Chapter 16
Delegation
• Delegation involves the transfer of responsibility for performance, tasks, and skills
without the transfer of accountability for the ultimate outcome.
• Involves a delegator and a delegatee
• Typically delegation involves tasks and procedures assigned to various unlicensed
assistive personnel.
▪ Term used loosely
What are benefits of “delegation?”
Advantages of Delegation
• Balanced workload
• Increased communications
• Opportunity for individuals to develop trust and respect
• Team environment and greater productivity
Delegation vs. Assignment
• Assignment is the downward or lateral transfer of both the responsibility and
accountability for an activity from one individual to another, often occurring between
licensed personnel.
▪ *Give me an example of each...
• Delegation is complex because it involves relationships, communications, and entrusting
others.
Supervision
• Supervision is the active process of directing, guiding, and influencing the outcome of an
individual's performance of an activity.
• Can be direct or indirect supervision
• Nursing involves supervision of a variety of personnel, including staff who directly
provide nursing care to patients.
Liability
• The delegator remains personally liable for the reasonable exercise of delegation and
supervision activities.
• Team leaders/nurse–managers are not liable merely because they have a supervisory
function.
▪ Everyone is liable for their actions/inactions
• The doctrine of "knew or should have known" becomes the legal standard.
Means of Ensuring Continued Competence
• Continuing education programs
• Assigning the staff member to work with a second staff member to improve technical
skills
• Requiring additional courses at institutions of higher education
Effective Discipline
• A vital part of supervision and delegation
•
To achieve high standards of nursing care, a formal discipline plan needs to be used
when performance fails to meet preset standards.
Principles of Effective Delegation
• Delegate tasks based on the individual needs of the patient, the complexity of the task,
the predictability of the outcome, and the abilities of the staff person to whom the
task is assigned or delegated.
Name some tasks that you would not “delegate.”
Principles of Effective Delegation
• Only tasks or procedures should be delegated, not the entire nursing process.
• The RN who delegates retains individual liability for such delegation.
• Delegation is not a list of tasks but a responsibility that requires critical thinking and
professional judgment
Five Rights of Delegation
• Right task
• Right circumstances
• Right person
• Right directions and communication
• Right supervision and evaluation
Unlicensed Assistive Personnel
• Individuals not authorized under respective nurse practice acts to provide direct
patient care
• Cost-effective measure
Legal Issues and UAPs
• UAPs work under the auspices and license of the institution, not the license of the
delegator.
• An organization must ensure that there is sufficient staffing so that professional staff
members may appropriately delegate patient care tasks.
▪ **issues with insufficient staffing?
• Competencies for all direct patient care staff members should be documented and
accessible to professional staff.
• There should be an institutional mechanism for orientation and training of UAPs.
• A lawsuit filed for malpractice/negligence against the health care providers will address
responsible delegation and supervision of UAPs.
Supervising UAPs
• Supervision is one of the keys to ensuring that delegation results in positive and
competent patient care.
• Supervision involves a thorough understanding of the skill sets and contributions of
UAPs and an appreciation of the division of effort.
Effective Supervision Strategies
• Know the UAP's role expectations, competencies, strengths, and weaknesses.
• Allocate sufficient time for supervision, making rounds, and evaluating care delivery.
• Develop and maintain clear channels of communication.
Effective Supervision Strategies
• Adhere to patient care and work performance standards.
•
Give timely feedback
▪ Make time for sharing information with UAPs.
Delegation Considerations
• Professional nurses must delegate tasks to UAPs that are within a delegable scope and
do not require licensure.
• Performed actions need to be checked to ensure they were performed correctly.
Factors to Consider When Using UAPs
• Nursing management should consider these factors:
▪ The type of UAP support being planned
• Will it be primarily supportive or patient care delivery?
▪ Previous experience and credentials
▪ Assignment of responsibility for supervising the UAPs, and that supervisors
understand the role and limitations of UAPs
▪ Type of staff mix that will be used in the institution
▪ Inclusion of professional and nonprofessional staff in work design efforts
▪ Specific tasks or responsibilities to be delegated
▪ Effective communication of changes across the institution
▪ The institution's policies, procedures, job descriptions, and performance
evaluations, and their match with these revised roles and expectations
▪ The types of communication to be available for staff to make their concerns
known
▪ The type of evaluations to be done to assess the effectiveness of UAPs
Patient Advocacy
• The U.S. jurisprudence system has continually enacted the role of nurses as patient
advocates through court decisions, thus creating the legal duty of nurses to serve in this
role.
