How long can a nurse wait to document?

Documentation is communication between you and any other provider who reviews your documentation.   So, if the documentation is not in place you are not communicating.  Standard practice is to document as soon as you finish the task you were performing.  Realistically, shifts are super busy to the point that the first time a nurse is able to document is when the shift is over and another nurse has assumed care of that nurse's patients.  If that is the case, the best you can do is to document then.

The exception to waiting till the end of the shift to document is the Medication Administration Record (MAR).  Documentation of medication administration occurs immediately AFTER the medication is given. There is no waiting and also you do NOT document before administering the medication.  Actually, all documentation is to be done after the task is completed and never before.  I like to say "There is no Fixing-To documentation."  

Some nurses have the mistaken belief that they can leave the hospital and then document when they come back for their next shift and that is untrue and a habit that if caught will result in disciplinary action by the Texas Board of Nursing/BON.  Think about what documentation is used for; it is used to communicate to others when you are not present to tell them in person. So, if you are gone and the documentation is missing then no communication is happening and patient care is impacted.

The best practice is to do the task then document.   You are also likely to remember more important facts if you document timely. So, not only is it nursing standard, best for patient care, but is also more likely to protect you and give  you documentation you can rely upon in case something comes up later.

Closing eyes while at work - DANGER, DANGER

You are tired, or sick, or just resting our eyes so you close your eyes for a short time period at work.  Of course right then is when another staff member, or management or a family member comes by and sees you "sleeping."  You are most likely about to be terminated and reported to the BON for sleeping.  You think I will explain that I just had my eyes closed for a short time period, but that explanation does not make the termination cease or the BON stop from taking disciplinary action.  The assumption always is if your eyes are closed, you are sleeping. So be very careful!!

A nurse passed on what she encountered when she started a new night job:   she was told by nurses who had been working at the facility for a while that if it was slow at work they would take turns watching each other's patients and take turns sleeping.  They assured her it was acceptable.  She said she thought it sounded off, but she wanted to check with an attorney that represented nurses.  I told her that it was not EVER acceptable and also she may want to reconsider working in a place like this where nurses thought it was acceptable behavior to be paid for sleeping on the job and ignoring their patients.

Timing for Giving Medications including Narcotics

 Nurses have said there is a  policy that you have an hour leeway to give medications. So, if a medication is ordered at 9 am you can give it as early as 8am and as late as 10 am.  First there is no national policy  supporting this practice. Second, you need to see with your own eyes that such a policy is in place where you work otherwise you are not protected by following this belief.  Do not rely on what others tell you.  Some hospitals do have policies that give 30 min to 1 hour either side of the selected time of administration.. You just need to be sure the hospital/clinic/prison/LTC etc  where you work has that policy.

If the medication in question is a narcotic you can end up being charged with giving a controlled substance outside the timing set by the prescribing physician.  If a physician orders a narcotic every 4 hours and you give it one hour early or even 30 minutes early, the Board of Nursing/BONs are saying you have failed to follow the physician order and gave a narcotic outside what was ordered by the physician's order.  When it comes to narcotics nurses need to wait until the stated time has occurred before giving the medication so that you are never too early and can avoid that complaint with the BON..

The same applies to scheduled medications that are tine specific.  You need to know what your facility's policies are and what the requirements are for that specific medication ( an example are antibiotics) and give the medication appropriately.  If the medication is strictly scheduled there is no time leeway.  

