Legal Issues for the Lead School Nurse/Nurse Administrator N. Genell Lee, MSN, RN, JD Executive Officer Objectives • Identify the legal foundation for nursing practice in Alabama. • Relate mandatory reporting requirements to experiences as a nurse leader. • Describe regulations specific to the lead school nurse. Regulation & Public Protection • Alabama Board of Nursing: 1915 • Based on state’s police power: protection of public health, safety and welfare • Initial regulation aimed at nursing education The Early Years: • Voluntary Registration • Education Standards License Represents: • Specialized knowledge • Independent judgment • Fitness and capacity to practice • Property Right for the Nurse: Can Not be disciplined unless DUE PROCESS is followed (notice and hearing) ABN Functions: Rulemaking and Adjudication of Discipline • Admission to practice • Standards of practice • Continuing Competency • Removal from practice • Readmission to practice Board Composition • Eight Registered Nurses: – Two designated as Advanced Practice – Three from nursing practice, nursing administration – Three from nursing education • Four Licensed Practical Nurses – Two from AFLPN – Two from LPNAA • One Consumer Board Member Information • Appointed by Governor • RN members nominated by ASNA Committee on Nominations • LPN members nominated by AFLPN, LPNAA on rotating basis • Staggered terms Board Activities • Meetings for one to two days every month • Comply with Alabama Open Meetings Act • Board meetings posted on Board’s web site and Secretary of State’s web site • Use of technology Laws • Nurse Practice Act • ABN Administrative Code • FERPA & other education laws • Section 504, Rehab Act • Act 2009-280 (2009 Legislative Session) • Pharmacy laws • Medical Practice laws • Declaratory Rulings • OIG: Medicare, Medicaid • HIPDB, NPDB • Case Law Declaratory Rulings • Anyone significantly impacted by statute or rule can ask for Board’s interpretation and relief • Posted on Board’s web site, www.abn.state.al.us under “Declaratory Rulings” Examples Nursing Practice • U.S. Department of Transportation Issued March 20, 2003 • J. Daniel Raulerson, M.D. Issued November 20, 2003 • Davis, Ward and Lynn Issued September 24, 2004 • Mary Haynes, RN Issued May 19, 2005 • University of South Alabama Issued November 19, 2005 Mandatory Reporting • ABN Administrative Code, Rule 610-X-6-.02(10): Accept individual responsibility and accountability for timely reporting of illegal, substandard, unethical, unsafe, or incompetent nursing practice directly to the Board of Nursing. Complaints • Must be in writing • Can be anonymous • Complaint form on Board’s web site for employer and consumer • Sufficient information to identify respondent (nurse) Process • Docketed in database • Reviewed by Executive Officer • Notice of Investigation sent to Nurse • Acknowledgment sent to Complainant • Subpoena(s) issued • Investigated Options: • Non-discipline: • No violation: letter of closure • No provable violation but conduct inappropriate: letter of admonishment • VDAP: – Drugs/Alcohol abuse and dependency – Mental Illness – Physical Impairment Discipline Option: Board must be able to prove violation • Informal vs. Formal Disposition – Informal: Consent Order – Formal: Administrative Hearing – Informal: Voluntary Surrender (self-revocation by nurse) Types of Discipline • Reprimand • Reprimand and Fine • Probation – Until conditions met – Specific time period (1-5 years) • Suspension: – Until conditions met – Certain time period – One year: automatic revocation clause in consent orders if suspension extends beyond 12 months Other Types of Discipline • Revocation: must wait one year prior to application to reinstate revoked license • Voluntary Surrender: self- revocation Substandard Practice Examples • Scope of practice • Fraudulent documentation • Medication error • Abandonment • Improper Supervision • Professional Boundary violation • Violation of HIPPA • Impaired practice (no abuse or chemical dependency) Nurse in VDAP or on Probation: • Required to give employer copy of agreement/order • Employer asked to submit document that nurse complied with above • Order should be read to be sure employer can commit to obligations – Narcotic restriction – Employment monitor – Quarterly reports to ABN – Restrictions on location of work Chapter 610-X-6, Standards of Nursing Practice • 610-X-6-.01 Standards of Practice • 610-X-6-.02 Conduct and Accountability • 610-X-6-.03 Practice of Professional Nursing • 610-X-6-.04 Practice of Practical Nursing • 610-X-6-.05 Standardized Procedures • 610-X-6-.06 Delegation by School Nurses • 610-X-6-.07 State of Alabama Independent Living (SAIL) Program • 610-X-6-.08 Local Anesthetic Agents • 610-X-6-.09 Patient Care Orders • 610-X-6-.10 Telecommunication for Pronouncement of Patient Death • 610-X-6-.11 Limits on Intravenous Therapy by Licensed Practical Nurse • 610-X-6-.12 Registered Nurse as Surgical First Assistant (RNFA) • 610-X-6-.13 Sexual Assault Nurse Examiner (SANE) • 610-X-6-.14 Reserved • 610-X-6-.15 Alabama Department of Mental Health Residential Community Programs Delegation • The act of authorizing a competent individual to perform acts supportive to registered nurses or licensed practical nurses in selected situations. • Delegation of selected nursing functions to others in accordance with the education and demonstrated competence of the persons. Tasks delegated to unlicensed assistive personnel shall not require the exercise of independent nursing judgment or intervention. Selected nursing functions that may not be delegated include but are not limited to performance of invasive or sterile procedures or administration of medications except as provided in Rule 610-X-6-.06, -.07. Delegation Specific to School Nurses: Rule 610-X-6-.06 • The school nurse is accountable and responsible for the nursing care delivered to students under the nurse’s jurisdiction. • Registered nurses or licensed practical nurses who provide nursing care in the school setting through the twelfth grade may delegate specific tasks to unlicensed assistive personnel. More on Delegation • The registered nurse is accountable for determining the tasks that may be safely