3
Legal and Ethical Issues
1. Define the terms law and ethics and list examples of legal and
ethical behavior
Define the following terms:
ethics
the knowledge of right and wrong.
laws
rules set by the government to help people live peacefully
together and to ensure order and safety.
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Legal and Ethical Issues
1. Define the terms law and ethics and list examples of legal and
ethical behavior
What will each of these guidelines for legal and ethical behavior
mean for an NA on the job?
• Be honest at all times.
• Protect residents’ privacy.
• Keep staff information confidential.
• Report abuse or suspected abuse of residents, and assist
residents in reporting abuse if they wish to do so.
• Follow the care plan and your assignments.
• Do not perform any task outside your scope of practice.
• Report all resident observations and incidents to the nurse.
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Legal and Ethical Issues
1. Define the terms law and ethics and list examples of legal and
ethical behavior
Guidelines for legal and ethical behavior (cont’d):
• Document accurately and promptly.
• Follow rules on safety and infection prevention (outlined in
Chapters 5 and 6).
• Do not accept gifts or tips.
• Do not get personally or sexually involved with residents or
their family members or friends.
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Legal and Ethical Issues
1. Define the terms law and ethics and list examples of legal and
ethical behavior
REMEMBER:
Each NA has a responsibility to promote legal and ethical
behavior in the workplace. Know what to observe and how to
report any illegal activity.
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Legal and Ethical Issues
2. Explain the Omnibus Budget Reconciliation Act (OBRA)
Define the following terms:
Omnibus Budget Reconciliation Act (OBRA)
law passed by the federal government that includes minimum
standards for nursing assistant training, staffing
requirements, resident assessment instructions, and
information on rights for residents.
Minimum Data Set (MDS)
a detailed form with guidelines for assessing residents in
long-term care facilities; also details what to do if resident
problems are identified.
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Legal and Ethical Issues
2. Explain the Omnibus Budget Reconciliation Act (OBRA)
The Omnibus Budget Reconciliation Act (OBRA)
• Sets minimum standards for NA training (75 hours)
• Requires competency exam for NAs
• Requires regular in-service training for NAs (12 hours
annually)
• Establishes state registry of NAs
• Sets standards that instructors must meet to train NAs
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Legal and Ethical Issues
2. Explain the Omnibus Budget Reconciliation Act (OBRA)
OBRA (cont’d)
• Sets minimum staff requirements
• Defines minimum services that LTCFs must provide
• Establishes resident assessment requirements (MDS)
• Introduced changes in survey process
• Defines Residents’ Rights
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Legal and Ethical Issues
3. Explain Residents’ Rights and discuss why they are important
Define the following terms:
Residents’ Rights
numerous rights identified in the OBRA law that relate to how
residents must be treated while living in a facility; they
provide an ethical code of conduct for healthcare workers.
informed consent
the process in which a person, with the help of a doctor,
makes informed decisions about his or her health care.
3 Legal and Ethical Issues
Transparency 3-1: Residents’ Rights
Residents have a legal right to
• Quality of life
• Services and activities to maintain a high level of wellness
• Be fully informed regarding rights and services
• Participate in their own care
• Make independent choices
• Privacy and confidentiality
• Dignity, respect, and freedom
• Security of possessions
• Be informed of and consent to transfers and discharges
• Voice complaints
• Have visits
• Have access to social services
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Legal and Ethical Issues
3. Explain Residents’ Rights and discuss why they are important
Think about this question:
How can an NA promote Residents’ Rights as she does her job?
3 Legal and Ethical Issues
Handout 3-1: Decision Quiz
Choices I have made today include:
1.__________________________________________
2.__________________________________________
3.__________________________________________
4.__________________________________________
5.__________________________________________
6.__________________________________________
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Legal and Ethical Issues
3. Explain Residents’ Rights and discuss why they are important
REMEMBER:
The Americans with Disabilities Act (ADA) prohibits discrimination
because of a disability. Providers of health care, including LTCFs,
must provide equal opportunities, which may include making
some changes to their services.
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Legal and Ethical Issues
4. Discuss abuse and neglect and explain how to report abuse
and neglect
Define the following terms:
abuse
purposeful mistreatment that causes physical, mental, or
emotional pain or injury to someone.
neglect
the failure to provide needed care that results in physical,
mental, or emotional harm to a person.
physical abuse
any treatment, intentional or not, that causes harm to a
person’s body.