• A nurse has a legal duty to advocate for the patient only when the patient's working
diagnosis itself indicates that inappropriate action is being taken or appropriate
measures are being ignored.
• It is incorrect to say that a nurse's duty to advocate can be used to open the deeper
pockets of the hospital any time a physician does not timely diagnose a patient.
▪ Advocacy with good intent for pt care and dx, not to increase diagnostic testing,
resource use, and increase pt spending
• Nurses do, however, have a duty to adequately assess the patient so that they can
correctly advocate for the patient.
Ethical Issues
• Delegating versus "dumping" tasks
• Fair selection process
• Ethics of balancing concerns of patients and care providers
• Daily examination of delegation and supervision
• Patient advocacy requires moral courage
• Chapter 17
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Acute Care Nursing
Requires knowledge of complex illnesses and use of highly sophisticated machinery
Acute care has changed dramatically in the last 30 years.
Today it is more difficult to differentiate between the practice of medicine and the
practice of nursing.
Patient Safety
Patient safety remains a nurse's most important responsibility.
Responsibility for patient safety includes protecting patients from injuring themselves or
others, medication errors, faulty equipment, unsafe conditions, and falls.
Hostile Patients
There are increased numbers of hostile patients.
Such patients present a safety hazard and increase the potential of liability for nurses.
Interventions that can assist with diffusing anger and hostility are:
 Spend additional time with patients, conveying that they are important
 Attempt to understand their anger
 Speak calmly and rationally
 Respect patients' autonomy
Interventions that can assist with diffusing anger and hostility are:
 Address underlying issues
 Ensure that patients are educated about their condition and treatments
 Practice patience
Workplace Violence
The institution should have a policy of zero tolerance for violence in the workplace.
Know the institution's policy on dealing with violent patients, and defuse the situation
according to the policy.
Document the patients' complaints or noncompliance and interventions taken to
resolve the situation.
In the event of a serious violent episode:
 Ensure a safe atmosphere
• Position oneself at least four arm lengths' away and to the side of patient
 Keep hands in sight and maintain eye contact
 Avoid touching, pointing, challenging, or interrupting the patient
In the event of a serious violent episode:
 Speak calmly, softly, rationally
 Address patient by name
 Request permission to ask questions and listen intently
 Acknowledge the patient's feeling
Psychiatric and Vulnerable Patients
Nurses in acute care settings must know how to recognize patients with psychiatric or
emotional disturbances and how to address them.
Psychiatric and vulnerable patients present unique challenges and legal risks.
Signs of Suicide
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Patients may respond to hospitalization with depression and suicidal thoughts.
Nearly all suicidal patients give some clues before self-destructive behavior is evident.
A major goal published in the 2012 National Patient Safety Goals is to determine which
patients are most at risk to attempt suicide as the patient is first admitted to an acute
care setting.
Nurses have an obligation related to suicide prevention.
Nurses should understand which patients are more likely to become self-destructive.
The majority of those who commit suicide have a diagnosable mental disorder.
Older patients are more likely to commit suicide than younger patients.
Women make more attempts but men more often succeed.
Most patients who attempt suicide have a history of doing so.
Physical Illness Most Often Associated with Suicide
Central nervous system disorders
Chronic pain
Autoimmune disorders
Cancer
Renal failure patients on dialysis
Peptic ulcers
Duty of Care and Suicide Prevention
Once a patient voices an actual plan for suicide, caregivers have immediate legal
responsibility to seek admission of the patient for inpatient psychiatric care.
Involuntary commitment in most states is a 72-hour hold.
If a patient is a suicide risk there are many nursing interventions that should be applied.
The failure to warn of a patient's dangerous propensities when the victim is identifiable
is a liability-producing situation in courts of law.
Failure to Protect
Occurs in instances when patients, because of their vulnerable state and their inability
to distinguish potentially harmful situations, must be protected by health care providers
False Imprisonment/Wrongful Commitment
Psychiatric patients may voluntarily admit themselves for treatment, or if a person is
unable to judge what is best, the state may voluntarily hospitalize the patient.
Case law abounds on the issue of detainment and determination of patient competency.
Level of Care Required
Courts of law determine the care required for psychiatric patients.
