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  1. Brooke, Penny Simpson RN, MS, JD

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Don't step out on shaky ground

I'm an RN who works full-time in the ED. My question is about my free time, though. One of my neighbors has a permanent disability, and he and his wife have run out of money to pay for treatment. I'd like to offer to help this man for free. Am I right in assuming that even though I'd be performing this care as a volunteer, I could be held legally liable if he were injured from an error on my part? Also, if at some point I felt I couldn't continue to help him, could he sue me for abandonment even though I volunteered my skills as a favor?-E.H., OHIO

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If you made an error and harmed the patient, you would indeed be held responsible regardless of whether you were accepting compensation. And you could face even greater risks than you would at work, because you won't have the backup and resources available to you that you have at your job.


You're not protected by Good Samaritan laws when you enter a relationship like the one you describe. Check with your personal professional liability insurance to see if you're covered if you take on this role. If not, you'll need to purchase the appropriate coverage before proceeding.


Abandonment could also be an issue. If you begin caring for your neighbor and then decide to leave that role, you'll need to find another person to whom you could safely pass his care, because by then he'd be relying on the care you agreed to provide. You already know how difficult this would be because your neighbor can't afford to pay for the care you want to give.


Because of all these drawbacks, I advise you to use your expertise to explore other community resources for your neighbor. Many free clinics are available, and your local not-for-profit hospital may provide charity care to those who can't afford to pay.



No second chances after rough behavior

I'm an RN at a skilled nursing facility. Two days ago, I was making my rounds when one of my patients told me a nursing aide had yelled at him and grabbed him by the arm the day before. I could see finger mark bruises on his arm. Of course, I immediately reported this to my supervisor, who talked to the patient, saw the bruises, and removed the aide from our unit that day.


Today I learned that this aide still works at the facility, just in a different unit. Is this legal? Shouldn't she have been fired right away?-L.R., ARIZ.


You're right to be concerned about the continued employment of anyone who's abused a patient. Share your concerns with your supervisor and request that the facility's legal counsel advise you both on how to proceed. Patient abuse is taken very seriously by licensing agencies as well as the Centers for Medicare and Medicaid Services (CMS). The facility is risking potential fines, and could even lose its license and funding if it doesn't take action, which includes reporting the aide to appropriate authorities.


Be sure to complete an event/occurrence report to document what you heard from the patient and saw for yourself, and to establish that you immediately reported it to your supervisor. This report shows that you neither overlooked nor condoned the aide's behavior. A lawsuit can result from incidents like this, and the RN is usually held accountable for the actions of those she supervises.


If the aide continues to work at your facility, follow up with your employer to find out what action is being taken. Let your employer know that if the unsafe situation persists, you have a professional obligation to report it to the facility licensing agency, CMS, protective services, or department of licensure if the aide is licensed or certified. Whistle-blowers are protected from employer backlash when they report a legitimate patient-safety issue that the employer is ignoring.



Time is short-ask the patient

I'm a hospice nurse who's caring for a patient with no living will or other advance directive. I feel it's part of my job to encourage her to complete one while she's still mentally competent and can express her wishes about end-of-life care. But the family is emphatically against the idea. They think that bringing it up will be stressful and just depress her during her remaining time. Can I legally bring up the issue with my patient, as her advocate, against her family's wishes? And if I do and she's upset by it, could I be in legal trouble for trying to do my job well?-N.W., N.D.


Patients with terminal illnesses need to convey their desires as they approach the very personal process of dying. An alert, competent patient has the right to make these decisions for herself. However well-intentioned, a protective family doesn't have the legal right to discourage her from expressing her wishes through a living will or other advance directive.


Instead of getting into a standoff with a caring family, try to convince them that allowing the patient to make these decisions is in the whole family's best interests. Help them understand why this discussion and these documents are important to the patient. They need to know her wishes in case they must make critical decisions on her behalf in the near future. They may be surprised to find that having this discussion turns out to be a comfort to the patient and actually relieves some of her stress.


Talk with your supervisor and investigate your agency's policies and procedures regarding living wills and advance directives. Find out what discussions you need to have-and then allow the patient to make her wishes known. If the family continues to resist, support the patient's stated wishes and continue to teach the family that a competent patient has the legal right to consent to care.



Who's the fall guy here?

One of my patients was injured in a fall, and I'm worried about my liability. She wasn't strong enough to walk without help, so we'd instructed her and her family to call us whenever she needed to get up. Yesterday her son tried to help her out of bed without calling a nurse for help. She fell and broke her hip.


Who's liable here? We did document our instruction to get help from us before getting out of bed.-R.P., WASH.


It's good that you documented your instruction for the patient to get help before getting out of bed, but this alone won't protect you from liability. Other facts must be considered and documented when a patient is identified as a fall risk. For example, a plan for preventing a fall should be documented in the patient record to demonstrate that she was assessed properly and caregivers took reasonable precautions to prevent her from falling. The patient's nurses are legally responsible for the patient's safety, and this duty can't be transferred or delegated to the family.


For details about fall prevention standards promoted by The Joint Commission, visit http://www.jointcommission.org and search for "fall reduction program."


If you're the nurse who finds a patient who's fallen, the first priority is caring for the patient. Call the house officer, who will assess her for injuries and order testing and treatment as indicated. Document all details relevant to her medical condition and care in the medical record.


In addition, document exactly what you witnessed-for example, that you found the patient on the floor-in an event/occurrence report. This report will serve as evidence on your behalf if the family claims you're at fault for not responding to a call for help or any number of other claims that have been made in fall cases. If the son acknowledged responsibility for the patient's fall, put his statement in quotation marks in your event report.


Submit the event report to risk management, which will use it to analyze the incident and look for ways to mitigate future risks. The report can also guide them in working with your patient and her family to minimize the risk of a lawsuit.


The duty to protect patients from injury is very great and will implicate both you and the hospital unless you have solid evidence that you did everything reasonably possible to anticipate and prevent the patient's fall.