Case Studies

Background

The nurse was working as the charge nurse in the intensive care unit. One of the staff nurses, XX, approached her, asking if she could be sent home due to a migraine. The nurse was aware that there was only one open bed for admission. If XX went home due to her migraine, the nurse would not have any open beds for admission and would have had to take a patient assignment.

XX was also aware of the staffing needs of the unit, she asked the nurse if she would insert a peripheral intravenous (IV) catheter and administer a one-liter bag of normal saline on her. XX told the nurse that the fluids should help alleviate her migraine and allow her to continue to work the rest of her shift. The nurse went to the supply room and took an IV start kit and IV tubing. She also obtained a one-liter bag of normal saline from the Pyxis.

The nurse and XX went to an office that was seldom used and she obtained peripheral IV access on XX. The nurse primed the tubing and administered the bag of normal saline. While the bag of fluids was running, the nurse agreed to watch XX’s patients for her.

After the bag of normal saline was completed, the nurse grabbed the supplies needed to remove the peripheral IV. XX told the nurse that her migraine had improved, and she appreciated the administration of fluids.

Reflection

• Reflect on whether the charge nurse acted outside of her scope of practice when she started the IV without a physician’s order.
• Reflect on whether the removal of the supplies was a violation of the Nurse Practice Act.
• Do you believe that the nurse’s employer has any policies or procedures that would have been violated in this scenario?
• What, if any, violations of the Arizona Nurse Practice Act occurred in the above case study?

Conclusions of Law

Currently cited as ARS § 32-1663 (D) as defined in § 32-1601 (27) (effective September 29, 2021)

27. “Unprofessional conduct” includes the following, whether occurring in this state or elsewhere:

(d) Any conduct or practice that is or might be harmful or dangerous to the health of a patient or public.

(j) Violating this chapter of a rule that is adopted by the board pursuant to this chapter.

And currently cited as Rule R4-19-403:

9. Failing to take appropriate action to safeguard a patient’s welfare or follow policies and procedures of the nurse’s employer designed to safeguard the patient;

12. Assuming patient care responsibilities that the nurse lacks the education to perform, for which the nurse has failed to maintain nursing competence, or that are outside the scope of practice of the nurse;

16. Removing, without authorization, a narcotic, drug, controlled substance, supply, equipment, or medical record from any health care facility, school, institution, or other workplace location;

Background

While working as a staff labor and delivery registered nurse (RN), the nurse performed an amniotomy (rupture of the amniotic membranes) of a laboring patient without the involvement of a provider, or a provider’s order. The nurse made comments about wanting to do something to move along the patient’s labor/delivery and informed the patient’s spouse that she did not share her actions with anyone prior to performing the amniotomy. The facility policy states that “It is not within the scope of practice for a registered nurse to perform an amniotomy.” The Arizona State Board of Nursing’s Advisory Opinion on Amniotomy concludes that it is not within the scope of practice for a RN to break amniotic membranes. The nurse inaccurately documented that the patient’s amniotic membranes broke spontaneously.

Findings of Fact

The nurse practiced outside of the scope of an RN when she performed an amniotomy on a patient.

The standard of practice for an RN is to follow state-issued standards of practice and organizational policy. The nurse violated the facility’s organizational policy and the standard of practice when she performed an amniotomy.

Additionally, it is the standard of practice of an RN to document accurately and truthfully and communicate honestly with colleagues regarding their actions. Respondent violated the standard of practice when she failed to inform her colleagues of her actions and documented that the patient’s amniotic membranes broke spontaneously.

Conclusions of Law

Currently cited as ARS § 32-1663 (D) as defined in § 32-1601 (27) (effective September 29, 2021)

27. “Unprofessional conduct” includes the following, whether occurring in this state or elsewhere:

(d) Any conduct or practice that is or might be harmful or dangerous to the health of a patient or public.

(j) Violating this chapter of a rule that is adopted by the board pursuant to this chapter.