Confidentiality right of mentally ill patients is meant to protect and thereby encourage
people who need help to access such help.
Restraints
Restraints, both physical and chemical, are used daily in many settings.
Restraints are not without serious side effects and harm
 Physical restraints can cause skin impairment and more.
 Chemical restraints may increase drowsiness and more.
Polices and Procedures for Using Restraints
All hospitals have policies and procedures outlining when and how restraints are to be
used.
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Use of physical restraints should be based on the patient's current condition, not
history.
Attempt alternative, less restrictive approaches first.
Guidelines for the Use of Restraints
Set forth by the Joint Commission
Use least restrictive device to restrict the patient
Document frequent assessments of the patient
Obtain an order for the restraints
The order must include the date/time restraints were ordered, type of restraint,
purpose, and specific short-term time limits.
Psychiatric patients may not be restrained for more than 4 hours for adults, 2 hours for
adolescents, and 1 hour for a child under the age of 9.
The order for restraints cannot be renewed without reassessment.
Documenting Restraints
Follow hospital policy and procedure regarding restraints and document adequately.
What constitutes a restraint for one patient may be used for another purpose in other
patients.
Medication Errors
The most common source of liability for nurses in all practice settings
These errors account for the most common cause of mortality and morbidity in hospital
patients.
The "six rights" of medication administrations are: right patient, right medication, right
dose, right route, right time, and right documentation.
Patient Falls
Patient falls are second to medication errors among untoward events that may happen
to patients.
They are the most common type of case filed against health care workers.
Liability will be assessed against the nursing staff if nurse is found to have used poor
judgment in preventing a patient's fall.
Steps Following a Patient Fall
When a patient falls:
 The first duty of care is to the patient
 Fully assess patient
 Notify the patient's physician and management personnel
 Document patient's condition, treatment or tests, and who was notified and
when
Liability and Technology
Nurses must know the capabilities as well as the limitations, hazards, and safety
features.
Equipment injuries occur primarily because of carelessness or misuse of equipment.
Proper Use of Equipment
Nurses need to:
 Conform use of equipment with manufacturers' recommendations and hospital
policy and protocols
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 Inspect equipment for any defects
 Report faulty equipment
 Assess equipment's appropriateness
Safe Medical Devices Act of 1990
All adverse incidents with medical devices need to be reported to manufacturers—and
in cases of death, to the Food and Drug Administration—within 10 working days.
Failure to Assess, Monitor, and Communicate
A nurse's most important duty is communication—verbal and written—to patients,
physicians, other staff, and members of interdisciplinary health team.
Failure to adequately assess, monitor, and communicate can occur in all aspects of
nursing and in all hospital units.
Communicating Across Culture
English is not the primary language for approximately 60 million U.S. residents over the
age of 5.
Nurses must ensure good communication with non–English speakers by using an
interpreter and ensuring that information shared is understood.
It is advisable to use hospital-provided interpreters whenever possible; when family
members or friends interpret, issues concerning sensitivity and completeness of
information may be compromised.
Failure to Act as Patient Advocate
Nurses owe a higher duty to patients than merely following physician's orders.
The role of nurses as patient advocate is to develop and implement nursing diagnoses,
exercise good patient judgment, and monitor the care given to patients by physicians as
well as peers.
Patient Education
Early discharge and the importance of communication:
 Until the nurse is satisfied that the patient teaching has been understood and
the patient can perform the task, the nurse has not met the standard for patient
teaching
Patient Education
Early discharge and the importance of communication:
 Nurses have a duty to protect patients, to question orders that are inappropriate
or likely to cause harm to the patient
Ethical Issues in Acute Care Settings
Right of the person to be free from restraint and allowed his freedom
Respecting patients who present because of possible suicide or because of self-harm
Differences of opinion among health care providers regarding the most appropriate
course of treatment and care for patients
Ethical Issues in Acute Care Settings
Conflict between the nurse's value systems and those of the organization
Medication errors and the nonreporting of such errors
Patients believe that the care provided is the most competent and complete care
available.
Chapter 18
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Ambulatory Care Nursing
Ambulatory care nursing is delivered in practice settings outside the traditional acute
care/long-term care settings.
It is evolving into a specialty that emphasizes health promotion, disease prevention, and
nursing care with extensive patient and family involvement.
The growth of ambulatory nursing is a result of onset of managed care and increased
need for outpatient care services.
