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]

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.