Texas Board of Nursing (TX BON) moves

 Moving day is finally here and the Texas Board of Nursing/ BON has moved to a new location.  Hopefully the new offices are nicer although I have heard they are still too small.  Here is the new address:  

                                   Texas Board of Nursing    
                  1801 Congress Avenue, Suite 10-200    
                  Austin, Texas    
                  78701  

You've Been Asked to Give a Urine Screen

 Your manager asks you to come to his office and tells you he has received a report you smell like alcohol and look impaired so they would like you to give a urine screen. Or maybe you were in an accident while working and a screen is part of the policy.  Or there are drugs missing so everyone is required to provide  a drug screen. There are various possible outcomes and below are helpful hints other nurses have utilized that you may want to.  ***This is not legal advice and I am not working as your attorney in any capacity, these are just an accounting of steps other nurses have used when they were in the same situation and are intended to be for information only***:

You give the screen:  even if you know the screen should be negative does not mean that a mistake may  not be made and the negative screen is now a positive and now evidence against you. So, make sure you then obtain your own screen as well.  There have been nurses who did this and had a screen that showed negative while the one obtained at work showed up as positive. Getting your own screen can help you have evidence to prove  your innocence.  

You refuse to provide a screen:  the biggest problem with this choice is the assumption that if you had obtained the screen it would have been positive. So it becomes an automatic assumption that the screen is positive and any argument is countered by "You would have given the screen unless you knew it was going to be positive, so we believe it to be positive."  It doesn't matter if it is not true, you do not have the proof to show the screen was negative.  So, if you refuse a screen at work for any reason, immediately obtain your own screen so you have something to support your assertion that the screen would have been negative. A nurse has obtained their own screen by use of a private physician or even a walk-in screening site.  Be sure the drug in question or alcohol is included in the screen or else the screen is useless.

Type of screen to get: Make sure the screen covers the drugs in question or get a minimum of a 10 panel screen (tests for 10 different substances).

What to watch for:   When providing a screen make sure the person obtaining the screen handles it correctly.  They should wash their hands.  The sample should be sealed in front of you with a strip across the specimen jar and this strip is signed by the nurse. The sample is then sealed in a sample bag that is signed.  If the sample is poured into another specimen container it must be done in front of you prior to the sealing of the specimen.  DO NOT sign the paperwork unless the sample is sealed in front of you.  DO NOT LEAVE AN UNSEALED SPECIMEN!!   When you sign the paperwork, you are confirming all fo this was completed.

Make sure you let the collector know any medications, prescribed and OTC, that  you have taken and make sure it is all documented on the form. If the test is positive, the Medical Review Officer (MRO) will contact you to go over any medications you may have ingested.

Sometimes, the collector tries to take the position that no, you cannot write on or list anything of the requisition form.  Insist on the ability to list medications and OTC substances you have taken because that is part of the collection policies.  As an alternative, make a notation of any substances you have taken on the a piece of paper and get the collector to sign it confirming that you showed it to them for your records.  

 ***This blog provides general information and a general understanding of the law, but does not provide specific legal advice. By using this site, commenting on posts, or sending inquiries through the site or contact email, you confirm that there is no attorney-client relationship between you and the Blog/Web Site publisher/author. The Blog/Web Site should not be used as a substitute for competent legal advice from a licensed attorney in your jurisdiction.***

Surrendering A Nursing License

 You have received notice you are under investigation by the BON and they offer to resolve the investigation by allowing you to surrender your license.  Maybe you no longer practice in that state or maybe you have not worked in awhile or you are just burned out and not sure if you want to return to work.  Surrendering a license may seem like a quick and easy resolution for a stressful process, but you MUST do research and think about the broad ramifications of surrendering your license.  Surrendering a nursing license could result in you being placed on an EXCLUSION list which means you cannot work for any employer in any capacity that accepts Medicare/Medicaid or Federal funds.

So, maybe you are thinking of quitting work as a nurse and returning to work as an aide so that you can continue to do patient care. If you surrender your nursing license and are placed on either the federal or state Office of the Inspector General's exclusion list you would not be able to work as an aide because the LTC facility accepts Medicaid/Medicare.  Remember the exclusion is for any employer and any position.

The exclusion list can have other impacts other than just working in different positions in healthcare. The exclusion has also impacted a nurse who wanted to obtain a reverse mortgage which is funded by Federal monies--no monies if on the list.  Surrendering a license can also keep you from obtaining another professional license.  A nurse applied for a real estate license and was denied because of a surrendered nursing license.