As more patients are cared for in ambulatory settings, the need for professional nurses
skilled in this practice arena expands.
Professional ambulatory care nursing is clinical, management, educational, and research
activities provided by registered nurses for individuals who seek care for health-related
problems or seek assistance with health maintenance and/or health promotion.
American Academy of Ambulatory Care Nursing
The AAACN mission is to advance and influence the art and science of ambulatory care
nursing through excellence in health care delivery, collaborative leadership,
partnerships and alliances among providers and other health care organizations,
proactive innovation and risk taking, customer-focused services, and continued
advancement of the profession.
Patient Education
Patient education takes on additional importance in the ambulatory and managed care
nursing roles.
Included in this is the issue of discharge planning.
To be effective communicators, nurses must be effective educators and remain current
in their medical knowledge.
Telehealth
Telehealth is the use of telecommunications technologies for the provision of longdistance clinical health care, patient and professional education, and health
administration.
Telehealth can be found in every area of health care and permits care when face-to-face
meeting is not possible.
Telenursing and Telemedicine
Telenursing refers to the use of telecommunications and information technology for
providing nursing services in health care whenever a large physical distance exists
between the patient and the nurse.
Telemedicine, another subset of telehealth, allows medical clinicians to provide care via
telecommunications.
Methods of Telehealth
Telepresence combines robotics and virtual reality to allow a surgeon equipped with
special equipment to manipulate surgical instruments at remote sites.
Video conferencing transmits sounds and images between two or more sites, allowing
interactions with a patient at a remote site.
Renewed Interest in Telehealth
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There is renewed interest in telehealth due to:
 Improved quality of computers and telecommunications technology
 inadequate access to health care, quality management, escalating costs
Telehealth Innovations
Some innovative uses of telehealth include:
 Real-time vital signs and data and video images of patients transmitted during
ambulance travel
 Educational and emotional support programs for families with high-risk
newborns through a hospital monitoring system
Some innovative uses of telehealth include:
 Systems for monitoring child abuse
Legal Issues of Telehealth
Security and confidentiality issues present legal issues with telehealth and telenursing.
The issue of confidentiality involves the Health Insurance Portability and Accountability
Act of 1996 (HIPAA).
Licensure, either within a single state or with a single license, allows nurses to be
licensed in one jurisdiction and practice in several jurisdictions.
Telehealth Standards
Basic concepts in the practice standards are quality, scope of practice issues, patient
safety issues, documentation, and the need for further research in this area of nursing
practice.
Case law in this area has centered on consultation and information given by nurses to
patients who telephone for health care advice.
Violence
Nurses frequently care for victims, perpetrators, and witnesses of physical and
psychological violence.
Nurses are at risk for experiencing violence in the workplace.
Verbal abuse or workplace bullying is defined as the deliberate, repeated, hurtful
mistreatment of a person by a cruel perpetrator.
Domestic Violence
Domestic violence is a major public health threat.
Consequences include immediate physical, emotional, and psychological injury, and
lifelong impacts such as depression, post-traumatic stress disorder, alcohol/drug abuse,
and suicide.
Addressing Domestic Violence
To meet the legal and ethical issues involved in domestic violence, nurses must be
aware of state and national mandates regarding domestic violence, including reporting
laws.
Nurses in ambulatory care are becoming better informed about dealing with abuse.
Volunteer Services
Many health care providers routinely provide volunteer services as part of community
service.
When volunteering, keep in mind:
 The legal statutes
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 Responsibilities and professional actions
 Donated services do not exempt the nurse from a possible lawsuit.
Many health care providers routinely provide volunteer services as part of community
service.
When volunteering, keep in mind:
 Disciplinary action may occur should the care delivered fall below minimum
standards.
When volunteering, keep in mind:
 The nurse–patient relationship is initiated when care is first given to the patient.
To protect oneself legally, nurses should:
 Never administer any treatment or medication without first obtaining a doctor's
order.
 Reread carefully their professional liability insurance policy.
 Maintain accurate records.
To protect oneself legally, nurses should:
 Know the state's Good Samaritan laws.
 Know the provisions of the nurse practice act.
Donating Health-Related Advice
There is no duty to donate health-related advice, but once given, the advice must be
competent and safe.
It is always acceptable to suggest that the person seeking advice consult with his own
physician.
Managed Health Care Organizations (MCOs)
Managed care is a health care system that integrates the financing and delivery of
health care services to covered individuals, most often by arrangements with selected
providers.