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Legal and Ethical Issues
4. Discuss abuse and neglect and explain how to report abuse
and neglect
Define the following terms:
psychological abuse
emotional harm caused by threatening, scaring, humiliating,
intimidating, isolating, or insulting a person, or treating him
as a child; also includes verbal abuse.
verbal abuse
the use of spoken or written words, pictures, or gestures that
threaten, embarrass, or insult a person.
sexual abuse
the forcing of a person to perform or participate in sexual acts
against his or her will; includes unwanted touching, exposing
oneself, and the sharing of pornographic material.
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Legal and Ethical Issues
4. Discuss abuse and neglect and explain how to report abuse
and neglect
Define the following terms:
financial abuse
the improper or illegal use of a person’s money, possessions,
property or other assets.
assault
a threat to harm a person, resulting in the person feeling
fearful that he or she will be harmed.
battery
the intentional touching of a person without his or her
consent.
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Legal and Ethical Issues
4. Discuss abuse and neglect and explain how to report abuse
and neglect
Define the following terms:
domestic violence
physical, sexual, or emotional abuse by spouses, intimate
partners, or family members.
workplace violence
verbal, physical, or sexual abuse of staff by other staff
members, residents, or visitors.
false imprisonment
the unlawful restraint of someone which affects the person’s
freedom of movement; includes both the threat of being
physically restrained and actually being physically restrained.
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Legal and Ethical Issues
4. Discuss abuse and neglect and explain how to report abuse
and neglect
Define the following terms:
involuntary seclusion
the separation of a person from others against the person’s
will.
sexual harrassment
any unwelcome sexual advance or behavior that creates an
intimidating, hostile, or offensive working environment.
substance abuse
the repeated use of legal or illegal drugs, cigarettes, or
alcohol in a way that is harmful to oneself or others.
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Legal and Ethical Issues
4. Discuss abuse and neglect and explain how to report abuse
and neglect
Define the following terms:
active neglect
the purposeful failure to provide needed care, resulting in
harm to a person.
passive neglect
the unintentional failure to provide needed care, resulting in
physical, mental, or emotional harm to a person.
negligence
actions, or the failure to act or provide the proper care, that
result in unintended injury to a person.
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Legal and Ethical Issues
4. Discuss abuse and neglect and explain how to report abuse
and neglect
Define the following terms:
malpractice
injury to a person due to professional misconduct through
negligence, carelessness, or lack of skill.
mandated reporters
people who are legally required to report suspected or
observed abuse or neglect because they have regular contact
with vulnerable populations, such as the elderly in care
facilities.
3 Legal and Ethical Issues
Transparency 3-2: Suspicious Injuries
The following injuries are considered suspicious and should be
reported:
• Poisoning or traumatic injury
• Teeth marks
• Belt buckle or strap marks
• Bruises, contusions, or welts
• Scars
• Fractures, dislocation
• Burns of unusual shape and in unusual locations, cigarette
burns
• Scalding burns
• Scratches and puncture wounds
• Scalp tenderness and patches of missing hair
• Swelling in the face, broken teeth, nasal discharge
• Bruises, bleeding, or discharge from the vaginal area
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Legal and Ethical Issues
4. Discuss abuse and neglect and explain how to report abuse
and neglect
Think about this question:
Why might NAs notice suspicious injuries that other members of
the care team don’t see?
3 Legal and Ethical Issues
Transparency 3-3: Signs of Abuse
Signs that could indicate abuse include the following:
• Yelling obscenities
• Fear, apprehension, fear of being alone
• Poor self-control
• Constant pain
• Threatening to hurt others
• Withdrawal or apathy
• Alcohol or drug abuse
• Agitation or anxiety, signs of stress
• Low self-esteem
• Mood changes, confusion, disorientation
• Private conversations are not allowed, or the family
member/caregiver is present during all conversations
• Resident or family reports of questionable care
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Legal and Ethical Issues
4. Discuss abuse and neglect and explain how to report abuse
and neglect
Think about this question:
What should an NA do if he sees signs of abuse?