Think carefully before surrendering your license and do your research.

Do You Need Malpractice Insurance?

YES, YES, YES!!!  Nursing Defense Attorneys advise nurses who interact with patients to carry their own malpractice insurance.

The biggest worry is not getting sued in civil court, but rather an investigation by the Board of Nursing.  Malpractice insurance typically covers professional license defense and this is a HUGE reason to pay a little money every year to a nursing malpractice insurance company to ensure that if a complaint is filed against you there is money to hire an experienced defense attorney.

Nurses continue to refuse insurance due to various myths:

1. I am a good nurse and won't get sued/reported to the BON:  Good nurses are reported every single day to the BON or named in a lawsuit.  Good nurses make mistakes and are reported or sued; being good at your job is not an absolute defense.  Good nurses can be the victim of mistaken identity or identity theft.  What about the nurse who had her information stolen and it was used to write fictitious prescriptions.  The board ignored the nurse's denial, samples of her handwriting, and letters from her employer and pharmacist stating the prescriptions were not hers.  The nurse had to pay legal fees, expenses and a private investigator fee out of pocket before the BON would believe she did not write the prescriptions and dismiss the case.  Bad things can happen to Good nurses.  Good nurses get their own malpractice defense policy.

2. My employer has insurance so I do not need my own policy:  I have never seen an employer's insurance used to provide legal defense for a complaint to the BON.  In addition, since most complaints originate from the employer, why would the employer also provide the financial means to defend against their complaint?  If you use your employer's malpractice insurance company the company/attorney's concern is the employer first.  This means any advice given to the nurse must first be a benefit to or not harm the employer.  If a nurse wants a non-biased defense, the nurse needs his/her own malpractice defense policy.

3. Having your own insurance will get you sued:  Plaintiffs find out a nurse has insurance two ways-first the nurse tells them (do not tell anyone you have insurance when an incident/error occurs) OR AFTER the lawsuit is filed interrogatories are filed asking if the nurse has insurance (so the insurance did not cause the lawsuit; they had already decided to sue you before they knew you had insurance).  Get your own malpractice defense policy because doing so will NOT cause you to be sued.


4. It is too expensive:  Not really.  A nurse told me that she obtained a policy and paid premiums for 10 years and the total amount was still less that what hiring an attorney out of pocket would cost her.  There is also a huge peace of mind aspect when you know you have the  money to take your case to the hearing stage and fight the allegations/complaint against you.  Many of the disciplinary actions occur because the nurse was forced to accept what the BON offered in settlement because the nurse could not afford to fight the BON (hearings before an Administrative Law Judge can cost anywhere from $10,000 to $30,000 or more depending on the length, number of witnesses and experts, and the complexity of the case; civil cases cost even more).

I received a sad phone call from a nurse who received notice she was named in a lawsuit.  I told her to contact the hospital immediately to see if they would cover her legal defense because they were probably also named in the lawsuit.  The nurse got very upset because the hospital had declared bankruptcy and was closed.  This meant the hospital was no longer in business and she was the only one named in the lawsuit meaning she was responsible out of pocket for her defense, expenses, and ultimately if she lost the case, she would be responsible for the cost of the judgment!!!   Very expensive and it could have been avoided if she had her own malpractice defense policy.

5. I was told in nursing school/at a CNE seminar/by a co-worker/etc. that I should not get insurance because.... Whatever the reason and no matter who is telling you, they are wrong.  The people who defend nurses are in agreement that nurses need to carry their own policy for malpractice/professional license defense.