It is generally prepaid
Managed care organizations (MCOs) offer:
 A package of health care benefits
 Standards for the selection of health care providers
 Formal programs for ongoing quality assurance and utilization review
Managed care organizations (MCOs) offer:
 Financial incentives for members to use providers/procedures associated with
the given plan
Health Maintenance Organizations
Health maintenance organizations (HMOs) are comprehensive health care financing and
delivery organizations that provide or arrange for provision of covered health care
services to a specified group of enrollees at a fixed periodic payment through a panel of
providers.
They are the most highly regulated of the managed care options.
Preferred Provider Organization
Preferred provider organization (PPO) has the most current growth and involves
contracts with independent providers and negotiated, discounted fees for services to
members.
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A majority of states have some regulation.
Point-of-Service
Point-of-service (POS) provides a set of health care benefits and offers a range of health
services.
Subscribers usually pay substantially higher premiums, increased deductibles, and
coinsurance if enrolled with a selected provider.
Little state regulation and infrequently accredited
Indemnity Plans
Indemnity plans allow patients to access their provider of choice and the provider files a
claim to the insurance company for reimbursement to the provider for service.
Managed only by the individual patients
Regulation is high; generally not accredited
Utilization Review
Utilization review is the process whereby a third-party payer evaluates the medical
necessity of a course of treatment.
Health Care Quality Improvement Act of 1986
The Health Care Quality Improvement Act of 1986 (HCQIA) provides persons giving
information to professional review bodies, and those assisting in review activities,
limited immunity from damage as a result of adverse decisions affecting staff privileges.
Quality review committees evaluate patient care and patient outcomes within the new
framework of managed care.
Quality Assessment and Performance Improvement Program
The Centers for Medicare and Medicaid Services require that hospitals develop and
maintain a quality assessment and performance improvement program that meets the
centers' guidelines.
Began in 2003
Ethics in Patient Referral Act of 1989
The Ethics in Patient Referral Act prohibits physicians who have ownership interest or
compensation arrangements with a clinical laboratory from referring Medicare patients
to that laboratory.
National Committee for Quality Assurance
The National Committee for Quality Assurance (NCQA) is an independent, nonprofit
health maintenance organization–accrediting agency focusing on quality improvement,
credentialing, members' rights and responsibilities, utilization management, preventive
health services, and medical records.
Emergency Medical Treatment and Labor Act of 1986
EMTALA established a right of access to medical care regardless of one' s ability to pay
for that care.
EMTALA
The law applies to every health care institution that has a Medicare provider agreement
in effect and has a list of requirements, including:
 Medical screening required when requested in Emergency Department
• Emergency medical condition
 Stabilize patient before transferring
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 Appropriate transfer
EMTALA: New Regulations
Emergency patient is any person that a reasonable prudent layperson would interpret as
having an emergency medical condition.
2008—two EMTALA amendments further ensure patient care:
 A community call plan
 "Good faith" requirement
EMTALA Court Rulings
With regard to EMTALA, the courts have made many findings, including but not limited
to:
 A hospital may adhere to its patient registration policies as long as they do not
conflict with the goals of EMTALA
 Patient screening is appropriate
With regard to EMTALA, the courts have made many findings, including but not limited
to:
 They do not second-guess the professional judgment of nurses and doctors who
screen and treat patients
EMTALA
Patients, regardless of whether they have insurance or the ability to pay privately for
care, have the right to sue for an EMTALA violation.
A nurse's assessment may trigger the hospital's duty to provide stabilizing care.
Antitrust Issues
Health care delivery systems are becoming dominated by large, for-profit centers.
Mergers and acquisitions lead to questions about antitrust and monopolies in health
care.
Antitrust laws contain specific restrictions for exclusive contracts, resisting utilization
reviews, and collusion.
They monitor the anticompetitive services of large corporations and regulate the
practice of health care providers.
Health Care Reform
Health care reform is anchored by:
 Enhanced coordination of clinical services for all eligible enrollees
 Reduced medical costs and wastes
 Improved quality of care
Antitrust Laws
U.S. antitrust laws are intended to promote competition while creating efficient
markets.
