School Nurses and the Law

1. School Nurses and the Law N Genell Lee, MSN, RN, JD Executive Officer Alabama Board of Nursing

2. Objectives • Describe the changes in the regulations that impact school nurses. • Discuss disciplinary actions related to school nurse practice.

3. Chapter 610-X-6 • 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

4. More from Table of Contents • 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

5. Definitions: • 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.

6. Definition: • 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.

7. 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.

8. Conduct and Accountability • 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.

9. More on 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

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

11. More on Documentation • 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.

12. Correction/Mistaken Entries • 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.

13. Medication Administration and Safety • 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

14. Decision-Making Skills • 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

15. 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

16. 610-X-6-.09 Assessment Standards • 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

17. Assignment, Delegation and Supervision • 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

18. Case Studies • 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.

19. Issues • 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?

20. Resolution? • 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

21. Case Study • 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?

22. Evidence • 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

23. Discipline • 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

24. Another one • 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??

25. Issues • 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?

26. Resolution • 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

27. DHR Report • 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!

28. School Nurses • A complaint does not equal discipline • Practice as a reasonably prudent school nurse