How to find a policy:  Search for nursing malpractice insurance and talk to the various providers.  Make sure the policy:
* covers professional licensure defense
*allows you to pick your OWN attorney [Some insurance companies have a list of attorneys you must choose from and these attorneys may not have experience with the BON or not enough experience]
*has a cap per incident of at least/a minimum of $25,000 [this usually provides enough money for a BON investigation and a normal hearing; there are some policies that have a cap of $5,000-$10,000 per incident and that is not enough to cover the investigation and possible hearing]

Criminal Conviction? Make sure you are getting up to date information

I continue to hear from nurses (who have spoken with other attorneys in regards to criminal convictions) that are told they are going to receive disciplinary action or that they will have to obtain some type of evaluation; in many cases this is not true because the guidelines changed.  The Texas BON revised  their criminal guidelines in 2018 and some attorneys apparently have not kept up with the new regulations and policies.  What the Texas BON used to do in response to convictions before 2/2018 has changed and you need to be sure you are receiving current information.  Before agreeing to anything, be sure to speak to several attorneys that have experience with the BON (check Google or AVVO.com for information on attorneys and their experience).

This is from my firm's website, www.nursingattorney.com:

Nurses always ask what can they do to improve  the regulation of their practice by the Texas Board of Nursing.  There are questions of how to make the process more fair, especially for those nurses who have never had a violation before and have a wonderful history of nursing practice.  Now, nurses can make a difference and ensure that two proposed rules pass; two proposed rules which will benefit nurses in Texas.

All nurses should read the recently proposed changes for the BON's  rules sections §213.32, Corrective Action Proceedings and Schedule of Administrative Fines and §213.35, Knowledge, Skills, Training, Assessment and Research (KSTAR) Pilot Program.  (22 Texas Administrative Code §213)  These rules will help nurses with minor practice violations resulting in disciplinary actions at the level of Remedial Education (§213.32) and at the level of Warning with Stipulations and Remedial Education (§213.35).  The levels include with and without a fine.

The Corrective Action Proceeding is non-reportable to the databanks and is not considered a disciplinary action.  Previously this option was restricted previously to administrative documentation type cases such as failing to inform the Board of a minor past criminal conviction or a failure to monitor the renewals of nurses under your supervision.  Expanding this option to practice issues will help the type of cases in the past where a nurse has a stellar nursing practice history but has made an error of some type; having these nurses put under disciplinary orders was one of the biggest problems facing the Board in my opinion.

Allowing deficiencies in nursing practice to be corrected by the KSTAR program is a great step in the regulation of nurses.  The  typical Board Order may not have addressed specific issues a nurse had and instead lumped all violations of a certain level into the same remedial courses.  The program will not be cheap for the nurse, but if the success is anything like that of other professions who have utilized a KSTAR like program, the program will be successful in preventing recurring Board Orders for additional violations.  This program will be reportable and will be a disciplinary action.

Each program has specific requirements and restrictions, but these two proposed rules are something nurses should support.  In order to help ensure passage of these rules, read the rules and if you are in support, send a letter to James W. Johnston, General Counsel, Texas Board of Nursing, 333 Guadalupe, Suite 3-460, Austin, Texas 78701, or by e-mail to dusty.johnston@bon.texas.gov, or faxed to (512) 305-8101.  An additional copy of the comments on the proposal or any request for a public hearing must be simultaneously submitted to Melinda Hester, RN, Lead Nursing Consultant for Practice, Texas Board of Nursing, 333 Guadalupe, Suite 3-460, Austin, Texas 78701, or by e-mail to melinda.hester@bon.texas.gov, or faxed to (512) 305-8101. If a hearing is held, written and oral comments presented at the hearing will be considered.

A public hearing is where the public is allowed to voice their opinions regarding the rule in person before the Board; a hearing is not required for comments to be considered if submitted in writing, to the two staff members above as directed and submitted no later than 5:00 p.m. on June 23, 2014  for §213.32, the Corrective Action Proceeding proposed rule and no later than 5:00 p.m. on July 7, 2014 for  §213.35, the KSTAR proposed rule.