Example case
 Merger of Hospital Corporation of America (HCA) with Hospital Affiliates
International (HAI) and Health Care Corporation (HCC)
Collusion
Some likely forms of collusion that result from mergers involve:
 Collective resistance to emerging cost-containment pressures from third-party
payers
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Conspiracies to boycott certain insurance companies that offer competitive
prices
Some likely forms of collusion that result from mergers involve:
 Refusal to undergo utilization review programs or provide information needed
by third-party payers
Antitrust Laws
Antitrust laws and mergers in managed health care force nurses to become more
valuable in the health care delivery system by taking measures to prevent the
devaluation and compromise of the nursing profession.
The inclusion of antitrust laws has strengthened the use of mid-level practitioners in a
variety of clinical settings.
Managed Care and Patient Rights
Patient rights became an issue with managed care's increased measures of cost
containment.
Many fear that individuals have no true rights in managed care settings.
Advisory Commission on Consumer Protection and Quality in the Health Care Industry
Created in 1997 to report on changes in the health care system
Consumer Rights
The commission adopted eight areas of consumer rights that are enforced primarily
through EMTALA and HIPAA:
 Information disclosure
 Choice of providers and plans
 Access to emergency services
 Participation in treatment decisions
The commission adopted eight areas of consumer rights that are enforced primarily
through EMTALA and HIPAA:
 Respect and nondiscrimination
 Confidentiality of health information
 Complaints and appeals
 Consumer responsibilities
Health Care Financing Administration (HCFA)
1999
 the Health Care Financing Administration (HCFA) enacted standards for hospitals
that participate in Medicare and Medicaid funding to ensure minimum
protection of patients' rights:
• Notification of rights
• Exercise of rights in regard to care
1999
 The Health Care Financing Administration (HCFA) enacted standards for hospitals
that participate in Medicare and Medicaid funding to ensure minimum
protection of patients' rights:
• Privacy and safety rights
• Confidentiality of records
1999
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The Health Care Financing Administration (HCFA) enacted standards for hospitals
that participate in Medicare and Medicaid funding to ensure minimum
protection of patients' rights:
• Freedom from restraints that are not clinically necessary
1999
 The Health Care Financing Administration (HCFA) enacted standards for hospitals
that participate in Medicare and Medicaid funding to ensure minimum
protection of patients' rights:
• Freedom from seclusion and restraints used in behavior management
unless clinically necessary
Patient Rights
Patients frequently cannot select their own practitioner, and have no means of
questioning the status of the person providing care; rates of complications of
practitioners are not available, and preapproval must be obtained for most treatments.
Congress continues to work on legislation that fully addresses patients' rights to
information about health care providers, etc.
Ethical Concerns in Ambulatory and Managed Health Care
Concerns of telenursing
 Inability to fully assess patient, need for certification of additional credentialing
Concerns of managed care models
 Cost-cutting measures interfering with beneficence
Concerns of violence
 Dilemmas when requested not to report violence, caring for perpetrators of
violence; concerns of violence despite patient denial of it
Chapter 20
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Ethical and Legal issues in Nursing
Nursing in Long Term Care Settings,
CHAPT 20.
Preview
NURSING HOMES
Also known as residential Living Centers
 Residential Living Care Facilities/
Nursing Home
 NURSING CARE SERVICES OFFERED
 Mostly activities of Daily Living BATHING, DRESSING,
 TOILETTING,
 FEEDING,
 SKIN CARE/ FREQUENT REPOSITIONING/ FULL RANGE OF MOTION EXERCISES,
 AMBULATION
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 DRESSING CHANGE
 MEDICATION,
MEDICAL CONDITIONS COMMONLY TREATED
 TOP !0 most common conditions :
 HYPERTENSION,
 DEMENTIA,
 HEART DISEASE
 DEPRESSION
 ARTHRITIS
 OSTEOPOROSIS
 DIABETES MELLITUS
 CHRONIC LUNG DISEASE
 CANCERS
 STROKE
EMPLOYEES IN NURSING HOMES
 ADMINISTRATORS
 SOCIAL WORKERS
 REGISTERED NURSES
 LICENCED PRACTICAL NURSES [ LPN}
 PATIENT CARE ATTENDANTS { PCA}
 PHYSICIANS
 DIETITIANS
 RESPIRATORY THERASPISTS
 DENTISTS
ASSISTED LIVING CENTERS
 Long Term services- Alternative for Seniors Who need more assistance that is
available in a retirement home.