3 Legal and Ethical Issues
Transparency 3-4: Signs of Neglect
Signs that could indicate neglect include the following:
• Pressure ulcers
• Body not clean
• Body lice
• Unanswered call lights
• Soiled bedding or incontinence briefs not being changed
• Poorly-fitting clothing
• Unmet needs relating to hearing aids, eyeglasses, etc.
• Weight loss, poor appetite
• Uneaten food
• Dehydration
• Fresh water or beverages not being offered regularly
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Legal and Ethical Issues
4. Discuss abuse and neglect and explain how to report abuse
and neglect
Think about these questions:
What might happen in a facility to cause neglect of a resident?
What might happen in the home to cause neglect of client (by
family or by home care staff)? How can neglect be prevented?
3 Legal and Ethical Issues
Handout 3-2: Who Is Vulnerable to Abuse or Neglect?
3 Legal and Ethical Issues
Handout 3-2: Who Is Vulnerable to Abuse or Neglect?
Some people are more vulnerable to adult abuse or neglect than others. They
include:
• Elderly
• Physically ill or disabled
• Developmentally disabled
• Mentally ill or disabled
• People with communication problems, such as hearing, speech, and
vision
All of these people have a few things in common that make them so vulnerable.
They are often unable to stand up for themselves, or report abuse or neglect to
others. They may not even understand that they have rights. Often these people
can be much more demanding to care for, which increases the stress that
caregivers have to deal with.
Caregivers may not have been properly trained to care for these particular
people, and they may not understand why these people behave the way they do.
Caregivers may also be overworked, tired, stressed, and unappreciated, all while
caring for someone who requires so much time and energy.
These are the people who most need your help in protecting themselves. They
may not be able to speak for themselves, but the signs of abuse and neglect
may speak volumes for them, if you just know how to recognize these signs.
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Legal and Ethical Issues
4. Discuss abuse and neglect and explain how to report abuse
and neglect
Think about this question:
Why are these people so vulnerable?
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Legal and Ethical Issues
4. Discuss abuse and neglect and explain how to report abuse
and neglect
Consider these ways in which people may be vulnerable to
abuse:
• Older people may be unable to stand up for themselves.
• Older people may be unable to report abuse or neglect to
others.
• Older people may not understand that they have rights.
• Older people may be much more demanding to care for.
• Caregivers may not be trained properly.
• Caregivers may not understand their behavior.
• Caregivers may be overworked, tired, stressed, and
unappreciated, on top of caring for someone who requires so
much time and energy.
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Legal and Ethical Issues
4. Discuss abuse and neglect and explain how to report abuse
and neglect
Think about this question:
How can NAs help protect those who are vulnerable to abuse and
neglect?
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Legal and Ethical Issues
4. Discuss abuse and neglect and explain how to report abuse
and neglect
REMEMBER:
An NA must never abuse residents in any way, and must try to
protect residents from others who abuse them. Reporting abuse
is not an option - it is the law.
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Legal and Ethical Issues
4. Discuss abuse and neglect and explain how to report abuse
and neglect
REMEMBER:
Follow the chain of command when reporting abuse.
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Legal and Ethical Issues
4. Discuss abuse and neglect and explain how to report abuse
and neglect
In addition to federal laws relating to Residents’ Rights, which
forbid abuse and neglect, there are other legal protections
designed to help elders and other vulnerable adults:
• Some states have Vulnerable Adults Acts or Adult Protective
Services laws.
• The Elder Justice Act of 2010 is the first federal law designed
specifically to combat elder abuse.
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Legal and Ethical Issues
5. List examples of behavior supporting and promoting Residents’
Rights
Think about this question:
What are some specific examples of ways NAs can promote
Residents’ Rights?
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Legal and Ethical Issues
6. Describe what happens when a complaint of abuse is made
against a nursing assistant
Remember these points about the Nurse Aide Training
Competency Evaluation Program (NATCEP):
• Makes rules about training and testing NAs
• State programs make sure federal rules are followed in
facilities that receive Medicare/Medicaid payments
• Sets up and runs registry, which keeps track of each NA
working in the state
• Investigates charges of abuse
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Legal and Ethical Issues
6. Describe what happens when a complaint of abuse is made
against a nursing assistant
REMEMBER:
If it is determined that an NA has abused a resident, NATCEP will
place that NA on an abuse registry. Any potential employer will
be told of the abuse.