performed by the unlicensed assistive personnel following appropriate training and demonstration of competency. Prohibitions on Delegation • The specific delegated tasks shall not require the exercise of independent nursing judgment or intervention. Specific tasks that require independent nursing judgment or intervention that shall not be delegated include, but are not limited to: – Catheterization, clean or sterile; – Administration of injectable medications, other than premeasured medication for allergic reactions; – Administration of rectal or vaginal medications; – Calculation of medication dosages other than measuring a prescribed amount of liquid medication or breaking a scored tablet; – Tracheotomy care, including suctioning; – Gastric tube insertion, replacement, or feedings; – Invasive procedures or techniques; – Sterile procedures; – Ventilator care; and – Receipt of verbal or telephone orders from a licensed prescriber. Acceptable Delegation • The task of providing prescribed oral, topical, ear, eye, nasal, and inhalation medications to a student through twelfth grade may be delegated to unlicensed assistive personnel by the school nurse only when the following conditions are met: • The school nurse identifies the appropriate individual(s) to assist in providing prescribed medications. • The unlicensed assistive personnel selected by the school nurse shall attend a minimum twelve hour course of instruction that includes a curriculum approved by the Board and demonstrated competency to perform the delegated task. Monitoring • The school nurse shall provide periodic and regular evaluation and monitoring of the individual performing the delegated tasks. • The school nurse shall routinely and periodically conduct quality monitoring of the tasks performed by the unlicensed assistive personnel, including, but not limited to: – Training; – Competency; – Documentation; – Error reporting; and – Methods of identification of the right student, the right task, the right method, and the right quantity at the right time. Delegating and Reporting • The school nurse delegating the task may, at any time, suspend or withdraw the delegation of specific tasks to unlicensed assistive personnel. • The School Nurse Consultant or School Nurse Administrator shall submit a report(s) to the Alabama Board of Nursing in a format specified by the Board upon request. Standardized Procedures: Rule 610-X-6-.05 • Practice beyond basic education • Organized program of study • Supervised clinical practice • Demonstrated competence to perform • Annual Report Required Medications: 610-X-6-.05(6), (7) • The RN or LPN shall not administer medications for anesthetic purposes or to render an individual unconscious without meeting the requirements of Chapter 610-X-9-.02. • Administration of medications by routes beyond basic educational preparation, including but not limited to intrathecal, intracavitary, intraosseus, require a standardized procedure. Nurses Not Employed by Hospital • Any RN or LPN providing patient care in a licensed hospital shall comply with the standardized procedure(s) of that hospital. (ABN Administrative Code, Rule 610-X-6-.05(8)) Chapter 610-X-8, Disciplinary Actions • 610-X-8-.01 Definitions • 610-X-8-.02 Grounds for Denial of a License • 610-X-8-.03 Grounds for Discipline of a License or Denial of Reinstatement • 610-X-8-.04 Investigation • 610-X-8-.05 Board Action Following Investigation • 610-X-8-.06 Administrative Procedure Act • 610-X-8-.07 Formal Disposition of Contested Cases • 610-X-8-.08 Informal Disposition of Contested Cases • 610-X-8-.09 Decisions of the Board • 610-X-8-.10 Application Following Denial of Licensure • 610-X-8-.11 Reinstatement of a Revoked License 610-X-8-.03: Grounds for Discipline • (4) Drugs/Alcohol • (a) Testing positive for alcohol and/or unauthorized mood-altering drugs. • (b) Misappropriation or diversion of drugs from the workplace. • (c) Obtaining an unauthorized prescription by fraudulent means for self use. • (d) A pattern of abuse or misuse of habit forming and/or mood-altering drugs or alcohol. • (e) Impairment while on duty due to alcohol or the use of unauthorized or duly authorized prescription drugs. • (f) Refusal to submit to drug screen for cause. • (g) Submission of a diluted, adulterated, or substituted specimen for drug testing. • (h)The use of alcohol or habit forming or mood altering drugs to the extent that medical or psychiatric treatment, rehabilitation, or counseling is medically determined or otherwise recommended by a legally authorized practitioner. Documentation • Failure to make entries, destroying or altering entries, charting before assessment or delivery of care, or making false entries in patient, employer, or employee records. • Failure to timely, accurately, legibly, and completely report and document 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. Directing, Assigning, Providing • Directing, assigning, or providing patient care in a manner that fails to take into consideration patient safety. More…. • Assigning nursing functions to others who lack the educational preparation, license, credentials, competence, experience, knowledge, or physical, mental or emotional ability to perform the assigned functions. • Failure to provide adequate supervision, management, or training of individuals to whom nursing functions or responsibilities are delegated or assigned. Specific for Nurse Administrators • Failure to ensure verification of current Alabama licensure and credentials of nursing personnel for whom the nurse is administratively responsible. Mandatory Reporting • Failure to report illegal, substandard, unethical, unsafe or incompetent nursing practices. Responding to the Board: • Failure to respond to official Board correspondence, including but not limited to: • (a) Requests for information. • (b) Subpoenas. • (c) Notices. Nurses as CE Providers: • Failure of a registered nurse or licensed practical nurse who provides continuing education to comply with continuing education rules. Other Issues • Group online license verification subscription service • OIG to check for exclusion: http://exclusions.oig.hhs.gov/search.html Questions No subject is off limits!