 Do not need intense Nursing and medical care provided in a nursing home,
 The residents live in congregate residential setting. Approx. 900,000 live in
assisted living
 Personal services and supervision provided 24 hours a day
 Planned activities- accommodate preference, autonom, dignity, independent
housing and safety.
 Family and community involvement encouraged
 Elderly 86 + , mostly Widowed .Mobile but require assistance with at least 2
activities eg shopping, preparing meals, use of telephone.
EMPLOYEES
 Registered Nurses
 CAN- Certified Nursing Assistant
 Personal Care attendant
 Health ? Wellness Direct
 Activity Director
 Administrative staff
 Dieticians
 Physical Therapists
 HOSPICE NURSING CENTERS
 Concept of Offering shelter and rest for a weary traveller.
 1967- Concept expanded to include specialized care to terminaly ill patients.
 Offering Comfort care to individuals who are within the last 6 months of life.
 Care may be provided in home settings,, specialized care units or free standing
hospice centers
 Over 3000 Medicare Certified Hosp
 Average stay 52-69 daysice Centers- independent, Hospital based, home health
agency based,
 Mostly Cancer and heart disease patients.
 ELDER DAY CARE CENTERS
 1970 – Initial idea was in place and by 1978 300 centers.
 Today Adult care Centers exceed 4.600 serving approximately 260,000 adults.
There are 3 Types of Adult Day care services;
 ADULT DAY SOCIAL CARE- Social activities, meals, recreation and limited health
related services
 ADULT DAY HEALTH CARE – Offers more intense health, therapeutic and social
service
 ALZHEIMERS- provides Social and health services only.
 BENEFITS OF DAY CARE
 FUNCTIONAL ASSISTANCE- Activities of Daily Living
 SAFE and SECURE ENVIRONMENT
 SOCIALIZATION
 PEER SUPPORT
 IMPROVEMENT IN MENTAL and PHYSICAL HEALTH
 ENHANCED INDEPENDENCE
 NURSING HOME REFORM ACT 1987
 Provides for Residents of Nursing Homes to Receive :
 QUALTY CARE – to Assist in Achieving and Maintaining BEST PRACTICES:
> HIGHEST LEVEL of PHYSICAL, MENTAL, PSYCHOSOCIAL wellbeing
>ESTABLISHED MINIMUM STANDARDS OF CARE, RIGHTS FOR INDIVIDUALS
/CLIENTS.
> ALLOWS FOR UNANOUNCED INSPECTION by SURVEYORS
> COMPLETE CARE PLANS
> SOCIAL SERVICES – Social worker on site.
>REHABILITATION
> PHARMACEUTICAL CARE
> DIETARY SERVICES.
 GOALS OF THE REFORM ACT
 PREVENT ABUSE, MISTREATMENT, NEGLECT and PHYSICAL RESTRAINTS
 ASSURE That RESIDENTS HAVE A RIGHT to :
> PRIVACY, DIGNITY,
> SELF DETERMINATION and
> ARE ABLE TO COMMUNICATE FREELY
 LAWSUITS FILED UNDER THE REFORM ACT
 PAGE 420 :
 Clear Lake Nursing Home vs U.S. Department of Health and Human ServicesMEDICATION – Failure to provide appropriate Pharmaceutical Services.
1. 69year old resident suffered from seizure disorder, dementia, agitation and
depression. He was highly agitated at breakfast. BP 190/120. Physician ordered
Valium for the patient. The remainder of the day was uneventful with the patient
sleeping most of the day, not unusual for a patient who had Valium.
At 8.45 pm the nurses found the patient unresponsive. He was taken to the hospital by
Ambulance, where he dies several hours late. On Autopsy it was determined he had been in
hyperosmolar coma with cerebral edema that led to a fatal brainstem herniation.. The
nursing home staff were faulted for not trying to wake the patient regularly and take his
vital signs for almost 11 hours after he received the Valium, a violation of 3 separate federal
regulations.
DISCUSS Ethical and Legal Implications
 Lawsuit filed Under the Provisions.
 PAGE 421:
 MEDICATION PRACTICE
A resident who needed to use an airway mask at night for sleep apnea. For more than 5
years he had to awaken and be give Cafergot for headaches he frequently had. The night
nurse woke him up, but gave him Darvocet instead of Cafergot. In report the night nurse
told the day nurse that they needed to order some more Cafergot. The day nurse finally
reordered the medication, which was delivered to the unit at 4.30pm. By the time the
patient received his daily dose of Cafergot, it was after 5pm, and the patients’ headache
had become so severe that he required both Ultram and Darvocet.