And currently cited as Rule R4-19-403:

8. Falsifying or making a materially incorrect, inconsistent, or unintelligible entry in any record: a. Regarding a patient, health care facility, school, institution, or other workplace location; or

9. Failing to take appropriate action to safeguard a patient’s welfare or follow policies and procedures of the nurse’s employer designed to safeguard the patient;

12. Assuming patient care responsibilities that the nurse lacks the education to perform, for which the nurse has failed to maintain nursing competence, or that are outside the scope of practice of the nurse;

31. Practicing in any other manner that gives the Board reasonable cause to believe the health of a patient or the public may be harmed. And currently cited as Rule R4-19-403: 2. Demonstrate honesty and integrity;

Board Outcome

The Board offered a Consent Agreement for a Decree of Censure as there was concern that the actions taken were willful, without regard to policy, and could have had an impact on the safety of patients. The nurse agreed to and signed the Decree of Censure. A Decree of Censure is a disciplinary action that does not encumber the nurse’s license or certification but is reported to the national nurse licensing and disciplinary information system, and the name of the nurse is published online, which is intended to protect the public from unsafe and/or incompetent practice.

Background

A Registered Nurse (RN) opened a mobile IV hydration clinic in 2019 and employed RNs to provide treatment to clients. The RN reviewed the clients’ present illnesses, medical histories, current medications, and allergies and noted them in their charts. The RN took vital signs and completed the assessments. The clients were given an IV hydration menu, and the RN compounded the IV fluids with the supplements of choice using “Standing Orders.” The clients were never assessed by a provider, but if an RN had any concerns they could reach out to the Medical Director.

Findings of Fact

The nurse was practicing out of scope when he assessed and diagnosed clients’ need for treatment without a provider assessment. During this time, the RN also practiced outside of scope when he compounded intravenous solutions with supplements, which according to Arizona revised Statute (ARS) 32-1961 is unlawful for any person except a pharmacist or a pharmacy intern acting under the direct supervision of a pharmacist. The RN practiced outside of scope when he administered medications in a dose and/or via a route that was not ordered by a provider, but was decided by the clients. The RN employed and supervised other RNs working at the clinic performing similar activities.

Conclusions of Law

Currently cited as ARS § 32-1663 (D) as defined in § 32-1601 (27) (effective September 29, 2021)

27. “Unprofessional conduct” includes the following, whether occurring in this state or elsewhere:

(d) Any conduct or practice that is or might be harmful or dangerous to the health of a patient or public.

(j) Violating this chapter of a rule that is adopted by the board pursuant to this chapter.

And currently cited as Rule R4-19-403:

1. A pattern of failure to maintain standards of acceptable and prevailing nursing practice;

12. Assuming patient care responsibilities that the nurse lacks the education to perform, for which the nurse has failed to maintain nursing competence, or that are outside the scope of practice of the nurse;

31. Practicing in any other manner that gives the Board reasonable cause to believe the health of a patient or the public may be harmed.

Board Outcome

The Board issued a Decree of Censure, a disciplinary action, for a violation of the scope of nursing practice. A Decree of Censure does not encumber the nurse’s license or certification but is reported to the national nurse licensing and disciplinary information system, and the name of the nurse is published online, which is intended to protect the public from unsafe and incompetent practice.

Background

Patient XX, a 38-year-old female admitted to a behavioral health facility on a Court Ordered Evaluation (COE) for a diagnosis of bipolar disorder, consistently refused psychiatric medications. Patient XX was not under Court Ordered Treatment (COT), and the patient was fighting the petitions in court.

Nursing staff noted in Patient XX’s medical record that the patient refused psychological medications because Patient XX felt the medications were unnecessary, was terrified of possible side effects, and taking the medications went against her beliefs. Patient XX occasionally took over-the-counter medications for pain and sleep. The nurse administered a psychiatric medication by putting the medication into Patient XX’s applesauce without her knowledge or consent. The nurse reported that the patient was emotionally labile, anxious, and agitated, and the nurse thought the medication would help the patient.