New design for Texas BON website

The Texas BON has a new website and I really like it.  They have made it more comprehensive and have information and documents present that were not easily available are now there for easy use.  A lot of work went in to the re-design of the site and it shows.  Good Job!

Texas Board of Nursing Agreed Orders-a Recent Problem

I am not sure why this year I have seen a huge increase is nurses contacting me soon after they have signed an Agreed Order with the Texas BON wanting the Order changed or removed.  Most of these nurses were not represented by an attorney, but there were also a few who were represented by an attorney who did not regularly represent nurses before the Board.  It is important to realize that an Agreed Order is a settlement agreement or contract between the Board and the nurse.  Like other agreements/contracts in life, the time to negotiate and question the Order is prior to signing.  It is very difficult to obtain a change in an Order and if that request occurs soon after signing, the likelihood of success is decreased immensely.

 Some of the nurses explained the reason they signed was the pressure the investigator was placing on them to sign.  Once again, an attorney can help with this by inserting themselves into the communication with the Board and freeing the nurse up to work and not having to stress over the Board.  A good lawyer will keep you informed of what is happening and also provides you with copies of all documents from and to the Board.  The attorney should also obtain approval for all agreements with the Board.

TPAPN Board Orders are now Confidential

As of September 1, 2013, TPAPN Board Orders are now confidential.  This is a vast improvement since the statute was changed a few sessions ago requiring the Board to be involved anytime there was a practice issue associated with a substance abuse/addiction issue.  This corrects situations where nurses had sensitive personal information available online for all to see.  Nurses who were referred to TPAPN by the Board and had a mental health  diagnosis or who had an evaluation detailing sensitive personal information had limited choices when they were referred to the Board.  It appears there will be further changes or polishing of the TPAPN process in the near future, so be sure to watch for information and remember it may be in your best interests to consult with an attorney who knows the Board and TPAPN.

To Clarify:  only new TPAPN Board Orders are confidential; the Board is not going back and changing previous Board TPAPN Orders from public to non-public orders.  Since the TPAPN orders are confidential they are not reported to the databank/NURSYS.

My blogs have moved to www.nursingattorney/b. I have not posted in a while because we were busy setting up the new blog site. I hope that putting the blogs on my website will help readers navigate the blogs and the articles. Let me know what you think.

Nurse of the Year???

This is from David Owens for the Hartford Courant on 8/6/09

" A Norwalk woman once recognized as "nurse of the year" was arrested today after an investigation found she's not really a nurse.

Betty A. Lichtenstein, who is also known as Betty A. Trudel, 56, of Norwalk, was arrested Thursday by inspectors from the Chief's State's Attorney's Medicaid fraud control unit on a single count of illegal use of the title "registered nurse," six counts of second-degree reckless endangerment and one count of criminal impersonation.

According to the warrant for Lichtenstein's arrest, the investigation began after a patient at the Norwalk doctor's office for which Lichtenstein worked complained she had acted unprofessionally.

An investigation then determined that Lichtenstein never had a license, yet had administered injections and given medical advice to the doctor's patients, according to the warrant.

The doctor and his employees' belief that Lichtenstein was a nurse was reinforced when in November 2008 she was honored as "2008 nurse of the year" by the Connecticut Nursing Association.

The investigation determined, however, that the Connecticut Nursing Association does not exist and that Lichtenstein used $2,000 of her own money to stage the dinner, according to the warrant.

"The doctor, his staff and a number of his patients received a letter with the letterhead of the "Connecticut Nursing Association," according to the warrant. "The letter stated there would be a special dinner to honor Betty Lichtenstein [and that she] was to received a $10,000 personal award and an additional $10,000 was to go to the charity of her choice."

On Nov. 30 the award dinner took place at the Norwalk Inn, and the doctor for whom Lichtenstein worked was a guest speaker, according to the warrant. Forty one dinners were served and the inn sent a bill for $3,211.11 to the Connecticut Nursing Association in care of Lichtenstein's employer's office. She then wrote a check for $2,168.02, according to the warrant.