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Legal and Ethical Issues
7. Explain how disputes may be resolved and identify the
ombudsman’s role
Define the following term:
ombudsman
a legal advocate for residents in long-term care facilities;
helps resolve disputes and settle conflicts.
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Legal and Ethical Issues
7. Explain how disputes may be resolved and identify the
ombudsman’s role
The following are typical tasks for an ombudsman:
• Advocates for residents’ rights
• Educates consumers and care providers
• Investigates and resolves complaints
• Appears in court
• Works with investigators
• Gives information to public
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Legal and Ethical Issues
8. Explain HIPAA and list ways to protect residents’ privacy
Define the following term:
confidentiality
the legal and ethical principle of keeping information private.
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Legal and Ethical Issues
8. Explain HIPAA and list ways to protect residents’ privacy
REMEMBER:
HIPAA applies to all healthcare providers, and penalties can be
serious if violations occur.
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Legal and Ethical Issues
8. Explain HIPAA and list ways to protect residents’ privacy
Think about these questions:
How might breaches of confidentiality happen? How could they
be prevented?
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Legal and Ethical Issues
9. Explain the Patient Self-Determination Act (PSDA) and discuss
advance directives
Define the following terms:
advance directives
legal documents that allow people to choose what medical
care they wish to have if they are unable to make those
decisions themselves.
living will
a document that outlines the medical care a person wants, or
does not want, in case he or she becomes unable to make
those decisions.
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Legal and Ethical Issues
9. Explain the Patient Self-Determination Act (PSDA) and discuss
advance directives
Define the following terms:
durable power of attorney for health care
a signed, dated, and witnessed legal document that appoints
someone else to make the medical decisions for a person in
the event he or she becomes unable to do so.
do-not-resuscitate (DNR) order
a type of advance directive that instructs medical
professionals not to perform CPR if a person’s heartbeat or
breathing stops.
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Legal and Ethical Issues
9. Explain the Patient Self-Determination Act (PSDA) and discuss
advance directives
Think about these questions:
• Why do you think it might be important to plan what kind of
medical care you want or do not want?
• How do you feel personally about a DNR order?
• Why do you think rights relating to advance directives are so
important?
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Legal and Ethical Issues
9. Explain the Patient Self-Determination Act (PSDA) and discuss
advance directives
According to the PSDA, the following rights must be
communicated to residents at the time of admission:
• The right to participate in and direct healthcare decisions
• The right to accept or refuse treatment
• The right to prepare an advance directive
• Information on the facility’s policies that govern these rights
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Legal and Ethical Issues
Exam
Multiple Choice. Choose the correct answer.
1.
_____ have to do with the knowledge of right and wrong.
(A) Laws
(B) Ethics
(C) Advance directives
(D) Living wills
1.
An example of ethical behavior by a nursing assistant (NA) is
(A) Protecting a resident’s privacy
(B) Changing the care plan if the NA believes it is inappropriate for a
resident
(C) Performing a task outside her scope of practice when a resident
requests that she do so
(D) Accepting a gift from a resident for a job well done
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Legal and Ethical Issues
Exam
3.
OBRA was passed as a response to
(A) Lack of funding for long-term care
facilities
(B) Reports of poor care and abuse in long-term care facilities
(C) Nursing assistants being unable to pass competency exams
(D) Staff members not reporting to work on time
4.
How many hours of training does OBRA require for nursing assistants?
(A) At least 50 hours
(B) At least 75 hours
(C) At least 100 hours
(D) At least 120 hours
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Legal and Ethical Issues
Exam
5.
How many hours of in-service education does OBRA require for nursing
assistants every year?
(A) At least 34 hours
(B) At least 28 hours
(C) At least 18 hours
(D) At least 12 hours
6.
A nursing assistant tells a resident that her grandchildren are noisy and
disrupt the facility and suggests that next time her daughter visits, she
should leave the kids at home. Which Residents’ Right might this behavior
violate?
(A) The right to voice complaints without fear of punishment
(B) The right to refuse medication and treatment
(C) The right to have visitors
(D) The right to confidentiality
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Legal and Ethical Issues
Exam
7.