Findings of Fact

The nurse knowingly administered an ordered medication to Patient XX, which the patient had previously refused, by putting the medication into the patient’s food without the patient’s knowledge. The standard of practice requires the RN to honor a patient’s right to refuse a medication.

Conclusions of Law

Currently cited as ARS § 32-1663 (D) as defined in § 32-1601 (27) (effective September 29, 2021)

27. “Unprofessional conduct” includes the following, whether occurring in this state or elsewhere:

(d) Any conduct or practice that is or might be harmful or dangerous to the health of a patient or public.

(j) Violating this chapter of a rule that is adopted by the board pursuant to this chapter.

And currently cited as Rule R4-19-402 (B):

2. Demonstrate honesty and integrity;

8. Respect a client’s rights, concerns, decisions and dignity;

And Rule R4-19-403:

31. Practicing in any other manner that gives the Board reasonable cause to believe the health of a patient or the public may be harmed.

Board Outcome

The Board offered a Consent Agreement for a Decree of Censure, which the nurse agreed to and signed. A Decree of Censure is a disciplinary action that does not encumber the nurse’s license or certification but is reported to the national nurse licensing and disciplinary information system, and the name of the nurse is published online, which is intended to protect the public from unsafe and incompetent practice.

Background

Patient XX, a 30-year-old female with a history of infertility and thickening of her uterine lining. Patient XX was scheduled for an endometrial biopsy to determine the cause of the thickened uterine lining.

A nurse in an infertility clinic received training to perform endometrial biopsies from a clinic physician. The nurse then scheduled and performed an endometrial biopsy on Patient XX, which resulted in abnormal uterine bleeding for ten days.

Findings of Fact

The nurse practiced beyond her scope when she performed an endometrial biopsy on Patient XX. An RN shall perform only those nursing activities for which the RN has a foundational education through a nursing program, and continued didactic and clinical training for advanced procedures, which are within the scope of practice of an RN as determined by the Board.

Conclusions of Law

Currently cited as ARS § 32-1663 (D) as defined in § 32-1601(27) (effective September 29, 2021)

27. “Unprofessional conduct” includes the following, whether occurring in this state or elsewhere:

(d) Any conduct or practice that is or might be harmful or dangerous to the health of a patient or public.

(j) Violating this chapter of a rule that is adopted by the board pursuant to this chapter.

And currently cited as Rule R4-19-403:

12. Assuming patient care responsibilities that the nurse lacks the education to perform, for which the nurse has failed to maintain nursing competence, or that are outside the scope of practice of the nurse;

31. Practicing in any other manner that gives the Board reasonable cause to believe the health of a patient or the public may be harmed.

Board Outcome

The Board offered a Consent Agreement for a Decree of Censure, which the nurse agreed to and signed. A Decree of Censure is a disciplinary action that does not encumber the nurse’s license or certification but is reported to the national nurse licensing and disciplinary information system, and the name of the nurse is published online, which is intended to protect the public from unsafe and incompetent practice.

Background

A nurse practitioner (NP) was reported to the Board for alleged fraudulent documentation and billing practices. The NP documented that she had a telehealth visit with Patient XX, but Patient XX confirmed that no visit took place on the date in question. After an investigation and chart reviews by the practice’s Compliance and Risk Management Department, it was found the NP had copied and pasted 47% of her visit notes, 34% of the visits did not occur or did not occur at the stated time and duration, and 12% had incorrect billing codes or point of service. It was noted that the NP also documented and billed for an in-office visit for Patient XX, which had been held via telehealth. She stated this was her first employment as a NP and she was told to copy and paste notes during her orientation training by another provider. The NP stated she did not receive billing and coding training during her orientation, and the electronic health record had telephonic, and in-person visit options, but not a telehealth.

