical equipment

Skills

RN Comprehensive and focused assessment:◦ Objective and subjective data◦ Analysis of data ◦ Developing plan of care based on assessment◦ Modify plan of care based on evaluation of patient

responses to plan. LPN Focused assessment:

◦ Objective and subjective data◦ Recording and reporting data◦ Reporting ◦ Anticipating and recognizing changes

610-X-6-.09 Assessment Standards

RN or LPN shall delegate only after considering various factors◦ Knowledge, skills and experience of the person

receiving the delegation◦ Complexity of the delegated tasks◦ Health status of the patient

Delegation may not include:◦ Exercise of independent nursing judgment or

intervention◦ Invasive procedures

Assignment, Delegation and Supervision

Board received a complaint that the school nurse failed to administer a child’s medication, failed to secure medication, and failed to notify parents when child became ill at school.

Case Studies

What was medication order?◦ Where to look for proof?

Was the medication administered?◦ Where to look for proof?

How did the error come to the attention of the complainant?

Were the records clear as to what happened?

Was there a pattern of similar behavior?

Issues

No documentation of medication being given or even available

Write ups in personnel file for failing to store medications properly

Child reported to parent that medication not taken at school

Nurse disciplined: Probation until conditions met

Resolution?

License renewal ended December 31 School nurse failed to renew School started January 5; students did not return until January 6

How do we know if the school nurse practiced on a lapsed license?

Case Study

Verification of Employment, including dates following lapse of license

Is it a licensed position? Did the individual practice during the times the license was lapsed?◦Schedule◦Payroll

Evidence

If worked on a lapsed license, < 1 year, Reprimand and fine of $500 plus $100 per month for any portion of the month worked with a lapsed license. Maximum $1000

If > 1 year, suspension of license, Fine $1000

Discipline

Parents complained that school nurse gave their child a couple of puffs on an inhaler

Child used an inhaler at home Did not have an inhaler at school Whose inhaler was used??

Another one

Were parents ever notified that inhaler was not at school?

Where was there an order for the inhaler?

What was documented? Was the child’s inhaler in the med room or kept on person?

Issues

School nurse used another child’s inhaler Did not chart that another child’s inhaler

was used; did not chart that any inhaler was used

No record of contacting the parents related to the missing inhaler

Did the child need the inhaler? Yes but the school nurse did not document its use, notify anyone and appeared to try and cover it up; discipline? Yes

Resolution

Parent complained that school nurse reported parents to DHR inappropriately

Children came to school with fleas, dirty, hungry

School nurse had ongoing relationship with children and reported to DHR on more than one occasion

Resolution? No discipline. Nurses are mandatory reporters for child abuse and neglect!

DHR Report

A complaint does not equal discipline

Practice as a reasonably prudent school nurse

School Nurses