Which of the following terms means harming a person physically, mentally,
or emotionally by failing to provide needed care?
(A) Neglect
(B) Assault
(C) Battery
(D) Abuse
8.
Which of the following terms means to steal, take advantage of, or
improperly use the money, property, or other assets of another person?
(A) Substance abuse
(B) Financial abuse
(C) Verbal abuse
(D) Sexual abuse
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Legal and Ethical Issues
Exam
9.
Which of the following is an example of sexual abuse?
(A) Rubbing up against a resident inappropriately
(B) Confining a resident in a separate physical space without the resident’s
consent
(C) Using alcohol in a harmful way
(D) Failing to provide needed care for a resident
10. Which of the following is an example of physical abuse?
(A) Stealing from a resident
(B) Showing a resident pornographic material
(C) Shoving a resident
(D) Threatening a resident
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Legal and Ethical Issues
Exam
11. Threatening to harm a resident if he tells another caregiver about a problem
is an example of which type of abuse?
(A) Physical abuse
(B) Psychological abuse
(C) Financial abuse
(D) Substance abuse
12. What is required of a nursing assistant if he suspects that a resident is
being abused?
(A) The NA should call the police and let them know that the resident is
being abused.
(B) The NA should discuss the issue with the resident to find out if it is OK
for him to report what he suspects.
(C) The NA should report it to the charge nurse immediately.
(D) The NA should immediately confront the abuser about what he
suspects.
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Legal and Ethical Issues
Exam
13. Which of the following behaviors promotes Residents’ Rights?
(A) Keeping a change in the care plan confidential so as not to upset the
resident
(B) Treating a resident badly if he has made a complaint about an NA
(C) Encouraging a resident to participate in care planning
(D) Borrowing money from a resident if it helps the NA continue to work
14. Which organization typically investigates charges of abuse against nursing
assistants?
(A) Centers for Medicare and Medicaid Services (CMS)
(B) The Resident’s Council (RC)
(C) The Federal Bureau of Investigation (FBI)
(D) Nurse Aide Training Competency Evaluation Program (NATCEP)
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Legal and Ethical Issues
Exam
15. What are typical duties of an ombudsman?
(A) An ombudsman advocates for staff members involved in disputes with
management.
(B) An ombudsman advocates for residents and helps settle disputes.
(C) An ombudsman teaches nursing assistant training classes.
(D) An ombudsman organizes activities and outings for residents.
16. For
(A)
(B)
(C)
(D)
nursing assistants, confidentiality means
Not telling the nurse about possible abuse of a resident
Not documenting resident problems
Keeping resident information private
Sharing resident information with the NA’s family
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Legal and Ethical Issues
Exam
17. With whom may an NA share a resident’s medical information?
(A) With the resident’s brother and sister
(B) With the NA’s parents
(C) With other members of the care team
(D) With the resident’s children
18. One reason that the Health Insurance Portability and Accountability Act
(HIPAA) was created is to
(A) Protect privacy of health information
(B) Help ombudsmen monitor care in
facilities
(C) Ensure that nursing assistants receive adequate health insurance
coverage
(D) Prevent abuse and neglect of residents
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Legal and Ethical Issues
Exam
19. Which of the following is the best way for a nursing assistant to keep
residents’ health information confidential?
(A) Discuss residents’ information in public areas away from care facilities
so that residents cannot hear it
(B) Bring friends to the facility to meet residents
(C) Store, file, or shred documents according to facility policy
(D) Post updates about favorite residents on her Facebook page to avoid
being overheard
20. What is the purpose of the Patient Self-Determination Act (PSDA)?
(A) To offer in-service training for nursing assistants
(B) To keep protected health information (PHI) private
(C) To encourage people to make decisions about advance directives
(D) To detail how abuse should be reported
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Legal and Ethical Issues
Exam
21. Which of the following is an example of an advance directive?
(A) Last Will and Testament
(B) Power of Attorney
(C) Divorce Decree
(D) Durable Power of Attorney for Health Care
22. Which of the following types of advance directives instructs medical
personnel not to perform cardiopulmonary resuscitation (CPR) if the
person’s lungs and/or heart have stopped working?
(A) Legal proxy
(B) Do-not-resuscitate order
(C) Protected health information
(D) Minimum data assessment