Finding of Facts

The nurse practitioner violated the standard of practice for nurse practitioners when she did not correctly document and bill appointments using correct visit codes; copied and pasted visit notes; did not accurately document visit notes to reflect the information shared and discussed during the visit; and documented and billed for an appointment that never occurred.

Conclusions of Law

Currently cited as ARS § 32-1663 (D) as defined in § 32-1601 (27) (effective September 29, 2021)

27. “Unprofessional conduct” includes the following, whether occurring in this state or elsewhere:

(d) Any conduct or practice that is or might be harmful or dangerous to the health of a patient or the public.

(g) Willfully or repeatedly violating a provision of this chapter or a rule adopted pursuant to this chapter.

(j) Violating this chapter or a rule that is adopted by the Board pursuant to this chapter.

And currently cited as Rule R4-19-403:

1. A pattern of failing to maintain minimum standards of acceptable and prevailing nursing practice;

7. Failing to maintain for a patient record that accurately reflects the nursing assessment, care, treatment, and other nursing services provided to the patient;

8. Falsifying or making a materially incorrect, inconsistent, or unintelligible entry in any record: a. Regarding a patient, health care facility, school, institution, or other work place location;

31. Practicing in any other manner that gives the Board reasonable cause to believe the health of a patient or the public may be harmed.

Board Outcome

The Board offered the nurse practitioner a Consent Agreement for a Civil Penalty of $1,000, to be paid in full in 60 days, which the NP agreed to and signed. A Civil Penalty is a disciplinary action that does not encumber the nurse practitioner’s license or certification but is reported to the national nurse licensing and disciplinary information system, and the name of the NP is published online, which is intended to protect the public from unsafe and incompetent practice. The NP was also placed on probation for 12 months with stipulations that include an Ethics evaluation, continuing education requirements for documentation and billing, chart reviews, and direct supervision while in the clinic.

Background

Patient XX, an 87-year-old female with heart failure, diabetes, and an altered mental status, who resided in a nursing home. Patient XX turned off her bed and chair alarms, was often restless, and had recently experienced an increase in falls.

A former nursing home Director of Nursing, who was currently working as a nursing home staff nurse, was caring for Patient XX. The nurse was also responsible for many other patients, passing medications, and assisting patients in getting ready for bed. Staffing levels did not support 1:1 supervision on Patient XX to prevent additional falls, so the nurse placed Patient XX into a recliner and placed a coffee table under the foot rest of the recliner to prevent Patient XX from getting out of the chair and falling again.

Findings of Fact

The Centers for Medicare and Medicaid Long Term Care Restraint guidelines state, “The resident has a right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms. For this purpose, “convenience” is defined as “any action taken by the facility to control a resident’s behavior or manage a resident’s behavior with a lesser amount of effort by the facility and not in the resident’s best interest.”

The nurse did not have, nor did the nurse attempt to obtain, an order to initiate a restraint.

Conclusions of Law

Currently cited as ARS § 32-1663 (D) as defined in § 32-1601(27) (effective September 29, 2021)

27. “Unprofessional conduct” includes the following, whether occurring in this state or elsewhere:

(d) Any conduct or practice that is or might be harmful or dangerous to the health of a patient or public.

(j) Violating this chapter of a rule that is adopted by the board pursuant to this chapter.

And currently cited as Rule R4-19-403:

9. Failing to take appropriate action to safeguard a patient’s welfare or follow policies and procedures of the nurse’s employer designed to safeguard the patient;

12. Assuming patient care responsibilities that the nurse lacks the education to perform, for which the nurse has failed to maintain nursing competence, or that are outside the scope of practice of the nurse;

31. Practicing in any other manner that gives the Board reasonable cause to believe the health of a patient or the public may be harmed.

Board Outcome

The Board offered a Consent Agreement for a Decree of Censure, which the nurse agreed to and signed. A Decree of Censure is a disciplinary action that does not encumber the nurse’s license or certification but is reported to the national nurse licensing and disciplinary information system, and the name of the nurse is published online, which is intended to protect the public from unsafe and incompetent practice.