Lichtenstein was arrested by Norwalk police in May in an unrelated charge of trying to illegally obtaining prescription drugs and forgery. According to the warrant, she tried to obtain 96 Oxycodone pills with a forged prescription. She used a prescription slip from her employer. That case is pending in Superior Court in Norwalk.

The illegal use of the title "registered nurse" charge is a felony that is punishable by up to five years in prison.

She was released from custody without having to post bail and is due in court Aug. 26 in Norwalk.

Copyright © 2009, The Hartford Courant"

It is amazing the amount of energy and money spent by this woman to fake being a nurse. Just bizarre.

Pondering

In the 60s, people took acid to make the world weird. Now the world is weird and people take Prozac to make it normal.


Hmm, think about it. Too true. Reuters reports that antidepressant use has doubled in the US.

Pandemic Information

I found a great blog with a lot of information about preparing for a pandemic: Pandemic Information News

On the right hand side is a list of links for preparation and even some of those links have more and more information. I continue to urge health care providers to get prepared now for any emergency or disaster since they are front line responders. We continue to hear about the flu gaining ground and that we are about to enter the prime time for flu, so preparation needs to happen now. Take the time to consider what you would do if a major outbreak occurred and make sure that you have all the items you need now.

Governor fires Nursing Board members

On July 14, 20009, the Los Angeles Times reported that "Gov. Arnold Schwarzenegger replaced most members of the state Board of Registered Nursing on Monday, citing the unacceptable time it takes to discipline nurses accused of egregious misconduct.

He fired three of six sitting board members -- including President Susanne Phillips -- in two-paragraph letters curtly thanking them for their service. Another member resigned Sunday. Late Monday, the governor's administration released a list of replacements.

The shake-up came a day after The Times and the nonprofit news organization ProPublica published an investigation finding that it takes the board, which oversees 350,000 licensees, an average of three years and five months to investigate and close complaints against nurses..."


We will have to watch for what the fallout/impact/repercussions will be at other nursing boards. I hope the other states do not overreact to the problems in California because there must be balance for regulation to be effective.

Camp Nurses

Sorry there have not been many postings, but summer is here and my husband (and I of course) volunteers to run the local Cub Scout camp. It takes up quite a bit of time which is why my blogging is scare this time of the year. Every year we are so grateful for all of the volunteers that take time off from work to sweat in over 100 degree weather and spend time with the kids. We are always grateful for the nurses that volunteer their time to staff the first aid office. This year kept them quite busy with several kids having heat exhaustion. It brings peace of mind to have trained and knowledgeable nurses available on site. So, to all of you nurses (and others as well) that take time to volunteer your time for Scouts, rescue groups, community services, etc. THANK YOU!!!

Tylenol and Soma

Just a little info in case you missed it: The FDA is proposing restrictions on acetaminophen (Tylenol) because it is the leading cause of liver failure in the US. Soma has also been made a scheduled medication instead of a dangerous drug.

BON License Applications

As new graduates are completing their applications for licensure, it is time to remind all applicants (and those nurses renewing as well) to be honest with the Board. I have found repeatedly that the Board's reaction is better when the nurse does not try to hide an incident.

Also, be very careful when answering the questions asked. If you are not sure if you should answer yes or no, please take the time to get competent advice. I have seen nurses end up with disciplinary actions because they answered no based on the advice of an instructor, an administrator and an inexperienced attorney. The deception to the Board was unintentional but it is still deception in the eyes of the Board and a disciplinary action is warranted--not how a new nurse wants to start their nursing career.

If your license application is still in the future and you have a criminal conviction (deferred adjudication etc.), it could be helpful to check with a criminal attorney to see if the criminal action could be expunged or sealed. Since the Board does not require a nurse to disclose an expunged or sealed incident, a nurse might be able to avoid a disciplinary action. Worth looking into.