According to the court ,Darvocet is not a substitute for Cafergot. It is substandard Nursing
practice to substitute a nonequivalent medication for an ordered medication. In this
instance there was a courier service on call for the nurses to obtain urgently needed
medications, but the nurse did not use the service. That was a violation of Federal
Regulations requiring nursing facilities to provide Pharmaceutical services sufficient to
meet the residents needs.
Discuss the Ethical and Legal Implications of this case.
Chapter 19
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o OVERVIEW OF PUBLIC AND COMMUNITY HEALTH NURSING
o Purpose is to focus, PROMOTE and MAINTAIN the health of populations, families
and individuals in Non acute care settings.,
TITLES – PUBLIC and COMMUNITY HEALTH NURSE
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PUBLIC HEALTH NURSING has emerged as the preferred title for nurses who work with
the entire public population to improve its health.
o LEGAL SANCTIONS- Actions taken to promote amd Maintain the health of the
public have a basis in LAW.
FEDERAL STATUTES
Examples of Legislation :
o Social Security ACT of 1935- by President Franklin Roosevelt - for Health and
welfare of communities- provisions for
o .Aging population
o .Blind persons
.Dependent and crippled children
. Maternal and child welfare
. Public Health and administration of state unemployment compensation laws.
Modified and added benefits- MEDICARE and MEDICAID 1965
MEDICARE / MEDICAID
The ACTS SPECIFY the nursing services to which clients and for how long
The ACT has been amended several times to include:
>Addiction to alcohol detoxification 1980
 Hospice reimbursement 1983
 Medicare part B premiums to be paid to eligible beneficiaries –1990.
PUBLIC HEALTH SERVICE ACT 1944
Consolidated all existing public health legislation under one law for the country.–
Regulating
 Nursing training for graduate students in specialized studies.,
 research, family planning services
 Prevention and control of heart disease, Cancer, Kidney diseases,
o >Sudden infant death syndrome
 Sickle Cell anemia and Diabetes
 HIV /AIDS .Infectious Diseases
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>All administered by Federal and state agencies
LEGAL RESPONISBILITIES
Public health Nurses working in different settings
Legal Responsibilities are slightly different depending on the facility /setting.
Liability closely related to liabilities in acute care settings.
Patients and family expect full health care services that are defined according to the
scope of practice.
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Safety, Autonomy, Privacy of health information, Consent and other ethical principles
apply in the care of clients in Public health as in acute care.
Assessment, Planning, Implementation, Evaluation and Documentation and verbal
handoff as needed - accomplished with excellence.
Patient and family Eduaction.
PATIENTS BILL OF RIGHTS 1
See page 400 Table 19-1
Home health Care patients have the right to:
Be fully informed by the Home health agency of all rights and responsibilities
Choose Care providers
Receive professional and appropriate care in accordance with physician orders
Receive timely response from the agency to request for service
Be admitted for service only if the agency has the ability to provide safe , professional
care at the level of intensity needed.
Receive reasonable continuity of care
Receive information necessary to give informed consent prior to the start of any
treatment or procedure
Be advised of any change in the plan of care , before the change is made.
Refuse treatment within the confines of the law and be informed of the consequences
of that action. informed of rights under State law to formulate advance directives
Have HEALTH Care providers comply with health care directives in accordance with state
Law requirements
Be informed within reasonable time of anticipated termination of service or start for
transfer to another agency.
Be fully informed of agency policies and charges for service including eligibility for third
party reimbursements.
Be referred elsewhere if denied service soleye on inability to pay.
Voice grievances an suggest changes in service or staff without fear of restraint or
discrimination.
Receive a fair hearing for any individual to whom any service has been denied service,
reduced or terminated, or who is otherwise aggrieved by the agency action. The fair
hearing procedure shall be set forth by each agency as appropriate to the unique
patient situation (eg funding source, level of care , diagnosis).
Be informed of what to do in case of an emergency
Be informed of the telephone number and hours of operation of the states home health
hot line that received questions and complaints about Medicare –certifies and state
licensec home health care agencies.
References
Ginny Wacker Guido,
o Legal and ethical Issues in Nursing,6th ed., Washington State University,
o Vancouver, Washimngton, Paped 400, table 19-1, 2014.